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Home My WebLink AboutApplications, WC and Licenses , . ; � � °� � TOWN OF YARMOUTH BOARD OF HEALTH-,� ��:� a . � � APPLICATION FOR LICENSE/PE�!'1VIIT-2Q09 =; ;�} (n�[s��[S Q�Vf j��p 4ro .�.. ! a• 53 a �N * Please complete form and atta.ch all necessary document��y��cember 1 2G1�1� � 4 2QQ9 Failure to do so will result in the return of your applicanon pac et. HEALT � NAME OP ESTABLISHMENT: ��-� t C� ��°g � �°�� 2- TEL. # �Ss� ��' � • ; LOCATION ADDRESS: �q �2o c�•( � C� 'y q Q,v��v i � �q �., G.�.� MAILING ADDRESS: o/ j OWNER NAME:_ G7 C�v,A�tr-- Q,q�i f��L TAX ID (FE1N Or SSN�� 1 CORRORATION NAME (I� APPLICABLE}: 1�,�n i 7r-.� Co�� MANAGER'S NAME: �r v�N �. p,�� - TEL. # ��.-�t n��o z z� MAILING ADDRESS: Co ci' !2 o v�t �� c..� �y A �z n�o c�i h� M I-1- o� G�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. � 1. '-e�'� -- � c� ��e.�-Z_ 2. � Pool operators must list a minimum of two employees cun ently certified in basic water safety, standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to this form. The Health Department�vill not use past years' recards. Yau must provide new � copies and maintain a file at your place of business. , �. s�.�.�-� `� 1��, 1 �a1 � 2. s-� � l� � �, 1L � 1 � �1 �,. 3• 4. I FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary CodE for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification to this application. The Health Department will not use past years' records. � You must provide new copies and maintain a file at your establishment. 1. 2. � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � i � 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMI7# LICENSE REQUIRED FEE PERMIT# _B&B �55 _CABIN �55 �MOTEL �55 �6�--0�9 _INN �55 _GAMP �55 �SWIMMING POOL $80ea. �D f 6?/` _LODGE S55 _TRAILERPARK �105 r WHIRLpOOL $80ea. �d9--�3�j FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS �85 �CONTINENTAL �35 ��`r NON-PROFIT �30 _>100 SEA7S �160 ^COMMON VIC. $60 _VVHOLESALE �80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQITIRED FEE PERIVIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —<�0 sq.�. �50 _>25,000 sq.ft. $22S _VENDITTG-FOOD $25 _<25,OOOsq.ft. S80 _FROZENDESSERT �40 _TOBACCO �5� j tia��cxa�cE: �io AMOITNT DUE _ � f �� c� c� 7�7� *"***PLEASE TUR'�OVER AND CONIPLETE OTHER SIDE OF FOl�"�*�* l� v� �.;� .� ...�:;.� , ( �, � _ � � � 4 �. ��. . . __�. �; ADMINIST'RATION � > � Under Chapter 1�2, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � ;:..��any lic,�e: or pernut to operate a business if a person or company does not have a Certificate of Worker's � . .� .�cx�pertsativ��surance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, UR CERT. OF INSURANCE ATTACHED OR WORI�R'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO � � � ` MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as ame�ded, shall generally be considered Transient. I , � POOLS � � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected b the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are 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 rnust 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 Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHeatth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmem is prohibited. N07TCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETCTRN � THE COMPLETED RENEWAL APPLICATION(S) AND REQUIKED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISF�VVIEEN'T, 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. , I r. DATE: ��'�lU� SIGNATURE: � �-G''��==�� ; � PRINT NAME&TITLE: C�"�''s>up�QR GA�P�/k�li ��i��-;9 P� ' iorzi!os a � ;, i r a._ , �. 1 - � � The Commonwealth ofMassachusetts Department of Indusd►ial Accidents �� 600 Washington Sheet, 7�"'Floor Boston,Mass. 02111 Workers'Campeusation I�serance ABidnvir Bailding/Plambing/Electrical Contractors �' � P'le�tse 1"lill�l'1'1�iUl+r �: �W1ea1c� �4�t1 HoS; �6 / I; L addtess• �9 �.4 i�V S'% citv C� � S i 4 I�RiYID�7/� srate• r✓i /'� zip �2 fv�-3 ohame# �'�?3 Fs ��-S 23 3 Z. work site location ffull addressl_ ` ❑ I am a homeowner perfomung all work myself. Project Type: ❑New Constcucrion QRemodel ❑ I am a sole proprietor and have no one working in anY caT�ih'• ❑Building Addition � �am an employer pmvidin workers'com S pensation f�my employees worlcing on this job. comoaav■ame: - _ -_ - _ . address: dri- nl�oae# ��, ce. �IA,�C�`1 SV��.c_r lJ�c��2Ct;S 1 ��ITS - � . # G�J C M (o � - ,..-::. - :;_. _ .,^-.':.. �-.:,- . :5.. �_ . , _. . .�,' . . r.Y ��.�:..�_ .F,iF ,t. 'a`�. �:.a�;:?r�":.�e,�'.�.a�z*�*.,.v.a_,. ' ❑ I am a sote propriefor,ge�erai coatractor,or homeowner(circle onc)and have hired ibe�tors listsd below whv have the following wotkets'compensation polices: ��o.�: f-�� -� 7 ,., s v � ) l _ �,�: , �� ,� s�-- � , �� de�: r�o�c e s f e� �� fl-1�o�c �# S o�' � 9 a '� - �o G i: �a �. # � �� ;: ...�:; � ��:; c_sme►uv�ame: address• citv �# --- ----— -- - � ---- - _ --- - —— -- ---- -- _ __ .. . ., . • # .. :: . , ;. .-..: . -�.... ... . .... .:,., -�� , .>.:: - ...::*.. �fi- ." ',� �' .�'"r;*,�.�-,.'r t �5,.;'` ra;.'; r'��tll^G`!lCOi�lf. .. .tl " %'-' ... _, .�s .._. _ , ,..._ . . � �j�111�.SEC�01 ZSl+��'�.ISZ ql��1Y!�Y�!!��[��t�b=Is�.N� �ne Yean'i�tiNammt as weB as dv�peealtlp ie t�e fon�s[a STO!'WORK ORDLR aad�8ne eE S19aYs a day aaai�nt de. 1 mdaslaad tbat a �9��hme�my be forwarded M tYe Omce�f lave�atloffi of tke DIA for wvenge vermeaYtls�. !do henby certijy xnder N6e pains awd pen�rhies ofPerjrrr�'tl6et tJie 1�rfor�n�low prov�ded aboae is trrre mrd com+ct �� .S �� /,.'�°--� Irate B � � .1.? !e?:4 � Pr;m name .�-��'u.v 9 S /�O �-- Phone# `� ��i- 1�S�t>- C o 2 L� o�'icial ese aaty de eet write�tl�is area to 6e cempleted by dty er 1�wa e�da1 city or tswn: permitl�ee°se S �BuidiaE Department ❑check if imme�ale respeme is reqait+ed �� ; contad ��D�at�am� c�� p�°°e#, �� ,,,�;�_ � �..� ,_ .. � ...__.--- _ � ! 1 1 � THE COMMONWEALTH OF MASSACHUSETTS ; TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT NUMBER: #09-079 FEE: �80.00 This is to Certify that Pari Dev ng Corn d/h/a Americ n Hoat Motel 69 Route 28, West Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a PubGc, Semi-Public Swiraming or Wading Poot At American Host Motel - INDOOR POOL 69 Route 28 West Yarmouth. MA � Ihis pernut is granted in confornuty with Article VI of the Sanitarv Code of I'he Commonwealth of Massachusetts,and expires December 31 2009 unless sooner suspended or revoked.� March 24.2009 BOARD OF HEALTH: .`�E�¢ft$� �,.1�, (�'vil�►ta,tt �. J��d� �tCE ��I►Ll�/t 2Ei�C. Sr�au�den III, C',�ex� Bruce urp y, ., Directar of Health THE COMMONWEALTH OF MASSACHUSETTS TQWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-033 FEE: �80.00 This is to Certify that Pari Devang Com_ d/b/a American Hoct Mot -1 , 69 Route 28 West Yarmouth MA ' HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF ', - GIVING OF VAPOR BATHS This License is issued in conforn�ity c��ith the authorit�granted to the Board of Health,bv Chapter 140,Sections 5 l,of the ' General Laws,and amendments thereto,and is subject to the provisions of the Laws ofthe Common«�ealth ofMassachusetts relating thereto, and upon such ternis and conditians, and to the rules and regulations in regard to the caming on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner revoked. March 24 2009 BOARD OF HEALTH: .`��E�F�IL S�l� ✓�..N. ��R.11ltltlYtt ' ��. �� ICC��tLatt I 2v- e. s�a�de� rrr, C�� B ce G.Mu h MP . CHO �� ` "� `� Director of Health ' � , � , � THE �OMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-048 FEE: �55.00 � This is to Certifv that Pari Devan CO � . a rp. d/b/a Amencan Host Motel 69 Route 28 West Yarmouth MA i 9 ! HAS BEEN GRANTED A LICENSE TO ' OPERATE MOTELS This License is issued in conformity with the authority granted to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C>32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relaring � thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner suspended or revoked. � _March 24_2009 BOARD OF HEALTH: ��t S�,� �,�/�/.