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Home My WebLink AboutApplications, WC and Licenses� � _-,.• � b�cti/fa�tsE : TOWN QF YARMQUTH gpqBp OF HEAL1'H ; APPLICATIQN F4l�t I.�CE11�8�/PEBMI�ZO�r, I�Q°o C�O M�D - �-i''�'�!� ,�� , � ; * Please complete fo�m and att�rci�al;l n�ec�ary dp�ps�t�,bj� Failure t�dra s�v�l�#�tl�rq�uu QC'�,�� `� , .-� .. NAME OF ESTABLISHMENT: . -; ..r f _ / L4CATION ADDRESS: -��— C,�.-- ,�: � � � hiAILING ADDRESS: , OWNER NAME: .,� � � ?` � CORFORAT'ION NAME(IF AP'P E�; � � MANAGER'S NAME: "" .� # ; MAILiNG AI�DItESS: .,a p��. -�_. POOL CERTIFICATIONS; Tbe pooi aupervisor mast be certified as A Poot Qper�tor,as reqairtd by State I�w. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2 Pool operaton must list a minimum of two la ecs currann�tly certified in basu watcr satfcty,standard First Aid imd cu :,ommumty Gardiogu�ary R�ua��t{ � Fk�se bu tltece d�oy�es bd�w aod aqach oo�i�s of a�pbya -earci�ic�tions to� �orm. Tk�H+a�ttb i�l��v��t wwe P�Y!�t's'�eecw�di�. Yoa 4uu�t provide new :opies and �t�ua a C�e s�t yoar pt�of basia�ess. l. 2. ;' 4. =00A PROTECTION M�1;NAf.,ERS-€ERTIFI�A�'IpNS: �ll food s�avia�e est�►hlishments are t�quired to havc at kast one full-time empbyce who is certified as a Food 'ro�t�aw AZa�ager, as defwed iu t�e Sc�e ' 'lease attas��kh copies of cerd�catu�n ta thi�►�yp��Code f��r Food Service Estsblisluuents, 1 US CMR 59Q.000. �ou m�st rovide new e `��Put�nt w�l�t t�re pngt ye�us'reconis. P �pies and a�arw��t�y�r apt�ot, , 1 � � � 'ERSON IN CHARGE: , :ach food est��6lish�nt uwst have at least one Pers�u�n C}�rge�PIC)on sit,e duriug hours afo�io�. i � �. IEIMIICH CERTIFICATIONS: .11 food scrvi�e establ�sh�a�ents with 25 seats 4r morc n�ust l�ve at l�ast one empt+r ce � in tl�e H��icl� 4ac�euver on t� prewises at all times. Please list your e�s trginad in au .t��r� ttach copies of empbyee�raet�s to t�s fci�m. T�e� �t wdt�t�e>p�y�s'� 'ou mtist ' pr�°v�de°ew"ca�es nsd a�a�st`�"� b�. 2. 4. ESTAURANT SEATING: TOTAL# OFFICE US�QNLY , 7DGl.�G: � CENSE REQL�IRED FEE PERMIT# LICENSE REQUIItED FEE pERMiT� LtC�JS��p � p�g�'� _l3�3 S55 �,CA81N S55 / A�1TEt. SSS �d -O�J7 _I�"� »> _CAMI� SSS _SW�IG POOL S80e�. _LODC;E S55 TTRAILERPARK SI05 WHtRLPOOL S$Oa. IOD SERVlCE: _ :ENSE REQUIRED FEE PERMIT# LiG�NSgREQUIIiED FEE PE�RMiT A� LICENSE REQUIRED FEE PEx�T� aioo sEars sss _.,LcaAr�'u�rr�u. s�s, �'b�i-�� tloiv.�a�r s_�a t ADrSII�TLSTRATION A ; i UndaE Ch�pta�152,S�25C, Subeection 6,the Tawa of Yarmouth ia now�irod to hold issuaace or renev, ' of�y.lic�eme or par�ait to opecate a bu�inase if a paaon or co�panp doea not have a Ce�tificate of Worker', C,ompero�stion imur�oc. TH� ATTACS�H sTA'i�E woRKER'S COi1�N3ATION n�iSiIRANCE AFFIDAVIT MU31'BE COMPLETED AND SIGNF.D�,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED� T�na of Y��d lie�a m�ust be Pe�d Pnor to renewal or ia�uance of your para�its. PLEASE CHECK AI�'Rt�P'RIATELY IF PAID: � � YES � Np M�OTELS AND OTHER LODGING ESTABLISHMENTS TB�AN�11'OCCUtA1�C'Y: For ptirpo�ea of the l�mitatioas of M�tel or�w�.Tr�oc�a�panc.y�Il be ��e�6e�r�d shoct ta�m�uprocy, � . or�n�Y�d c�oma�il3►a�ed v�+i#h motel and ho�e1 use. Tn�reeE occt�s��aod besbk�u a�t�the��qm�t p��oftdideoaedsew�hane. Tr� ooa�cy �di �aHy t�efer to c�uous ocaip�ncy of not mare t6m thirty (30) days, and an �ofeo�t mtme ti��ety{90)days witbin anY a�c�6)nwmh Pe,ciod. Use of a�uait ss s re,sidm�ce or dw�e�g ua� �t1t no�t�e c�omi�ed traeu�. a►cc�ncy that ia �to the�oe of Rc�om powp�r Faccmq aa da�e�d 'm M.G.L. c. b4G or$30 CMR 64G, as amm�ded, shail gme�yr be oo�+ed Traasimt. �'t'1+L1IS 1'ty+dL`t�!'�'S�:At!sar�d�g�v�g�wr��}�,a bem�tosed f�r the sa�muat be' bY.��"�eet; to p CAt�tt��Ievth�le�to s�et�e the u�pecxia�five�� • l'e�op�le ue NOT�to a�t m tht pod sr+ea un�tbe pool has bee,�mapecxad oPene�i• POOL WA1'ER TESTIrTG: The water must be tested for pseudomonas,total coliform and standard plate count by a State oat�tad lsb,prioz to oparing� aad qu�nt�ly t�eC,e�.. ; i �'OOL C'I.OSING:Evesy outdoor in gound sw�m8 Pooi nwst be drained or cove�ed wittun seven(7)days of claging. � � F�WH 9�RVTCE � � �!"�IG l�t�ll�t:Y: � A��b�+e�s�iedie Tair�af Y�are�o�yaut a�iFy th�'Yac��1�e�elt • . H�Food Servioe Applir�tiar�n T2 6e�s�r�ar ta t�s�e�. T'6�e��be�obt'�na�i� � ; ; �D�'.4.4�`�1tT3: R P�dae�xrta m�ut be te�on s mcm�r b�ia by a State cait�fied tsb. Test ra�ulta muat be a�nt to the Health ' De�t. Fa�m to do fo w�71 resuh in the suapenaion or re�ocation of y�au Frc�en Dca�rt Permit w�til the abav�e tarms hsve be�n mCt. O�t�CAF�s O�e c�(i.e.,o�tdoor sea�g with waitat/a�s eavicx),mu�have prlor�fivm the&�erd�T3e�. OIITt)t)OR COOKII�TG: Outdoor cookin8.P��a4��P�Y of�Y�P��by a retail or food service a�tablishtne�rt is prol�i�ed: � N01YCE:Pmmeta nm anrxuily from Jaauary 1 to Dec�aa�bc�r 31. 1T�Y�� :��At�T TI�t�'LL�'�;��*�k�'�T�.1��d�tJ�#��'��lP�3i��:��,'�; ; ALL RIIYOVATIONS TO ANY I�D �'AS�.IS�i�NT, MDTEL OR PUOL (i.e., PAIlV1'IIVG, NEW EQLTIPMENT,ETC.�M[73T SE 1t�TED T4�lND AFP'RO'VED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUiRE A SITE PLAN. t �.� � DATE: ! 1� SIGNATURE: �-•� G«'�� ! � PRIlV1"NAME dt TT1'I.E: �t ti f�'4 �'u�'`� G'��' ; � � i i �o:��oa � � • � i OF � � � � Y Y i V 1J � 1 .C'� lt � 'V iJ 1 11 Healrh Division _ ! i 1�6 Rt)UTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 " �'°� Telephone(508) 398-2231, Fax{508} 764-3472 Builfling Division November 8, 2007 Clifford Hagberg d/b/a Bea.ch House at Bass River 73 South Shore Drive South Yannouth,MA 02664 Re: 2008 Motel Licenses Dear Motel Owner: As you are aware, the Town of Yarmouth is working to facilitate the motel license process to encourage the appropriate utilization of motel properties: To that end, the licensing procedure has been rew9xkeci, and additional materiaLs developed. Enclosed please find the following materials relating to your 2008 Motel License: • Applicatian for LicensetPermit • 2008 Motel Census • Motel Lic�nse GuidelineslProc,ess Elowchart • Motel Use Inquiry Form Please complete the application and census according to the instructians provided. Please note that applicatian materials are to be fded with the Heatth Division by December 14,2807. The Motel Inquiry Form is being provided for yow convenience, should you have a question regarding the current utilization of your property for non-transient use. Questions regazding non-transient use or the Motel Inquiry Form should be directed to the Building Division, 508-398-2231, ext. 261. All other questions should be directed to the Health Division, 508-398-2231, ext. 241. Thank yQu,�z�.advanc.s for your c�p�ratiQn Si ely, Br�uc. �r. Murphy, Dir�tQr<zf.H�alth � ��Y=�-.