�`(?��t ✓ ��.QA� 'VLC6 �a�lQ(�IGtitlX/t * 79 Units;79 Bedrooms 2�� e. Sti,tiU��¢tL .rr.l, ��X� 3`d Floor Unit–Storage Only. ce G.Murp ,MP , . ., CHO Director of Health TOWN OF YARMUUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT TTLTMBER: #09-164 FEE: 535.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General La�vs,a permit is hereby granted to: Pari Devan� Corp., 69 Route 28, West Yarmouth, MA Whose place of business is: America_n Hoct MotPi Type of business: Continental Breakfast To operate a food establishment in: Town of Yaxmouth ' Permit expires: Deeember 31. 2009 BOARD OF HEALTH: ,i�Ee�¢tt Sj�� ✓�,J�/. ('�czv�rrtcut , �. ��, �IiCe ('�aixrtuut 2�1� C. Snacuden III, e� . March 24.2009 � � �,.-,�, �;�` . ��._..� ruce . rp y, . ., ; -----. 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Arnei-icai� Host Motel 69 Main Street 4�%es� Yarmouth MA 02673 , lZ�: #7743A85-6-07—Workers Compensation :�� ,.� i?�t��'L. �:r��lased is th� above policy wi�h Travelers lndemnity Ca. for the renewal term of €�-1�07 to 8-1-08. The premium is $1450 and this has been paid. '['his policy cavers the following classifications and payroll: Ctass 9052 —�111 Motel Employees $ 56,Q91 You rvill shortly receive from Travelers a Voluntary Audit Report Form to complete on tt�e Workers Compensation Policy term: 8-1-06 to 8-1-07. Please take care of this as soon as vou receive sarne to avoid any passible cancellations. `To report a w�rk related injury under this poticy, please cail the followin� nii�nl�e1• and � th�� will assist you: �-sao-s32-7g39 P1�ase feel f'ree to cali me if you have any questions. 1�%ery truly Yours, �� :R��._.` . (�'�ry�!�`ar eno Senior�Ac` unt 1�•ian�a�er � E��closiir� 0.p�prn� �..- . l' ��,. s�uM�• ' �✓,�.. � �.. T:� i�2 l;c�n�r�t Str e�t,E�ev�r•i�•,M�i tt i 9 i.`i ;FL 978-�I2-??8� Fr'�X 97£� �':,? ;''<� i:��x'"v'";�i�sr��€:L�rt �`tec�c,St�ite 1£��.�'ec'��t�i:.M,� �?G?£� TFL �,'�ii-;?�9-54�� ; 78. ?:'�-�t��,` 1 TRAVELERS� WORKERS COMPENSATION AND EMPLOYERS LIABILITY PO�ICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POUCY NUMBER: (6KU6-7743A85-6-07) jRENEWA� OF (6KUB-7743A85-6-06) � IINSURER: THE TRAVELERS INDEMNITY COMPANY 1 NCCI CO CODE: �1347 INSURED: PRODUCER: MESHWA CORP DBA APP�EBY & WYMAN INS AGCY AMERICAN HOST MOTEL 858 WASHINGTON STREET 69 MAIN STREET SUITE 104 WEST YARMOUTH MA p2673 DEDHAM MA 02026 � (nsured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-01 -07 to 08-0� -08 �2:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy appfies to the Workers ' Compensation Law of the state(s) listed here: MA � �,,.__ a.� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in � � �— 0 item 3.A. The limits of our liability under Part Two are: o= Bodily Injury by Accident: � . 50000o Each Accident o Bodily Injury by Disease: � 500000 policy Limit 0 � Bodily Injury by Disease: � 500000 Each Employee — C. C?THER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: � COVERAGE REP�ACED BY ENDORSEMENT WC 20 03 06A o� � �� ' � �� T.,.._ D. This policy includes these endorsements and schedules: 4� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE ' O 4. The premium for this policy wilt be determined by our Manuals of Rules, Classifications, Rates and Rating ' 4 Plans. Ali required information is subject to verification and change by audit to be made ANtvuA��v. � � �,.:r... �< �';�y_ ° "``�� ------- DATE OF ISSUE: 08-08-07 DS ST ASSIGN: MA OFFICE: ORLANQO INDUS AFF 161 1 i . • TRAVELERS�, WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WG 00 QO Q1 ( Al i ; POLICY NUMBER: (6KUB-7743A85-6-47) I I INSURER: THE TRAVELERS INDEMNITY COMPANY 11347-MA INSURED'S NAME : MESHWA CORP DBA AMERICAN HOST MOTEL RATE BUREAU ID: 000048617 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL C�ASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM �, IOCATION 001 01 FEIN ENTITY CD 001 MESHWA CORP DBA AMERICAN HOST MOTEL 69 MAIN STREET WEST YARMOUTH, MA 02673 HO7EL : ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9052 56091 i .96 1099 s HOTEL : RESTAURANT EMPLOYEES 9058 IF ANY 1 .96 m�� o� �� o�� a � �� o�� -� �� o� _ �� ' --------------------------------------------------------------------------------- ^i— 1 .00% EMPL . LIAB. INCREASED LIMITS(9807) $ 11 o•�— ADD FOR INCREASED LIMITS MINIMUM (9848) 39 ! �� .950 MERIT RATING MODIFICATION (9885) 57 ' � TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1092 , EXPENSE CONSTANT(0900) 284 a"� 0.0300 FOREIGN TERRORISM / TRIA (9740) 17 �� 5.50% MA WC SPECIAL FUND AND TRUST FUND 57 TOTAL ESTIMATED PREMIUM 1450 DE POSI T AMOUNT DUE 1450 ��-�°"�' ,�`�'. ' ��'" _,_----- ------- � �. � . . ; � ' THE COMMONWEALTH OF MASSACHUSETTS � TOWI�i �F YAItMQUT� BOARD OF HEALTH PERMIT NL7MBER: #08-052 FEE: $50.00 This is to cenify that Meshwa Corp. (Pari Devan� Corp.)d161a American Host Motel 69 Route 28 West Yartnouth A�IA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by.Chapter 140,Secrions 32A,32B, 3ZC,32D and 3ZE as amended,and is subject to the pmvisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. March 17.2008 Bo�oF��,�: 3Ee�eti S�h, �..N.,Cf�ai�,cnrarc �'�ar�c�� .�.��i�E'�iR�e�c `11ice Cf�awrnr� * 79 Units;79 Bedrooms �ll�i'�4lilt 3.✓�.�t4tWt� � 3`�Floor Unit—Storage Only. ' QlZtt � �../V. �_ B e .M y, , .5.,CHO Director of Health TOWN OF YARMOUTH BO�I:RD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-168 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a permii is hereby granted ta _ Meshwa Corp. (Pari Devang Corp.), 69 Route 28, West Yarmouth, MA � Whose place af business is: American Host Motel Type of business: Continental Breakfast ' To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2008 BOARD OF HEALTH: .`�EE�R.IZ SI�tX�, `J�..N., �.'RavYrnatt , C'�a�c�es .�. 3�eP,�iR�e�e `�iee C'f�acvrnurri ' J`�v.�cext s.J��acurz, C'�exP� t�nn C��eeettBaum, J`�.,.tv. ' ��. ' March 17.2008 '°��'� ' '��"'' ruce M -" Direetor of Healtyh� � � � � , . , . �• • THE COMMONWEALTH OF MASSACHUSETTS j TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #08-081 FEE: $75.00 This is to Certify that 69 Route 28 West Yarmout MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public 5wimming or Wading Pool At American Host Motel - INDOOR POOL 69 Route 28 West Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31,2008 unless sooner suspended or revoked. March 17,2008 BOARD OF HEALTH: .�E¢eett Sf�Ac/�� ..lV., ��i'Alt'iuut C'f�arai�eo .� 9�eC�iR�erc `?�iee CF'�awcmacn J`2aG'�ct.!.J`3.xa�n, C� � Qn�rc C�ceere�iuun, J2.,.N. ce G. , H,R. ., Director of lth _ __ _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-052 FEE: $75.00 This is to Certify tl�at Meth�:Ia .orn (P ri v ngso�-n d/h/a Ameriean Iznst 1��o el 69 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF ' - GIVING OF VAPOR BATHS ' This License is issued in conformity with the authority granted to the BQard of Health,by Chapter 140,Secrions 51,ofthe General Laws,and amendments thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto, anc�upon such terms and condirions,and to the rules and regulations in regard to the carrying on of the ' occupation so licensed as adopted by the Board of Health,and expires December 31,2008 uuless sooner revoked. : March 17.2008 BOARD OF HEALTH: ;��¢�¢IZ$�f�� ,,,/�(.� (��n� � � C'��avcPe� .�E. 3'�e�P�i#e�c `1IiCe C'Par�rnuut ; 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- -- . __ _—_______— --- -- _ � �o s�{�p(�)uanas un��u+n paiano�io pauteip aq�snux Iood�tnuiuzrnns�uno�ui.�oop�no�ang :��0'I�ZOOd . �ia}�a.�aq��jia�nb pu� `�uivado o�.�oud `q�et pagi�za�a��e�s ��iq �uno�a��eid p.�pu��s pue uuo�o��e}o�`s�uouiopnasd.za3 pa�sa�aq�sniu.�a��n�aus :��S�.L 2I�.L�AA'IOOd ' ��u�ado o�.�oud s��ep(�)ang uor�adscn ac�ajnpau�s o��uaw�daQ u�TeaH au��uo� ��u�uado o�.�oud�uaui�daQ c��aH au��q pa�adsut aq�sriui uos�as a�io�pasot�uaaq an�eq u�n�n�sYoodiin�nn puB�uip�enn`�unucurn�s�:��u�d0'IOOd E ' � S l�Q�l 4 i ��uaisueaZ paiapisuo�aq�C�e.