��-. t es Brandolini, Building Commissioner �� - ��, . - 8 Fx►c,� {fo uSE °`;:�a�o TOWN OF YARMOUTH BOARD OF H�;t�I�`i�� 7�" � �: . �;� APPLICATION FUR LICENSE/PEPQ��0�0-h�`b �� ,�JAN � 7 2007 * Please complete form and attach all necessary docu��'by��mber 31, 2006. Failure to do so will result in the return o�your apphcation packet. NAME OF ESTABLISFIlVIENT: �C� C"I'� TEL. # �' - 34�C-�J`6/ LOCATION ADDRESS: `Z 3 �: rZ_ p� , ✓{�c/' ��,.c., 'tir MAILING ADDRESS: �",,� ��. � OWNER NAME: J � T IN r • CORPORATION NAME(IF APPLIC LE): MANAGER'S NAME: �(�Cc- � k � TEL. #�- 3G L - � rG/ MAILING ADDRESS:� o. � rf --�-�, ! POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State[aw. 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 emplayees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. ; 1. 2. j 3. 4. FQOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments a.re required to have at least one full-time employee who is certified as a Food : Pratection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. 'i 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 establishmen� l. 2. ' PERSQN IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' 1. 2. -- , HEIlVILICH 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 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE TtEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# , B&B �SO CABIN $50 �MOTEL $50 ��7��Y5 INN $50 CAMP $50 SWIlvIlvIII1G POOL$75ea. ' LODGE $50 TRAII,ERPARK $100 WHIIZLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMfr# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PfiRMIT# c� _ _ _____ _ 0-100 SEATS $75 ,�.COrfTIlVENTAL $30 O� 7-t 5�I NON-PROFIT $25 >I00 SEATS $150 COMMON VIC. $50 WHOLESALE �75 RETAIL 5ERVICE: _RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# ,<50 sq.ft. $45 >25,000 sq.ft. $2t� _VENDING-FOOD $20 _Q5,000 sq.R. $75 _.FROZENDESSERT $35 _TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE _ $ g O.00 '*•'•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R�k* f _ F. ::x i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town af Yartnouth is now required to hold issuance or renewal of any license or permit to aperate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEL�IF PAID: YES NO � _ _- -- --- - _ _--- __- - 1 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 of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (3p) 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 amendeci, 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 operung. 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 Fnust be drained or cavered within seven(7)days of - __ _- - ---- _ - - .__ __--- � c osing. - . � FOOD SERVICE � CATERING POLICY: Anyone who caxers within the Town of Yazmouth must notify the Yarmouth Health Departmeirt 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. FIxOZEN 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 from the Board ofHealth. � OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited. __ . --- --- ---— _ __ - -- - _ _ __ ----__ _ . __ - _ -_ _ . _ -- _ . NOTICE:Permits run annually from January 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RET[TRN ..._ THE C4�LE`i'�D�PPLIC-t�9N(S)AND REQI3IREEI}F£E{�}��D�EMBER 31; 2006__ __ � ALL RENOVATIONS TO ANY k'OOD ESTABLISFIlViENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIl'MENT,ETC.),MUST BE REPORTED TQ AND APPR(?VED BY THE BOARD OF HEALTH PRIOR E TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � C� , t DATE: � /' < SIGNATURE: ,�� j , PRINT NAME 8c TTTLE: �4�i v�-r� G�✓�k y ..