�aua�Iteus `papuaure se `Jb9 ZIL1i�0£8 3O Jb9 '� ''I'J'L1I�Pau�ap s�e `asi�x� �f�u�dnaap uioo��o uoi�aiio� au� o��aa�qns si ��q��i�usdn��p ��uaisu�.0 paiapisuo� aq �ou ileus �.tun �u�jannp ; io a�uapisa.��s��iun�san��o asn •pouad u�uoui(9)xTs�u�un��nn s�i�p(Q6}�auiu uu��a.�oui�ou�a a��a.�B � ue pue `s�ep (p�) �� u�� aioui �ou�o ��uedn��o snonut�uo� o� .�a�ai �i�.�aua� �qs �uedn��o �uaisu�as ' 'aiaun�asia a�uapisai�o a�id jed�auud B ure�ureui�fau�i�u�a��.�s�owaP a�aIQ�aQ Pu�an��snw s�uedn�a�uais�s ; 'asn ia�ou pu�Ia�ou�u�rnn pa��i�oss��Iu�uxo�sn�pue��rr�uiplo `�ouBdn��o uua��aqs pu�e�.zodwa�au�o�pa�nuii aq�s�uedn�o�uaisu�e.zZ`2sn ja�og io Ia�oy��o suoi��nu�au�.�o sasod.md io3 :,�K�r��p yx�S�� ssu�s��a�zs��u�ao�x�o�sz�.r.or� _ ___ � oN s� � �QI�'d��'I�.L�'I2Id02Idd�' � �I��Ei��S�'�'Id 's�iuuad ino��o a�u�enssi io�n�auai o�ioud pred aq�snuz sua�pue sa��q�nouue�,�o un�oZ Q�H��'.L,L�'QNH Q�PItJIS ZIA�'�.3�' 'dY1t0� S�2I�Ot1A ?IO � Q�i��.L.L�'��f1Sl�lI d0 '.L2I�� xo `Q�x�Ts ax�a��z�o��g.�snru.Lrn�� l�i`b'2IRS11II l�IOI.L�SI�I�dI�iO� S��on� �s�is Q��zi� �i �a�� uoi��esuadcuo� � s�.zaxiom�o a��gr�za� e an�u �ou saop �iueduio� �o uosiad ��i ssauisnq � a��.�ado o� �iuuad .�o asua�� iu��o � Tennauas.to a�uenss�piou o�pa.nnba.�nnou si u�nouz.��o uh+oZ au�`g uor�asqnS `�SZ u��S `ZSt �a�d��.�apun I�I OI.L�2L.L S I I�IIi�i Q� , , r . . . -- - . . . � The Commomvealth of Massachusetts Ilepart�erent of Industrial Accidents ' �Nrw� 6118 Washiagtow S'h�ee� 7`�"Floor Bostrmi,bfas� 02111 - --------- Work�a'Com tiou I�s�rasee Affi�vit:B�t ' �al Co'tnetors �• �.��4.[t�) t5. (�rP aadress• C3 �%l �'`^r�U,`� �� i �y W '`�0.�"'r'�Oc�.4� S18tt �"�'�- zi» Q 1��'� Dhme# SO'�` - �"�'S ' � �d g work site locati�(fnll addtessl- � I am a homoowner performing all waa�C myseif. Ptoject Type: ❑New Ca�oai QReanadel I am a sole and have no ane w in an Addition _ � I am an e.mPloYer Pto�idang wa�s'co�e��fac my employees working an this job. M�5'(� . G�.�` o�ca.. — ' , � ; ❑ I am a sole p�roprietor,g�al c�atractor,or itomeewser(cude awe)and have hired the c�at�tors listed below wlw have the following worlce,�s'compea�ation Polices: m�r�� ; ..�.�.�.N.,.�.�.... i �= � , �� Fairre�see�e a�rera�e as re��6ed u&r SeetlN 2SA�f MGL i�eu le�d b tYe�p�ti��f ct�ial peaalia da 1�e�p b fl,l�f�N a�dhr -- --�ue�s'�b�mtws we�as dA pmlNes irtre finrsia�3'O?WEfRI[ORDER aad s Que�iS1As N a dtY aPbet�e-I odn�uA tlnt• i c�py�f tl�Na�t my be farwaMed M Ne Odke of Im�ot tl�e DIA t�r a�age v�atlN. , 4 I ro ba�eby c�r�f'y� tJbe owd pe�raTt�s of perjr�ry tlY�t tl�e iuforiwado�provided abore la l�xe aed oomcx sign�un � t z-�O r 10 '� Print na� O 5�N A�rt T_Q� Phone# �O� �� ` �,� efficiai ase asly da�et wrke Y t�b ara te 6e esmpided bY dly er trwn s�eial cily or tswn: p�ee�e!� ��Depaltteet Qlix�BMrd ❑eke�if�Ie reap�me h reqtta+ed D��t ' �aet pets�o: p�we S; 0014Q �n�oa scpc zaw� . ��ics NOTICE N � NtJTICE TO � � a Ta :� EMPLOYEES �s EMPLOYEES 7 �'� � v O,�M Sv� : The Commonwealth of Massachusetts F DEPARTMENT OF INDUSTRIAL ACCIDENTS a 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia Ar requircd hy Massachusetts Gencral Law, Chapter 152, Sections 21, 22&3Q this will give you nc�tice that I (we} havc provided i'ar payment to our injured emplc�yces uneler thc above mentioned chaplcr hy insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY ONE TOWER SQUARE ' HARTFORD CT 06183 ADDRESS OF INSURANCE COMPANY (6KUB-7743A85-6-06) OS-01 -06 TO 08-01 -07 POLICY NUMBER EFFECTIVE DATES �= APPLEBY & WYMAN INS AGCY 252 ELLIOTT STREET �'� BEVERLY MA 01915 �= NAME OF INSURANCE AGENT ADDRESS PHONE# a,� ' — MESHWA CORP DBA 69 MAIN STREET a� = AMERICAN HOST MOTEL �� WEST YARMOUTH � MA 02673 �— EMPLOYER ADDRESS � �= = EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DA'I'E __ = MEDICAL TREATMENT � ; ^'� The above named insurer is required in cascs c�f personal injuries arising out of and in the course ��E- �= employmenl to t'urnish adequate and reasc�nable hospital and medical serviees in accordancc with the �= provisions of the Workers' Compensalion Act. A copy af thc First Report of Injury mus� be given to the �� injured employec. The employce may select his or her own physician. The reasonable cost ol lhc services �= provided by thc treating physician will be paid by the insurer, iF the treatment is necessary a�d reascmahly '� connected to the work related injury. In cascs reyuiring hospital attention, employces are hcrchv nc�tified that the insurer has arranged tor such attenlion at the NAME OF HOSPITAL ADDRESS ', 00048� W20P1G02 TO BE POSTED BY EMPLOYER � STPAIiL TRAVELERS One Tower Square, Hartfiord, Connecticut ost s3 HOTEL COMMON POLICY DECLARATIONS ISSUE DATE : 06/09/06 POLICY NUMBER: I-660-7626A363-IND-06 F INSURING COMPANY: THE TRAVELERS INDEMNITY COMPANY 1 . NAMED INSURED AND MAILING ADDRESS : ' MESHWA CORP DBA AMERICAN HOST MOTEL ' 69 MAIN ST ' WEST YARMOUTH, MA 02673 2 . POLICY PERIOD: From 06/28/06 to 06/28/07 12 :01 A.M. Standard Time at • your mailing address. 3 . LOCATIONS Premises Bldg. Loc. No. No. Occupancy Address SEE IL TO 03 4. COVERAGE PARTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COMMERCIAL PROPERTY COV PART DEC�ARATIONS CP TO 11 01 03 IND COMMERCIAL GENERAL LIABILITY COV PART DECLARATIONS CG TO 01 11 03 IND COMMERCIAL INLAND MARINE COV PART DECLARATIONS CM TO 01 07 86 IND 5 . NUMBERS OF FORMS AND ENDORSEMENTS FORMING A PART OF THIS POIICY: SEE IL T8 01 10 93 �= �,� 6. SUPPLEMENTAL POLICIES : Each of the fallowing is a separate policy �; containing its complete provisions: — Policy Policy No. Insuring Company �,=_ ��- � �� DIRECT BILL �.�.—� 7 . PREMI UM SUMMARY: — Provisional Premium $ 13,512 `° Due at Inception $ �= due at Each � NAME AND ADDRE55 OF AGENT OR BROKER: COUNTERSIGNED BY: � APPLEBY & WYMAN INS AGCY (KJ409) � � 858 WASHINGTON ST SUITE 104 o� DEDHAM, MA 02026 Authorized Representative ' o� = DATE: � IL TO 02 11 89 PAGE 1 OF 1 � OFFICE : HUDSON/BOSTON MA 002286 �iSTPAlIL OneTowerSquare, Hartford, Connecticut os�es ri TRAVELERS POUCY DECLARATIONS POLICY NO.: WSF-CUP-7730W058-IND-06 COMMERCIAL EXCESS LIABILITY ISSUE DATE:06-09-06 {UMBRELLA� INSURANCE POLICY INSURING COMPANY: ' THE TRAVELERS INDEMNITY COMPANY THIS POLICY DOES NOT 1. NAMED INSURED AND MAILING ADDRESS: COVER LIABILITY MESHWA CORP ARISING OUT OF DBA AMERICAN HOST MOTEL ASBESTOS MATERIAL 69 MAIN STREET SEE ENDORSEMENT WEST YARMOUTH MA 02673 UM 01 96 07 96 2. THE NAMED IIVSURED IS A: XQ CORPORATION Q SOLE PROPRIETOR [� PARTNERSHIP OR JOINT VENTURE Q OTHER 3. POLICY PERIOD: From 06-28-06 to 06-28-07 12;01 A.M. Standard Time at your mailing address. 4. PREMIUM: * $ 2,915 XQ Flat Charge Q Adjustable (See premium schedule) * DIRECT BILL 5. LIMITS OF INSURANCE: COVERAGES LIMITS OF LIABILITY AGGREGATE LIMITS OF LIABILITY 5,000,000 Products/Completed Operations Aggregate 5,000,000 Generai Aggregate COVERAGE A-Bodily Injury and 5,000,000 any one occurrence subject to the Products/ Property Damage Completed Operations and the General Liability Aggregate Limits = COVERAGE B -Personal and 5,000,000 the Genepal A nre rate L m taaf L ab�by ct to "—' Advertising Injury gg g �= Liability �� RETAINED LIMIT i 0,000 any one occurrence or offense .