— �G�k L�� - i i 10/17l06 � t 4 t � � The Commonwealth of Massachusetts ' Departutent of Indus�rial Accidents �N�M� 6118 Washixgton Stree� f'"Floor Bosuia,Mas� t12111 —_ -------- Worl�era'Cem ' e I��aice A�davl� ' leetricxl Coghxctors '. : name• `�� ZI�SS .L`�. `�iSt 'r�cJ c'v�-- �` �i1J�`-�i�'C V /�//��'✓�G��' aadress• `C3 �'6 , �(•t�� , �F-GG/ ��y �j--f S' �2t>Q�L. s�te. ""4� ziQ U 1�°�� nbane# �� '� g�l• G (�G � , ��s��i��c�nu�s�- o I�a,�,,,�,,��W�m,,�: Project Type: ❑New Co�ructia�� I am a sole aud have no one w in an Buil ' �lddition I am an e�tployer provid'mg wakecs'compensation far my e,mployees warking on this job. � , �2.uc:E-t v t' � �� /��'' . '�� o. ��.c dl/v t/L.- s� ` � � � ' � -� �/ /�CQ us d r+.� ❑ I am a sole p�oprietor,g�al�tractor,or�omeowaer(urde o�e)and have hicrd the c��ctors listed betow who have the following wor�rs'compensation polices: m�s�' _....��_ .a�...., +F�Ys, ��= ura�tirunr� �., . _. . ._ �. dty; ,�� Faqare�secm cnerase as reqtired uda 3atla�2SA�f MGL 15'l cu lad b tl�e irpaitiN�[Qi�d�al pe�fNia�f a f e�p b tl,3N�N a�dl�r �e years'isprirei�eat m we�as dv�pe�tia i�tie fonr�f a 3T0!WORK ORDEA aed a Ane�f S1N.N a day apidt se.1 adast�d tiat a dpy�fib�tale�t�y be torwanded 1�Ne OQice otlm��1Ye DIA L�r c�vera�e v�aliw I ifo IYa�eby ca�y xnder dYe �a�N.rr�of��e��r r��,�,��,p�o�aoa��,�a��a� � Signature Date l / �' � _ ' Priat name �L{('-�v►�c��✓�Q� � Phone# �� l+G� ,f�j D � o�dal ase only do�t wdce ia thh u+ea te Ue a�plaed 6Y rltY er eh.n e�dal dly or tswn: Per�tlioeme/ �� ❑cYeck if��e respsa�e h req��ed �'�� c�pKt Pec'�: P�e/; �014a' c�a s�r.sa«+� % Make ctreck paya6le to Inte�rGUARD, Ltd. GUARD � INSURANCE Remittanc:e Address: �r�ou P P.o. BoX4�688 Philadelphia, P/1 19101-1688 www.guard.com INSTALLMENT BILLING STATEMENT Workers' Compensation Premium BASS RIVER RECREA i ION, I�fC. Agent: 978-469-8300 73 South Shore Drive '�f��' E.A. KEL�EY OF MA�S. Bass River, MA 026b4 � � 45 Wingate St., Suite 402 Haverhill, MA 01832 Statement Date: 08/27/Z006 Policy Number: BAWC703390 Carrier: NorGUARD Insurance Company Policy Period: 07/12/2006 - 07/12,�2007 Transaction Oate Pol[cy Activity Trans�action Amount Balance Forward $ 491.50 ; 08i 26/2Q06 Endorsement � -312.00 ' Account Baiance $ 179.50 ' Current Amaunt Due - 09/12/2006 ; 179.50 Total Amount Due r t� ; 179.50 �t You must pay the To±al Amount Due by the date shown to maintain coverage in farce. To ��void addit�enas installment fees, you may pay the Account Balance at any time. � i �' , ' _ � �l Payments received after the due date may be subject to a $f0.00 late fee. `S �� j feel free to direct any questions yau might have to aur Custmmer Service Representa#ives at 1-800-675-2465, extension 13Q0, or e-mail csr�gu��rd.com. I I • � • y THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD UF HEALTH PERIVIIT NUMBER: #07-045 FEE: $50.00 This is to Certify that ifford Hag}Lg d!b/a Beach House at Bass River 73 South Shore Drive Bass River MA HAS BEEN GRANTED A LICE1vSE TO OPERATE MOTELS This License is issue�in confornuty with the authority granted to the Board of Health,by.Chapter 140,Sections�2A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachuset�s relating thereto,and upon such terms and conditions,�d to the rules and regulations in regard to said Motels so licensed as adogted by the Board of Health,and expires December 31,2007 unless sooner suspended or revoked Apri14.2Q07 Bo�oF�ai,�rx: B �. A�l.�., . ��Sl�1�, ��Gk�v�� Rad�t� B�, Gl� � n�� ,v.�r a.� ruce G.Murp y,1vIP , .