� � 6. SCHEDULE OF UNDERLYING INSURANCE: � POLICY LIMITS (000 omitted) COVERAGE COMPANY o� �=� SEE ENDORSEMENT CG DO 23 04 96 �� ,� o� o� � � 7. On the effective date shown in Item 3, the Commercial Excess Liability (Umbrella) Insu�ance Policy �_ numbered above includes this Declarations Page and the Policy Jacket (Form UM 00 76 which contains the � ^,+ Nuclear Energy Liability Exclusion) and any endorsements listed hereafter: . Q= SEE END. IL T8 01 01 01 a� ^= NAME AND ADDRESS OF AGENT OR BROKER: COUNTERSIGNED BY: �_ APPLEBY & WYMAN INS AGCY KJ409 �r s tative 858 WASHINGTON ST SUITE 104 DEDHAM MA 02026 __ _ * ___ ' CG TO 14 04 96 Page 1 of 1 OFFICE: HUDSON/BOSTON MA 000zz-r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-017 FEE: $SQ.00 'rhis is to ce�tify that Meshwa Corp. dIb/a American Host Motel 69 Route 28. West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in canformity with the suthoriiy granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachu,9etts relating thereto,and upon such teims and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Heaith,and e�ires December 31,2007 unless sooner suspended or revoked. January 31.2007 BOARD OF HEALTH: B��ti�t�. ,/��., ' o�+elesi�� ?lr��hrart R�t� 8� � � P��s� �4�� , R.N ruce G.Mwphy, H,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #07-060 FEE: 30.00 In accordance with regulations promulgat�under authority of Chapter 94,Section 305A and Chapter 111,S�tion 5 of the General Laws,a permit is hereby granted to: Meshwa Corp., 69 Route 28, West Yarmouth, MA Whose place of business is: American Host Motel Tyge of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires_ December 31. 2007 BOARD oF HEALTH: B `n. , /1�_`?S., ' _ �i��"�s�, ��v.'�`�, v�e�.�.� R�t�.e�, e� !��a�5�ott �4� , R . � January 31.2�7 . Director of H 1 , , •, , �. , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF�ARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #07-030 FEE: $75.Q0 This is to Certify that Meshwa Co�-n_ dlbla Ameri n Ho�_Mo el 69 Route 28. West Yannouth MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel -INDOOR POOL 69 Rouie 28 West Yarmouth, MA This pern►it is granted in confrnmity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires D�ber 31 2007 unless sooner suspended or revoked. January 31.2007 BOAItD OF HEALTH: Q ui�. o�oit,l��., . ��, k�rv, v�e�-� R�t� e�, � A��s� �4� , R.N. .. B ,�hy,� ., Director of Health __ _ . ._ _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #07-012 FEE: $75.00 This is to Ce�tify that Meshwa Corn_ d/b/a American Host Motel 69 Route 28. West Yarmoutt�MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF -GNING OF VAPOR BATHS This License is issued in conformity with the suthority granted to the Boazd of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subjecf to the provisions of the Laws of the Commonwealth of Massac�usetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�cpires December 31,2007 unless sooner revoked. January 31,2007 BOARD OF HEALTH: B �1. /��., ' d�e�y�S��Sa�i,�rc��iai�xc.�ss � R�t� B� G'� !��i�ott �4��j , R.N. G. 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I�INIl.L�2i O.L�i.LI'IIBISI�tOdS�2I�IllO�i SI ZI �i€-�aquza�aQ o� j �.renuer uzo.r��i�nuue uru s�iuuad=��I.LOI�I __ � ON S� ' ��d.�I�'I�.L�'I�d02Idd�' � �I��I��5��'Id 's�ncuad mo��o a�u�nssi io �nnaua.z o�ioud pred aq�snui sua�pue sa��q�nouu��o unnos i . ! Q�I��'.L.L� QN�Q�t�IJIS .LIA��33H 'dY1I0� S�2I�I2IOtY1 XO Q��ss�a��nsru 30 �ixa� xo `a�u�Ts au�Q�s�ainto� �g isn��n�� I�I�'2il1Sl�II l�iOIZ�Sl�i�d7r1i0� S�2I�?I?I�AA �.LVZS Q�H��'.L.L� �H,L 'a�u�msuI uoi��suaduco� s�.�ax.�o��o a��e�gi�a� e an�u �ou saop �ueduzo� .zo uosiad B�i ssauisnq � a��iado o� �iuuad .zo asua�ii �iue�o len�auai io a�uEnssi pjou o�pannbai n�ou si q�nowre��o unnos au� `9 uoi�aasqnS `�SZ�QT�aS `ZS i ia�d�eu�iapun I�iOI.L�'2IZSII�II�Q� - r � i J I ; �� APP �EBY�.�'WYMAN ' INSURANCE AGENCY, INC. - ;ir��t_ rst;3 BEVERLY • DEDHAM • WESTFORD �'� , i , July 27, 2005 Mr. Kevin Patel � American Host Motel � 69 Main Street - � ''' i West Yarmouth,MA 02673 ; Re: #7743A85-6-OS—Workers Compensation �. , i Dear Kevin: ` Enclosed is the above policy with St. Paul Travelers Insurance Co. for the renewal term of 8-1-OS to 8-1-06. The premium is $1035 and this has been paid. We are advised by St. Paul Travelers that they returned to you $4 as their quote was for $1039 and it came in at$1035. This policy is based on the following Classification and PayrolL• ' Class 9052—Hotel Employees $34,467 , You will shortly receive from St. Paul Travelers on the expired Workers Compensation � ; term: 8-1-04 to 8-1-05, a Voluntary Form to complete for the Audit. Please take care of this as soon as possible and return to them as requested. i � , To file a work related claim,please call the following number and they will assist you: ; 1-800-832-7839 , � and please,`always call me if you have any questions. ery truly yours, ' Mary ar no ' Senior cc nt Manager Enclosure ,, $58WASHINGTON STREET, SUiTE 104, DEDHAM, MA 02026 TEL 781-329-5420 FAX 781-329-$861 www.applebywyman.com . '• � .Gi STPALlL �i' TRAVELERS WOFiKERS COMPENSATION ; AND EMPLOYERS LIABILITY POLICY '� I TYPE AR INFORMATION PAGE WC 00 00 01 ( A) i i � POUCY NUMBEH: (6KUB-7743A85-6-05) � � i RENEWAL OF (6KUB-7743A85-6-04) I I 4 INSURER: THE TRAVELERS INDEMNITY COMPANY ' NCCI CO CODE: 11347 j � 1. ; , INSURED: PRODUCER: j ' MESHWA CORP DSA I AMERICAN HOST MOTEL ' 69 MAIN STREET WEST YARMOUTH MA 02673 i � i Insured is A CORPORATION � ; Other work places and identification numbers are shown in the schedule(s) attached. I I � 2. The policy period is from o8-Ot -05 to 08-0� -06 �2:�1 A.M. at the insured's mailing address. ; I 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers � Compensation Law of the state(s) listed here: � ' I i MA � � , .� i m �� i �'� B. EMPLOYERS LIABiLITY INSURANCE: Part Two of the policy appiies to work in each state listed in °'— item 3.A. The limits of our liability under Part Two are: o= i � Bodily Injury by Accident: � 50000o Each Accident j , o� Bodily Injury by Disease: � 500000 policy Limit � Bodily Injury by Disease: $ 500000 Each Empioyee ; o= i � �� C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: i � SEE ENDORSEMENT WC 20 03 06 I , i o� I �� — � D. This policy includes these endorsements and schedules: � ' �� ; o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� i — 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating � LL� Pians. Ail required information is subject to verification and change by audit to be made ANNUA��Y. i — � w— j i ,I - � I � DATE OF ISSUE: 07-11 -05 WC ST ASSIGN: MA I OFFICE: ORLANDO INDUS AFF 161 � PRODUCER: APPLEBY & WYMAN INS AGCY 72TLW � 000958 I I I i . ! � STPALIL WORKERS COMPENSATION � TRAVELERS AND ' ' EMPLOYERS LIABILITY POLICY ; , , , � EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) �I POUCY NUMBER: (6Ku6-7743A85-6-05) I I � ' INSURER: THE TRAVELERS INOEMNITY COMPANY 11347-MA � INSURED'S NAME : MESHWA CORP DBA I ' AMERICAN HOST MOTEL j i RATE BUREAU ID: 000048617 � I PREMIUM BASIS j ESTIMATED RATES ESTIMATED � TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM i I i i LOCATION 001 01 i I FEIN ENTITY CD 001 i MESHWA CORP DBA AMERICAN HOST MOTEL i 69 MAIN STREET � i WEST YARMOUTH, MA 02673 i HOTEL : ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS 9052 34467 2 •08 71� i " �� HOTEL : RESTAURQNT EMPLOYEES 9058 IF ANY 2 .08 � j m�� I m�� m-- � o� � i � O� I O� � O� i �� i N�� I O� �� ^_— �� _____________________.___________.._____�________�__�______'___'_'_______-______-_____ i .. �� = 1 .00% EMPL . LIAB. INCREASED LIMITS(9807) � � ! ADD F O R I N C R EASED LIMITS MINIMUM (9848) 43 � � .950 MERIT RATING MODIFICATION (9885) 38 �� TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 729 I '�'� EXPENSE CONSTANT(0900) 264 � ^ 0.0300 TERRORISM RISK INS ACT 2002 (9740) 10 i � 4.40% MA WC SPECIAL FUND AND TRUST FUND 32 ; "� TOTAL ESTIMATED PREMIUM 1035 � DEPOSIT AMOUNT DUE 1035 ; I � I � DATE OF ISSUE: 07-11 -05 WC ST ASSIGN: MA SCHEDULE N0: 7 OF LAST j I� 000959 ' srPau� TRAVELERS LENDER'S CERTIFICATE OF �00 CROWN COLONY DR Qu�Ncv MA 02169 INSURANCE–FORM B (ssue Date: 05-16-05 �1. CERTIFICATE HOLDER: Policy Number: I-660-7626A363-TIA-05 COMPASS BANK f 715 WEST MAIN STREET � HYANNIS MA 02601 j � I 2. NAMED INSURED: MESHWA CORP DBA AMERICAN HOST MOTEL 69 MAIN ST WEST YARMOUTH �qq 02673 i 3. CERTIFICATION - We certify that we have issued the policy to the Named Insured for the policy period as identified in this Certificate. Notwithstanding any requirements, terms or conditions of any contract or other document with �espect to which this Certificate may be iss�aed, the insurance is that which we customarily ' provide for the coverage indicated in item 6. below. This Certificate is issued as a matter of information only ', and does not amend, extend or alter the coverage afforded by the policy. i 4. POLICY PERIOD: From 06-28-05 to 06-28-06 �� 5. INSURING COMPANY: THE TRAVElERS INDEMNITY COMPANY OF AMERICA ; ._.. 6. INSURANCE �— Buildings or Buiidings Under Construction–The policy names the Certfficate Holder as a Mortgagee, �,_ according to the Mortgage Holder Conditions on page 2, for the buiidings described below: � � �— � �� — Loc. Bldg. Limit of Coins , �— No. No. Address Insurance �� SEE IL T8 97 03 96 $ a� ��- � o� � ^�' �� 0 0 Coverage-Covered Causes of Loss: Basic Form Broad Form Speciai Form �� Deluxe Property Form a 7. SPECIAL PROVISIONS (if any) ;�� Pa e1 of2 I L TO 11 03 96 g 002756 : PAu� �� : TRAVELERS One Tower Square, Hartford, Connecticut oste3 � . �; LENDER'S CERTIFICATE OF INSURANCE—FORM B-SCHEDULE ` ISSUE DATE: 05-�6-05 POLICY NUMBER: I-660-7626A363-TIA-05 � :RTIFICATE HOLDER: coMPass BANK ' Loc. Bldg. Limit of Coins Cause of � No. No. Address insurance % Loss ! � 1 1 69 MAIN STREET $ 1 ,400,000 100 SPECIAL WEST YARMOUTH MA 02673 , 2 2 69 MAIN ST 1 ,200,000 100 SPECIAL WEST YARMOUTH MA 02673 , T8 97 03 96 . . � a ,,�� i y � �OTICE � I\T�►TIC� TO � ' TQ ; EMPL�YEES El'V��'Lf�Y:EES The Com�on�v�ve��th o� �►�I�ssachusetts I�EPAR15I�lEl�TT �3F Il'�DUSTI�I�►I.� ACCIDENTS 600 'VV�shington Str�et, �iostc�n, lViass�chusetts Q2111 ' 617-727-4900 As required by Mas�aehusett5 G�:nerat Law, C'hapter 152, Sectians ?�, 2? cYc 30, this wi11 give you ' notice tltat I{cr�e) ilave prcyvided for payyuea�t to �ur a�ijured empt�yees unc�cr the aboe�e rnenti�p�ed chapter hy iiasuring with: ` �iSSdGIATED EMPLOYERS EiVSLRANC�CC3MPANY �_..^___._. ��._...__ NAME()F Iri'SI;RANC�COMPAN!' - — - _�_.___ _� '!1 NORTH AVENUETMP.O. B�X 4070, BURLING`1'OIv, MA 01803-0970 ADDRESS OF IN5[►RAIVC�:COMP�IN�'J_.�W �..�.�,.....�_....__ WCC 5002830U12005 ^_^ t76/0712005 - 06/07!2006 ; YOt.1C"Y NUMS�R EFFECTIV�:DAT�:S � MiNer McCartin 222 VY�st Main�treet dba Dowli�g & O'IVeil Ins Aycy Hyannis, M,�C26(}'1 � ____� (508}775-1620 � lVA1VIE Clh i�SUI2AN("k��4GENT 4i�1DR�;SS PFlO1VE Rmerseana Inn inc _ _ dba Americana Holid�Motel 98 Ftaute 2B _ ___ �West Yarmouth, MA 02873 _ i F.MPLOYER � .A1?DIZESS 04lU4�2�05 �;:�IPL01'ER'S i1�'OKKk�RS COFvT�'E1tiSA'P10N QFFtC�:[t(IF�1tiY) ��'T` �� DATE i�s�I�AL 1�1��r1,M�lr� The abo�•e named Insaree•is re�quired ii►cases of personal injuries arising u�t of und in the e�urse of EmploynienY to furnish aclequafe ancf reasos►able hospit�el and�nedical s�rvises in aecordance v��ith the provisioses of the Worl�ers Compensacion Act. A c��py uf the F'irst T2epart oflnjury must be gi�•en to the injured employec. Th�empEoyee may select his ar her c�wn phy�sieia�. 'I'he rer�so�reble cost ot thr servires wrovi�fed by tiie treati��g physscian wil!be paid!ry tiie insurer,it the treat�nent is necessary a►i�i t•eason�bl��conneeted to the�wot•k retate�!inJtiry. in c,�ses requiring huspiiai uttentian,employees are hereby hatifieri that the insurer has ar�•unged lu►•sucb attentdun at the NEA#�EST A,ND i3cST MEDIGAL FACIUTY ' NA;t�fE(3F NCiSPi'TAL ADllT2FSS � �l! 13.� a V� 1 :L:1L .� 1 i:�t11�LLJ 1 11� THE COMMONWEALTH QF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-02'7 FEE: $50.00 This is to Certify that Meshwa Corp. d/bla American Host Motel 69 Route 28 West Ya.rmouth MA '' i � � - - - HAS BEEN GRANTED A LICENSE T� - i OPERATE MOTELS � This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,�ections 32A,32B, ' 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopbeci by the Board of Health,and e�ires December 31,2006 unless sooner suspended or revoked. January 31,20(?6 BOEIRD OF HEALTH: B �. , /��., ' � d�E��i, �sce L�rx� � � R�t� Bn�urs�, C'!�k ; !��1�� i , �4�� , � ru G.Murphy H,RS.,CHO Director of Heal i i - _. _ __ _ _ _ _ ; � f TOWN OF YARMOUTH ; BOARD OF HEALTH , � PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT N�JMBER: #06-118 FEE: $3Q.00 In accordance with regu1ations promulgatai under authority of Chapter 94,Section 305A and Chapter 111,S�tion 5 of the General Laws,a peimit is hereby granted ta _ � Meshwa Corp., 69 Route 28, West Yarmouth, MA Whase place of business is: American Host Motel Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Pemut e�ires: December 31, 2006 BOARD oF HEALTH: B .`73. �a�.ors,/l�l._`15., ' , e4��►�lg .IV., 'l/ice G'�i�i�a�rs � Rc�ii,t� B�iau�, G'!�Z n��a�� ; ,�� , . January 31,2006 ` ruce _ y H�R a H Director of H th -- THE CC)M1120NW��LT-H OF MASSACHUSETTS -- - TOWN QF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #Ob-057 FEE: $75.00 This is to Certiffy that Meshwa Co� d/b/a Americ n o t Motel 69 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel -IND40R POOL _--- 69 Route 28 West�armouth,MA This pennit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31_2006 unless sooner suspended ar revoked. Jan 3 L 2006 BOARD OF HEALTH: �R tusa�. //I��5., ' � ati��'k�k, �sc�G�du�chau-�sc Rode�it�Ly'3ouKc, C� � /��isc��c�S� �q�(�' . R.N ruce .Murphy H,R ., . Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH . ' PERMIT NUMBER: #06-024 FEE: $75.00 This is to Cerkfy that___ Meshwa Corn_ d/b!a America�n Host Motel � 69 Route 28 West Yarmouth MA � HAS BEEN GRANTED A LICENSE TO �ENGAGE IN THE BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS � This License is issued in conformiiy with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the � General Laws,and amendments�hereto,and is subject to the provisions of the Laws of the Cominonwealth ofMassaachu�tts � relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the cartying on of the � occupation so licensed as adopted by the Board of Health,and expires December 31,2006 unless sooner revoked. I January 31.2006 BOARD OF HEALTH: B �. aRc�ut 1��., ' a��lr�di,�.1Y., ?�/sce G��r� Rc�iit� B�xur�, �'1� n�� ! � , R.�ir G. urphy, ,RS.,CgIO Director of Health � � 1"�`r�r,�' o�''Y`��,� �� .. . , , o T � �TN � F YARMOUTH �(/� � `'3 1146 ROUTE 28 SOUTH YARMOU'I'H MASSACHUSETTS 026644451 " MATTACHEES � Zelephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 � . � ��oqaoaaTto`6j9� . B O A R D O F H E A L T H �j � n � I � _`_._. .�. , To: �armouth Board of Health Permit Holders . From: David D. F�aherty Jr., R S. � �r �{�� Q Q 5 � Health Inspector � HEAL�� . `� ��PT, Town of Yarmouth Re: Federal Tax ID Number � � Date: fi�Iarch 22,20�5 � The Massachusetts Department of Revenue is now requiring that we furnish 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 establishmeut's Federal Em�loyer lde�tificatic�n Number(FEIN)otherwise known as your"Tax ID Number". This is purely for administrative purposes only. So� businesses use the owner's Social Security Number (SSl� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public �. record� , Please fill out the fields below and return this letter to Yarmouth Health T�partment 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any qnestions regarding this matter, please cio not l:esi�ate t� cal�. '�ae ofl�ice hours ar�Monc�!�t� Fri�.�y, 8:3Q_a.m.ta4�Q_�T1�--_ _,_ __-- telephone number is(508) 398-2231,e�.241. 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Ptoject Type: ❑New Ca��ode1 I am a sole and lmve no one w in an ca Addition ' � I am an emP�Y�'Pmviding wadceas'co�atian for my employees wo�cing ar�this job. _ .__ — -:. _ _ �_w � � M� �- , . a�: � �2 1V�A-t'' s ? ;�r. . f,,, .�p►�rvt ec�t�l ,F.r�. c7�.-5�� ui�e�e#�; �t�', � �� ' �'33 zr ... `�e�7��st,e�� -v�de_�; �-e • ,v �<v(� • � � �f 3 ��S_ � _t�� ❑ I am a sale proprietor,ge,eral eostracter,or komeo�(ciral�ow�)and have hi�+ad the contr�ctors lisied below who have the following worke,rs'compensation Policesr ��` , , „ -, !!