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TU OPERATE A F�OD ESTABLISHMENT PERMIT NUMBER: #07-154 FEE: $30.OQ In accordance with regulations gmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Clifford Hagberg, 73 South Shore Drive, Bass River,MA Whose place of business is: Beach House at Bass River Type of l�usiness_ Continental Breakfast To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2007 BOARD oF HEALTH: B `h. �� 1�l�., . ��r�, .�, v�e�-.:� � Rad�t� B�, � ��M��` ��j R.N. Apri14.2007 ��G. ��n�, ,Rs.,exo Director of H�a1th I ` � - TOWN OF YARMOUTH BOARD OF�E�� 6 � �•f` R•S ,�0' Q � � �� ' !��' �� (J `O APPLICATION FOR LICENSE�F�`� �; .;? }�t`� DEC 0 6 Z005 * Please complete form and attach all necessary c�oc�etits by Decembe 31HE2�O�..H �,��T. Failure to do so will result in the return��f your application pack � NAME OF ESTABLIS�IlVIENT: TEL. # �'��I�l'�S G� LOCATION ADDRESS:� '�� S6. S'l,�e, � :C�rz.. MAII,ING ADDRESS: OWNER NAME: T ID or S • - CORP'ORATION NAME(IF APPLICABLE): MANAGER'S NAME: ��e � � TEL. # P- 4 y�-� �/ MAILING ADDRE S S: ��-�-- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated _ � ,Pool Qperator�s) aia��-�.�,�n� �g�..�,� �Sa��:��:�fQrm,� ;s�,._ _ . _ ---_�= - _ -�.� _ :_ -_ L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commuruty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new ' copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protectian Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.00Q Please attach copies of certifica,tion 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. PERSOI�IN GHAI3C�:- ---.:_- ________ _ __----- --- _ _ _- - _ __ _ _--- .__-.- - -_ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlb��H 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 at�a�i-eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. ' 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMTP# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# B&B $50 CABIN $50 �MOTEL $50 Q(p� Z� INN $50 CAMP $50 SWIIvIl��IING POOL$75ea. LODGE $50 TRAII,ER PARK �50 WHTRLPO()L $75ea. FOOD SERVICE: LICENSE REQiTIRED FEE PERMIT# LICENSE TtEQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# 0-100 SEATS $?5 � CONTINENTAL $30 Q�lr b-�OI� NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# I,ICENSE REQUIRED FEE PERMTf# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SO• OO **"*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*"" z- � ADMINISTRATION ' i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's E Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR 4 CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � NOTICE:Permits run annually from Januazy 1 to December 3 L IT IS YOUR RESPONSIBII.ITY TO RE'I'LTRN ' TI� COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVVIEENT'S ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- ' 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i � ADDITIONAL REGULATIONS � POOLS � POOL OPENING:All swimming,wading and whirlpools wluch ha.ve been closed for the season must be mspected 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. � f FOOD SERVICE � CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING 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. " s �FROZEN DESSERTS: �`� _ _ �rozerr�esserts�nust b�tt�sted on a marniily�asis by a State certified iab.