�'lQ�s" �X= ��e� �t �� ; i , �: u�a�c�: , � FaY�e b sccu+e�rw�e as reqieed oder SeeW�2SA�f M6L 152 cn Ind b/Ye i�p�lfu�f crvdui�s�llin�f a gu�p�=1,SM.N aidl� ~ e'e yan'6epH�eant as wd n cM pwk��t6e�•ta STO!'WORK ORDER aed a be a[t1i1LN a day ataMt�e. 1 adnslaid tl�a apy dHit stal�e�em�y be ferwardcd te He OIDce�lav�o[tlrc DIA tore�va�age vertliatlw. I�o benby cerdjy xwder N(�e es and ojpeyrwy tllret Me�jonri�to�pr+ovided oboae ta trxe a�d onmct s�s� � nan �r 'i�-b i�� Print name k,�irU'.� P/t"llr`L_ P}wne# -�� "� _��q!' . �{ offieial ax o$ly ao aet write b t�is ara ta be o�pleted b9 dty ar Mwn�1 c�y or te�vn: per�fl�c�ee� I�l�i�D�t ❑ekecic if�ale rdpene b req�ed �Sd�'s O�ee ❑�� ce�act Pvaas: Phe�e#, � (�a smc 2om) � . i y 7 ' ^ �:3V�eC3 � `�.....-�� WORKERS COMPENSATION �ND EMPLOYERS L.IABiLIT1f POLICY TYPE AR IPiFC?RMATIOIu PACaE WC 00 i)0 01 ( A) POLICY NUMBER: (6KUB-7743A85-6-Oq�) RENEWAL OF (6KUB-7743A85-E�-03) iN�iURER: THE TRAVELERS IMDEMNITY COMPANY NCCI CO CODE: 11�47 ' 1. 1N�.�'URED: PRODUCER: f�SHWA CORP DBA APPLEBY & WYMAN INS AGCY ��IMERTCAN t�ST MOTEL 858 WASHIIVGTDN ST STE 104 G9 MAIN STREET DEDHAM MA 02026 ��EST YARMOUTH MA 02673 Insured Is A CORPORATION Other work piaces and ider�tification nambers are shown in the scheduie(s} attached. 2. The policy period is fram 08-01-04 to 48-41-05 12:01 A.M. at the insured's mailing address. 3. A. WORKERS CfJMPENSATION INSURAidCE: Part One af the palicy applies to the Workers Compensation Law of the sta#e(s) listed here: �r MA .� o,.:�� B. EMPLOYERS LIABILiTY INSURAMCE: Part Twa af the palicy applies to waric in each siate I(sted in Oa'�s —: item 3.A. The limits of our liabtlity under Part Two are: ��, Q� Bodily InJury by Acciderrt: � 500000 Each Accident o,� Bodily Injury by Disease: � 50000o pdicy Limlt o�; Bodily Injury by Disease: � 50000o Each Emplayee �;�;; C. OTHER STATES INSURANCE: Part Three of the palicy applies to the states, if any, listed her�: � �� ..;�,, SEE ENDORSEMENT WC 20 03 06 a�:s� �`E ^d�s to�� :� ;� �� D. This policy includes these endorsements and schedules. �� oi� SEE LISTING OF ENDORSEN�NTS - EX'T'ENSION OF INFO PA�E o�� ;�: �;,� �. The premium for this pdicy will be determined by our Manuals of Rules, Classlfications, Rates and Rating �:= Plans. All required information is subject to veriflcation and change by audit to be made ANNup��.Y. :� .�.:� ��A'TE OF ISSUE: a�-3o-04 Rs sr asszc�v: �wa OFFICE: ORLAPDO INDUS AFF 161 PRODUCER: APPLEBY & WYiNAIV INS AGGY 72TLW �054f t �, ' `%� WOHKERS (:OMP�NSATlON ANO EMPLOYERS LIABILI7Y POLICY EXTENSION OF INFO PAGE-SCHEDtJLE WC OQ 40 di ( A) POLICY NUMBER: (6KU6-7743AS�i-6-04) INSURER: THE TRAVELERS INDENpdITY CONff'AfVY 11347-MA AMERICAN HOST MQTEL RATE BUREAU ID: OOOQ48G17 PREMIUM BASIS ESTIMQTED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REN�JNERATIQN REMtJlVERAT�ON PREMIUM ' LOCdTIQN 001 01 FEIN ENTITY CD 001 PAESHWA CORP DBA AMERICAN HOST MOTEL 69 MAIN STREET ' WEST YARP�OUTH, MA 02673 F�fEL : ALL OTHER EMPLOYEES & SA'_ESPERSONS, DRIVERS 9052 20881 2.08 434 Ra�. � HO"TEL : RESTAURANT EMPLOYEES 9Q58 IF ANY 2.08 �� •-� .�..: .� �� .��. - o� oE� � ■�. w__, �a�. �� ti�a-� �r� 'Csfrr� � �� m�� "'.'��'_�'�'��..�"_��_""'�.��'_��_�_�'��.��^'�'��_��.��_�_"'��'_....'�__^�� I. �� =� 1 .00% ENIPL . LIAB. INCREASED LIMIi'S(9807) $ 4 °=� ADD FOR IPICREASED LIMITS MINIMUM (9848) 46 �== .950 MERIT RATIiVG MODIFICATION (9885) 24 -==' LOSS CONSTANT (0032) 2a �= TO'fAL ESTIMATED AI�IUAL STAI�DARD PREMIUM 484 �=- EXPENSE CONSTANT(Q900) 264 '�� TERRORISM RISK IIdS AGT 2002 (9740} 6 4.90% MA WC SPECIAL FUND AND 1RUST FUND 24 TOTAL ESTTMATED PREMIUM 774 DEPQSIT AMOUNT DtJE 77q DATIc OF ISSUE: 07-30-04 RS ST ASSIGN: MA SCHEDULE N0: 1 p�'L.AST Q(5481 . , 1�UTICE � � � NOTIC�', �ro � � ' TO :� 0 _ EMPLOYEES �� EMPLOYE�F;� �� ,�M S�� T:he �ommonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sect'rons 21,22&30, thi�wiil give you natic�;tl:at T (we) have providect For payment to our in�jured employees under the above mentioned chapter by tnsuring vv�th: THE TRAVELERS IIdSURANCE COMPANIES NAME OF INSURANCE COMPANY QNE 70WER SQUARE HAR7FORD, CT 06183 ADDRESS OF INSURANCE COMPANY � {6KU6-7743A85-6-04) 08-01-04 TO 08-0':—p5 P4LICY 1VUIv�BER EFFECTIVE DATE�r �_ . .��_ ��z APPLEBY & WYMAN INS AGCY 858 WASHINGTON 5T STE 104 �c= �� DE DHAM MA 02026 �= NAME t)F INSURANCE AGENT qDDRESS PHON�# � ,�� MESHWA :.ORP DBA 69 MAIN STREET � ANERICAt'V HOST MOTEL • ��' WEST YARMOUTH °,� MA 02673 �� EMPLO'YBR ADDRESS � = a� -� EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DAT� `°�� MEDICAL TREATMENT � �� ^c The abave named insurer is required in cases of persona! injuries arising out of and in the cou:-se of � employment to fumish adequate and reasonable hospital and medical services in accordance with the �== provisions of the Workers' Compensation Act. A ccspy of the First Report of Injury must be given to the �� injured emplayee. The emplayee may select his or her own physician. The reasonable cost of the servi�;es �-, provided by th� treating physician wiil be paid by the insurer, if the treatment is necessary and reasc�na�ly •� connecte�� to the work related injury. In cases requiring hospital attention, employees are hereby notif:ed that the u�surer has arranged for such attention at the NAME OF HOSPITAL ADDRE5S �i TU BE P4STED BY EMPLOYER a � o�.aez W20P1G02 • t I 1 7 T'HE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-008 FEE: $SO.OQ This is to Cerafy that Meshwa Corp. dJb/a American Host Motel 69 Route 28 West Yarmouth.�MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,'S�tions 32�,32B, 32C,32D and 32E as ame�ded,and is subject to the proyisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditians,and to the rules and regulations in regard to said Motels so licensed as adoptecl ! by the Board of Health,and e�ires December 31,2Q05 unless sooner suspended or revoked i �t�ag Zooa. Bo�oF��.Tx: Be.r��S. ��it9.�. • p�� v�e�� s�� 4.t.��j , R.N. ruce G.Murphy S.,CHO Director of Heal i i __ _ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT i PERMIT NUMBER: #OS-020 FEE: $30.00 In accordance with regulations promulgated under suthority of Chapter 94,Sectian 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Meshwa Corp., 69 Route 28, West Yarmouth,MA Whose place of business is: American Host Motel ' Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Pemut expires: December 31, 2005 BOARD oF HEALTH: Be�rfa��9. C'r,�,�+�,,/�l.$. ' p��,�, v�� R�t�e� e� ��' R�R.IV. , �t�ag.Zooa Director of Heal � � �^ R 1 ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT NUNiBER: #OS-010 FEE: $75.00 Tlus is to Certify that__ Meshwa .om d/I/a meri an Hnct l��o e] — 69 Route 28_ West Yarmouth,MA ; IS HEREBY GRANTED A PERNIIT To Operate a Public,Semi-Public Swimming or Wading Pool � American Host Motel -IlVDOOR POOL 69 Route 2$ _ West Yarmauth, MA � This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts;and I expires December 31_2005 unless sooner suspended ar revoked. D��2g.Zoo4 Boax�oF�.Tx: 8�;��. (fond,o,�,�1+1.`n. • A��l��s�, v,�G�v�� Ro�t 4 B� Gl� �Sl� R.N. ��i , R.N. ruce .Murp , ., H Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NCTMBER: #OS-004 FEE: $75_00 This is to Certify that_ Meshwa orn d/I/a American Hns Mo 1 b9 Route 28 West Yarmouth MA HAS BEEN GRANT�D A LICENSE TO ENGAGE IN TI�BUSINESS �R PRA�TICE OF -GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subj�t to the provisions of the Laws of the Commonwealdi ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�ires December 31,2005 unless sooner revoked. December 28.2004 BOARD OF HEALTH: B �. (R''w,�,/j�f,�., . p i�� v�e�� R�,t�,.B� � ��l�, R�� : , ruce G. . 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(fo+�Rrrg, /�l.`?�. ' /��#�ic�b d�a�e�Cv#� ?lscas ��ce-.� �elQa�a�r, R.%Ye� �� R.