--T�st resuits mustfi� s�irtt�th��t�r___ � Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. i OUTSIDE CAFES: ' Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval fromthe Board ofHealth. ; OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmeirt is prohibited. i DATE: SIGNATURE: � PRINT NAME&TITLE: ` 09/28/OS � i � �"'��\ __—=___- The Commonweahh of Massachusetts � =-- - - Depart�r�ent of I�diislnial Accidents -__ — N�a�irwli� - -=- < �o�w�h��►M sm.� �"'Fr�r =-�,��` Bostn�,Mas� OZIll Workera'Com�sahoa Lsorn�oe Affidavit� ' ' kcdricat Co�traetors � ...... ;. a« y, � � ,. � ,�,� � , , _ . ,�.nY. �: � �v��, ,�us� l�r3ll✓�SJ �-� /��i� �� : ��C� ��f �� ri------��:X1 CS ��J.�� n:�� :�� # ��-?�! �f 6 J a / � ��i�a�rruu�si- ❑ I am a homoownea perForming all w�k myself. Prajact Type: ❑New Ca�a��odel I am a sole 'etar and have no�e w � in an ' . ❑B ' ' Addition ' I am an e�nployer providing wadce�s'compemati�f�my employces wo�cing an this job. �.__ �,, e�_ �_.W ___..�,�, �. _ _ — —.�_� .. _ -_ _ _ _,;�_� ao�ouv�: _ �: cbh. oi�e�c�: ❑ I am a sole proprietor,ge�erat coitracter,or homeo�vier(cude o�)and have hired the con�s listed below wlw have the following woike,rs'compensation polices: �o�r�: �: : t�iv: of�a�e�; �m�er �> s�' BiY�s� Fa�m�c M secm+e erwsa�e as reqi�al eider SedM�2SA d MGL 1S2 eu kad b tl�e i�paW�a�f ai�rid�a�f a 8�e�p a:1,SM.M a�dhr oee y�ears'in�tia�smt as wd aa dv�pm�qa is tbe fsret ef a STO!WORK QRDBR ud a Me et f1AS.N a day s�aimt re. 1 ndnstsrd t6at a cNry et tik�ale�e��y 6e ferwarded 10 tYe Oma ef Im�K tlrc DIA far erMaa�e verMeatlei. !do JYenby ee�y�rn Nie ixs and aur of perJwy tlYtt the hrfonw�lon provlded aboNe is trxe awd d � �� y�' Date r� �� Print name (� L�l i�� /lY��(�C��" Phone# � �.�!G� �f�� •ffi�1 me oniy a•a.t.rrke ia t�s ar�ea b be or�pleted by elly e�in.a.�cial c�y or tewn: pe�/�oeese� �� ❑eLut if�be nsps�e is rerl� �'s Offia ��alt�Dqnr�wt nviecd s�pc� P�#' � / GUA R D Workers' ComQensation and Emnlover's L1abilitv Po�icv ' .. NorGUARD Insurance Company - A Stock Company INSURANCE Poljcy Number BAWC547212 ' G�O � � Renewal of 8AWC529218 ; NCCI No. [25844] , [i] Named Insu�ed and Mailin� Address Aqency , BASS RIVER RECREATION, INC. E.A. KELLEY OF MA55. ' '3 Sauth Shore Drive 45 Wingate St., Sulte 402 ! Bass River, MA 02b64 Haverhill, MA 0l832 Agency Code: RiEAKEll Federal Employer's ID Ynsured is Corporation ' Risk ID Number OOCa41036 [2] Policy Periad ', �rom lu!y 12, 2C05 to }uiy 12, 200fi, 12.01 AM, standard time at the insured's mailing address. [3] Coverage a,. Workers' Compensation Insurante - Part One of this poficy applies to the Workers' Compensation �aw of the foilowing states. Massachusetts B Employer's Liability Insurance • Part Two of this poiicy applies ta work in each of the states 1�sted in item [3}A. The limits of our liability under Part Two are: Bodily Injury by Accident - eac� accident 55QQ,OOG ; Bodily Injury by Disease - each emp4oyee $5Q0,000 Bodify Injury by Disease - poNcy limit 5500,000 C. Other States insurance - Part Three of this pciicy applies to all states, except any state I�sted �n Item [3JA, ar�d the states of Narth Dakota, Ohfo, Washington, West Virginia, and Wyorrzsng. � This poliCy indudes these endorsements and schedules: See Extension af information Page - 5chedule of Forms ' �4] Premium-- _. .. . _. _. . . -- -- . The Premium Basis and, therefore, the premium wfil be determined by our Manual of Rules, Gass+ffcatiors, Rates, and Rating Plans. All required Information is subject to verification a�d change by audit. (Contirued on another page} ' _ ------------�- .