�ir. Aprii 8.2004 ruce . u�'P Y, � •, H Birector of Health THE COMMONWEALTH OF MASSACHUSET'I'S TOWN 4F YARMOUTH BOARD�F BEALTH PERA�IIT NUMBER: #44-OS8 FEE: $50.0(} This is to certify chat Meshwa Corp. d/b/a American Host Motel b9 Route 28. West Yarmouth�MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in eonformity with the authority granted to the Board of Heatth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as aznended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels sa licensed as adopted by the Board of Health,and expu�es I7ecember 31,2004 unless sooner suspended or revoked. Apri18,20Q4 BOARD OF HEALT�I: Be�a�. �rc, /��. ' ��s� v�e��.� �� R.�. ,� ruce G. Murphy, , S.,CHO Director of Health � � , i �co�arTwEa�,�a oF�rassACHusErrs TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #Q4-039 FEE: $75_{l0 Tlus is to Certify thac _ 1yleshwa Com_ d/b/a America.n Hc,st Motet 69 Route 28_ West Yarmouth.. MA HAS BEEN GR,ANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PI�ACTICE OF -GIVIl�IG QF�APOR BATHS This Licet�.se is issued in conformity wifih the suthority granted to the Board of Hea1th,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the pmvisions of the Laws of the Co�ma2onwealth o�fMassachus�.ts relatutg thereto,and upon sucli ter�.s and canditio�,aad to the rutes and regulations m regard to the carrying cxt of the occupation so licensed as adopted by the Bosrd of Health,and e�sires December 31,2004 unless sooner revoked. �s.Zoaa Bo,�o o��,�: B �5. l'�� !.$., . ��t c�.i�lc$� '�/ios�lru�s�as� /�A�e�� B�lo�er�s, � f4� �` R R./V. Bruce G.Murphy,MP , .,CHO Dir�of Health THE COMMONfWL+'ALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-092 FEE: $75.� This is to Ce�tify that IVieshwa Co�-n_ d/b/a Afnecrican Host Motel � 69 Route 28.West Yarmouth MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or W�ding Pool At American Host Motel -Il�tDOOR POOL 69 Route 28 West Yarmouth, MA This pemut is granted in conformity with Article VI of the Sanitary Code of The Couunonwealth of Massachusetts,and expires December 31_2IX}4 ualess sooner suspended ar revokec3. Ap�i18.2004 BOAR�OF�3EALTH: ��,a�it4$. �jn'r�a� 1��. ' P�� v�e�� aad�t�. a�, er� �� S!� R.N. �.r.�� R.N. B � . � , x Director of Health �''-` t..��r,.m,a ��r�ccir, 1�4c>>-}-- Nloi�j ' TOWN OF YARMOUTH BOA��Q�H�ALTH � � '�' �� P �� R � APPLICATION FOR LICENS ;�IT-2000 D�C 1 4 1999 �; ��35 ��5� � , , * Please complete form and attach all necessary documents by December 31, 1999. Failure Hc��' the return of your application packet. ------------F E----------------------------- -----vtCrt�----- -ST-- -G`1�------------------------ --#-;7-�,��-------• L AT Z �:w� L Q� T N kl.�r�CT7.v� n.0 . �A iAGER'S 1'�TAME- .i�,� l7A�C�"" TEL # '7��7odd �ING ADDRESS: .�A-Lfvl,� �'OOT CERTIFiCATION..S:tl---------------------------------------------------- -;--________---_--_---------------------------_____. The pool supervisor 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.�� -6"� 2. �O�/��" ��-d�r�� Pool operators must list a minimum of two emp oyee�c�ntly certifie�basi�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 wiR not use past years' records. You must provide new copies and maintain a file at your ptace of business. 1. f��M/,�l//�'< <�L A-,'T� Z. �b�J�/��C��/�� 3. — 4, E�. 'v'�Q HEIMLTCi-�CERTIFICATjONS• 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-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. 2. 3. 4, RF4TAIJ1t�NT SEATING: _'TOT�AI,# _ _ _ .-NOI�t-�A4��TC �EA'FF.�'-4TAL#__ _— -- ----------- -------------------------------------------------__---------�-------------------------------------___..___------------------ QFFICE USE f„�NLY 1 ODGING: LICENSE REQiIIlZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $50 CABIN $50 _INN $50 CANIl' $50 LODGE $50 �TRAILER PARK $50 ; to�Y 2k-3o i MOTEL $50 y?.�-ZO �- SWIl�IlVIING POOL $SOea. C�)y��3 I �VVHIRLPOOL $25ea. �_ FOOD SERVICE• LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 10-100 SEATS $75 I CONTINENTAL $30 `/2k-71 _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 � WHOLESA,LE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 '; _>25,000 sq.ft. $200 1 : NAME CHANGE• $10 � ' ,' AMOUNT DUE _ $_�U`.7�' "•""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""R• , � � � . ADMINISTRATION ` �TNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS I`�OW REQUIRED '�O�iOLD,ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A �ERSON' OR COMPANY DOES NQT 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF Y4UR PERMITS. PLEASE CHECK ROPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNUALLY FR4M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S),,BY DECEMBER 31, 1998. SEASONAL ESTABLISHIVV�ENTS ARE TO C4NTACT THE HE.ALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIlVG FOR'THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR FOO�, (i.e., PAINTING, �TEW EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR�TO � COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS : POOL OPENING: ALL SVV'[1VIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR ' PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, ANA QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SVt�IlvIl��IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(�)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS VVITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQiJIRED TEMPCIRARY FOOD SERVICE APPLICATION FORM '72 ' HOURS PRIOR TO TI-� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-� HEALTH DEPAR.TMENT. FROZEN DE� S�TS: 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 TI-� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII.THE ABOVE TERMS HAVE � : _ --_ _ � BEEN MET. _ _ - - — —- OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. C�t�TDOOR COOKING� �UTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE EST LIS NT IS PROHTB . ,� DATE: � SIGNA ,� �-y _ . PR1NT NAME&TITLE: G �-- �- l�(��"Z� P/e-��<�� 11/12/99 � � ': ' �G �f _ � . �. �. : - . � . : : � " �� [ - .: . �.��Irl��f-"�,� n,� � �"��Rt�'r�y ra_ ��M�� : ��C�� N�. r�`��w&i j �. �. �r ° "�v� v z ��`i�f".�� d�n�� - ' _ . ' - - :� ,��ryv-Sg r�.u!,�,�a�,z.� ¢r^.�¢-u`�` �$i I i i�^ a,+r��I1Na �:L� m�< N ° ""� 'ir'��a �r1 . �. -' - . " '" . .,�, r„�; �..�aw'- �+ .:� x^ `�"t€;,��4..��e t.��4, r .�,�.��, . . �:� , "�"a,E,. :� , � .: ,.. . . - .. ...�. _ . ... _ PR�CT�EI-T- -- ----_— --- --- Th'�(�CERTiFiCA RTTER OFiNFDRM�TiDN _ — ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden&Sullivan Insurance Agency Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW PO BOX P Hyannis, MA 02601 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED G3L� :� [� � N1CD American Host Motel Corporation Po BoX$s� D E C 2 0 1999 West Yarmouth, MA 02673-0000 , HEALTN DEPT. :•:4i'Y.'FL'.'�..''�^^�..•..��`.1�.��^a, �G=i�.'w.,'v. ..-::�.: ..>a .�.-:;, o :��"��a�.�`�.°a.�.'�"�',�i�r �Rt;"�.u�.r �en+�,'�'�t^�x�� t»ax .a�.�-; a .�..� .--s�z x�.�4 hfl',e��v�"''�j`.�. X �" � ;�. �,<,":» THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN - - __. -- __ _ _ __. - _ _ __ —__ - --- ---- _ MAY HAVE BEEN REDUCED BY PAID CLAIMS. - co LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE A ORKERS COMPENSATION ND EMPLOYERS'LIABILITY LIMITS ' HE PROPRIETOR/ ��m�� '�� '�� PARTNERS/EXECUTIVE + ��r� " FPICERSARE: ��h� 7'�°''�#' INCL O EXCL❑ 1`�'rj�9$$ $�`�Q�199g 8�`�g�'�00� STATUTORY LIMITS �'��,�"��ha � �� THER overage Applies to MA Operations Only. � EACHACCIDENT $ �OO,OO DISEASE POLICY LIMIT $ 500,00 DISEASE-EACH EMPLOYEE $ 1 OO,OO DESCRIPTION OF OPERATIONSNEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION TOW N OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN: HEALTH DEPT-KELDA W ELSH EXPIRATION DATE THEREOF,THE ISSUING COMPANY W ILL ENDEAVOR TO MAIL 10 YARMOUTH, MA 02664 DAYS WRITfEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABLITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ ___ _ _ _ __ _ � - __ . _ _ _ � �__ -- �..� ' THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-11 FEE: $25.00 This is to Certify that Daale& Martino Inc d/bla Ame^��^ u^�r Motel 9 Main Street West Y o th MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS lfiis License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner revoked. December 22 , 1929 BOARD OF HEALTH: �c` ///. �ettae, ��iairm.ah �oan� �ullivan., K.I'/., Vice ��irman KoberE� �rown, �larh a�riel�e�a�iol.