__ _.____..-------------._ . __. . . _ . _ _. _. ._. ; -- - i ; . j ; � i I � f-'-_.�__._..___. ..r....��_�� -- - �.�.__�..�..�... �.......�.�......_. � Total Estimated Poltcy Premium s 1,2B7 � � Total SurcharpeslAssessmertts � 49 Total Estimated Cost s 1,336 � . . . ...._..r..........+..+..s+r�.....+.r —__ ��...'.�.as:a��o_..�..... .... .. _ . . I t^+�:a�,,;.us= xx Page - 1 - infcrmation Page ; r^G� 6A�vC6a�212 WC OQOOOlA Q3;e.- C6/e"4i20�5 ._�—� � � - . ; � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' BOARD OF HEALTH � PERNIIT NUMBER: #06-023 FEE: $SO.QO This is to Certify that Clifford Ha�berg diF la Beach HoLce 73 South Shore Drive Bass=River MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confornuty 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 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 adopted by the Board of Health,and expires December 31,200�unless sooner suspended or revoked January 26.2�6 BOARD OF HEALTH: B �. , /y�., ' ��, �'�`�', v�e��.� ��,�t�8.�, et� ��/l�la�l�t �1��,��, R.N ruce G.Murphy, S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH , PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-102 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Z�eneral Laws,a permit is hereby granted to: Cli�ord Hagberg, 73 South Shore Drive, Bass River, MA Whose place of business is: Beach House Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l, 2006 BOARD OF HEALTH: B $. ,117�., ' d�� ire��s Ro�ent�.Bncr�, G� /��iiic�/�c$�o� �4.�fj' , R./Y. January 26,2006 ruce G. urphy, RS.,CHO Dire�tor of Health 1 l�'�� f F�t . �� Y�� (" 's� �G;_ i� �J '�I -� �D ��' .� : ;�o TO �" N OF YARMC� UTH � o -. _y APR 2 5 2005 H 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 H E A L T H �j " MATTACMEES � ✓EPT. �'��,,,�A,to�� Te lep hone (5 0 8) 398-2231,Ext. 241 — Fax (508) 760-3472 B O A R D O F H E A L T H To: Yarmouth Board of Health PermiE Holders From: David D. Flaherty Jr.,RS. �� Health Inspector Town of Yarmouth Re: Federal Tax ID Number Date: March 22, 2005 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 establishme�t's Federatl Employer ldentification Number(FEIN}otherwise known as your"Ta.x ID Number". This is purely for administrative purposes only. So� businesses use the owner's Social Security Number (SSI� 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 Department 1146 Route 28 . South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, �l�s`. da not�esitate�� c�ll. 'Tl�e o�ee haurs are Nt�o_nd�y to Friday, 8:30 a.m. tQ 4.�D g.m._.The _ telephone number is(508) 398-2231,ext.24L Establishment: � �G�� FEIN or SSN: � Locarion Address: 3 �0 • 1 l�/L 4 � �` G `�� -W � / Signature: ' Print: �(�-T�a/l� �� Title: `� �`t-� "- i �� Printed on � �'' � ( Recycled ��y Paper ; I } �'�� fe�ICl4 N�i15L °f f R� TOWN OF YARMOUTH BOARD OF HEAL ,�� _ .,o G3 � (� L� L� M � D o �_ ";y APPLICATION FOR LICENSE/P ,~ `` �'s �'�'� �� Y MAY 1 0 2005 * Please complete form and attach all necessary� �_ �l�ecemb 31, 2004. Failure to do so will result in the returt��yo��phcation pack t.HEALTH DEPT. NAME OF ESTABLIS�IlVIENT: ui'� 1' � TEL. # �� 3�11,�-�Sb/ LOCATION ADDRESS: �,� �Lr�y- � ` � �ii� �2�--- ` MAILING ADDRESS: �L�f-_ a w-�,G y� OWNER/CORPORATION NAME: � �� MANAf'rER'S NAME: �v1t' ' TEL. # -S/�'� 6► 6 MAIL,ING ADDRESS: fa � F1� rl U L 6!y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s)and attach a copy of the certification to this form. l. 2. ' Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Commwuty Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of ' employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 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 Healt6 Department will not use past years'records. You must provide new copies and maintain a fde at your establishment. l. 2. -- ��Sf3N • - ___ -____ ----- ---.