��i�-J�taoPed ic�l � ou hlin Bruce G.Murphy,MP ,R.S HO Director of Health t THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT NUMBER: Y2K-30 FEE: $50.00 Tt►is is to Cer�ify that Daale& Martino. Inc. d/b/a American Host Motel 69 Main Street. West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel -OUTDOOR POOL 69 Main Street West Yarmouth. MA 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. December 22 , 19�9 BOARD OF HEALTH: �c�� }etEe�, ��iairman �oaa C�. �u[[ivan� K.//.� Vic¢ (,�irman Kobert.}. 9�rocun, C�lerh a�rielle�a�o(.��iy-.�tooPea ��0' ou��,� ruce . urP Y, � . ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-31 FEE: $50.00 This is to Certify that Daale&Martino. Inc. d/b/a American Host Motel 69 Main Street. West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel -INDOOR POOL � 69 Main Street West Yarmouth. MA 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. December 22 , 19Q� BOARD OF HEALTH: �i`� �elte�, C`iai�man �oan.� �u[livan, �//, Vice C,hairman Kobert� �rown, C�lerk a�rie[le�a�o(��y-�ooPe� ' �l O� o �lin. Director of H�e,altt�i 1 THE COMMONWEALTH OF MASSACHUSETTS • � � TOWN OF YARMOUTH i BOARD OF HEALTH PERMIT NUMBER: Y2K-20 FEE: $50.00 This is to Cercify that Daale& Martino Inc d1b/a�merican Host Motel 69 Main Street. West Yarmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adoptai by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked. December 22 , 199Q BOARD OF HEALTH: �c�� etEe�, C,`cairman �oa�z� �uL[ivan, �//., Vice ��irman Kobert�`. �rouia� C,[er� abrie[le Jakol�hy-✓�tooPed • �e�0�o��.�.� Bruce G.Murphy, MPH, .S., O Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-71 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: naale&Martino, inc_, 69 Main Street, West Yarmouth, MA Whose place of business is:____American Host Motel Type of business: Continenta.l Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:��/. �aft�, C'�irmah �oan� �ul6ivan, K.//., Vice (..�irma ,�o�g,�� ,�W�, c�,� a�rie�[e�a�o��y✓G� p�� ic �� ou$hlin December 22 , 19 99 ruce G.Murphy,MP ,R. ,CHO Director of Health �fYYY• b1RI03 30��S 2I�HJ,O�Z�'IdbQO�Ql�id ZI�AO 1�RI11Z�SV�'Id...�y \' ! �� . s = �nQ,�unoru� _ . ots ooz$ ��bs 000`sz< SZ$ Z2I�SS�Q I�I�ZON3 SL$ '�I�bs 000`SZ>� OZ$ O��gO,LT Sb$ �8�� OS> #ZII�1i2I�d ��3 Q�IIf1��2I�S1�I��I'I #,LIY1RI�d ��3 Q�2IIf1��I�SN��I'I Z SL$ �'IHS�'IOHAA OS$ �.LaIA 1�iOWL�iO� SZ$ ,LI302Id-l�ION OSI$ S.L��S OOI< S� 0£$ 'I�ZN�[�II.LNO� � SL$ S,L��S OOI-0 # ZIY�t2I�d ��.3 Q�III1��I�SN��I'I #ZIY�RI�d ��3 Q�Itf1��I�SN��I'I •� 2I �j=� ��aSZ$ 'IOOdTiIII3t1c1 { LZ' '�a05$ 'TOOd�Jr�]JN7�IIAAS Z �'�� OS$ 'I�.LOY1I � � OS$ �I2I�'d 2I�'IIH2I.L OS$ �jJQO'I OS$ dY11�� OS$ Ni�II OS$ l�tI�'�� OS$ g�8g � #ZIYY2I�d ��3 Q�2IIf1��2i�SI�I��I'I #.LIY�RI�d ��3 Q�2IIf1��I�SN��I'I #�.�o� �si�as�ruxor�s-uou #�ios ��rui��s i�xn�is�x �� £ �z �i •ssauisnq 3o aau�d ano�f�B a�,�B ui�;uigw paB saidoa �+�+au aptno.cd ;smm �o� ' •sp.�oaa.� �saua�f�ssd asn�oa i��,r�;ua�u�BdaQ q��ag ayZ �uuo�s��o�suoi��ogi�ao aa�oidu�a3o saidoo uo�� pu�n�otaq salnpaooid �unioqo-i�ue ut paure.z�saa�oiduza.zno�i�sij as�a�d �sauii�� sasnua�d au�uo iannau�y� q�iiuziag at�� ui paur�.�� aa�olduza auo �s�ai ��e an�u �snuc a.�oux io s��as SZ u�inn s�uaun�sijq��sa aowas poo� I� ��.-,�,�y n�a I �' '� n '£ �s�"R 7Q-�L-'�! ��1� z � V�/ �� j ✓ •ssauisnq 3o aaBid ano��B aI� B uig;uigai pug saidoa n�au ap�no.�d ;snw no� •spaoa�.� �s.�Ba��sBd asn �ou I��n�►;uam�agdaQ q;Juag aq,I, �uuo3 s��o�suot��ogi�a� aa�fotduza�o saidoo uoB�� pue nnojaq saa�oldiva asa��s�aseaid �(gd�)uoi��t�snsag�uou�nc�oip.��iunuz�uo� P�PR� �s.��3 p.r�pu��s `�a�s �a��nn ois�q ui pa��i�uaxmo saa�oi uza oncu3o umunuTtu��s��snu�sxo��iado iood DN�� d . . 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Aolicy# company namr. _ -- _ --- -- ____. -.__-- .__ _ ------ __ a�dresr. — ----------- c�.y: nbone i{• insurance co. p�,y* Failure to seeure coverage as�equired under Seetioo 25A of MGL 152 ea�lad to tbe i�paitioo oltrisi�l pe�altla of a O�e op to Sl*500.00 a�d/or one yean'imprisonment a�w�ell as civil penalNa io thc(orm of a STOP WORK ORDER and a Aae of SI00.00 a dag a�tiost sa t a�denta�d t�at a eopy of tAy statement mav be forwarded to the Of'1'ice of Invatigation�of tbe DU for eoven`e veriflado�. /do hrreby r►i u er rhe pnins a nalties oj� r'ury�hm tht rnjo►n�ation providtd abovt is lnte and co eG Signaturc ; /� ' �-{� � 1�� Print name ��'r�-- � ��'Tl 0� b Phone M 7[S ��"�� .- olTicial use onl�• do not M rite in this area to be completed by city or town oAlcial ciry or town: YA��DT� _ permiNicenu# nBuildiog Departmeot QLiceasiog Board �check if immediate response is required 261 OSeleetmen's ORiee �Healt6 Departmeet contact person: phone#;_ �508� 398�2231 egt. nOther Ire��ued 3;95 P1A1 ��.: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: 99-23 FEE: $50.00 This is to certify that Daale&Martino. Inc. dlb/a American Host Motel 69 Main Street West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel - INDOOR POOL 69 Main Street West Yarmouth,MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and eapires December 31. 1999 unless sooner suspended or r�oked. Janu ,at�6 , 1999 BOARD OF HEALTH: �c`� �}e%�ee� �`iairmaic �oan � �ullivan� K.//., Vice C�hairmaic Ko�art� 9.3rown, C�lerh adrielle�akol��i�ooPe� ' hae6 Odo hlin I'RCC • il� y, , •, Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: 99-13 FEE: $50.00 This is to certify that Daale&Martino,, Inc d/b/a American Host Motel 69 Main Street, West Yarmout�.i, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued'm conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amendeci,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating • thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31, 1999 unless sooner suspended or revoked. Januar�26 , 1999 BOARD OF HEALTH: �c`� �ettee, (�`cairmarc �oaa� �ullivan,K.//., Vice C��irman /Co�rt..J. 9,rourr�� l..lerh adrielle�a�o(e�i�ooPee /�� eae[0� �ilin � Bruce G.Murphy,MPH,R S CH Director of Health THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-22 FEE: $50.00 This is to Cetify that_ __l?aale&Martino, Inc. d/b/a American Host Motel ; 69 Main Street,West Yazmouth�MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At American Host Motel -OITTDOOR POOL 69 Main Street West Yarmouth M� This permit is granted in conformiiy with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and earpires December 31. 1999 unless sooner suspended or revoked. Janusry 26 , 1999 BOARD OF HEALTH: �c`� .}e�ee, C�iai.rman � �oaa.� �u��vaa,/C.�/-� Vice (..�irman Kobert� l.�rown� (..lerk a�rie��a�Zole��ooPe� [ooCo �in Dii2CtOr Of��1 � � , i ' THE COMMONWEALTH OF MASSACHUSETTS ; TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT NUMBER: 99-10 FEE: $25.00 This is to ce�tify that Daale&Marino,Inc. dlb/a American Host Motel 69 Main Street, West Yarmouth- MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Secfions 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31, 19 99 unless sooner revoked. January 26 , 1999 BOARD OF HEALTH: C�c`///. �eftee� �`iairmaic �oara� �u[livara�K.//.� Vfce (_.hairman Kobev�.}. p.�rown� l�lerh a�vie6le�al�of��Zcf-�ooPee alOoCou hfirC � Bruce G.Murphy,MPH,RS.,CH Director of Health TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIV�NT PERMIT NUMBER: 99-81 FEE: $30.00 In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 af the General Laws,a permit is hereby granted to: naale&Martino, Tnc_, 69 Main Street_ West Yarmo � h, MA Whose place of business is: American Host Motel Type of business: Continental Breal�ast To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 1999 BOARD OF HEALTH:�d�/. �ot�,, C'�M,„a„. • �oan� �uL�ivam��/•� �/ice C,�irman o�ert� /�rown, �ler� � abriel[e�a�ofeh�-.J�tooP¢� 'i/ic�elOoLou �6in � Jannar�6 , 19 99 Bruce G.Murphy,MPH,RS.,CHO Director of Health