-__-- _ _ _ _ . _ Each food establishment must have at lea.st one Person In Charge(PIC) on site d�ring hows of operation. 1. 2. HEIlVILICH CERTIFICATIONS: f � - All food service establishments with 25 seats or more must have at least one employe�e 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. L 2. 3. 4. RESTAURA�NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiTIRED FEB P'ERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMTP# B&B' $50 CABIld $50 �MOTEL $50 �� INN $50 _ _CAMP $50 _SWIlvIlvIIl�iG POOL$75ea. LODGE $50 TRAII,ER PARK $50 WHIItLPOOL $'75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIKED FEE PERMTf# 0-100 SEATS $75 �CONTIl�iENTAL $30 �5 ''I�� NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<SO sq.ft. $45 >25,000 sq.ft. �200 yVENDING-FOOD $ZO _<Z5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOITNT DUE _ $ H O.O� •""""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORMw w�e�e• �.-�.r.. � �. .r.4. ..`/ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � r of any license or permit to operate a business if a person or company does not have a Certificate of Worker's j Compensaxion Insurance. THE ATTACHED STATE VVORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR ! CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES NO =_,. .� . _ - :.:-_ f 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, 2004. SEASONAL ESTABLIS��IENTS ARE TO CONTACT THE HEAL'THDEPARTMENTFORINSPECTION'7-10 DAYS PRIOR TO OPENING FOR TI� SEAS4N. ALL RENQVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQIJIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ( TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. E { 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 standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7)days of � closing. � � FOOD SERVICE CONSUMER ADVIS�RY: Each food estab 'shmem which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be obtained at the Health Department. _ FRO��1�F-�ESSE3tTS: - ----- Frozen esserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the ' above terms have been met. � � OUTSIDE CAFES• � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING• Outdoor cooking,preparation,or display ofany food product by a retail or food service establishment is prahibited. i � DATE: 61 / SIGNATURE: PR1NT NAME& TITLE: �L�C��o� ��`��— ' � 10/22/Q4 .�- . ; �/ ARD� �►oricers' Comoensation and Emol4Yer's Liabiiitv Policv G� NorGUARD Insurance Company - A Stock �ompany i N S U RANC E Poti�Y N�,mber BAwcsz9zis Renewal of BAWC4260i6 M � � � � � NCCI No. [25$44] __.___._. .___..... _._.�.._ _.__..________�._._�. `___.___ ._.. [1] Named insured and Mail�ng Address Agency ' SASS RIVER RECREATIOfV, INC. E.A. KELLEY OF MASS. 73 South Shore Drive 45 INingate St., Suite 402 5ass River, MA 02664 Haverhill, MA 01832 ' Agency Code: RIEAKEII Federal Emptoyer's ID insured is Corporation Risk ID Number 000441036 ' �.__..�_.___--.--____.______.______� � ----r______..___ _..._---.____; [2] Policy Period ; From )u�y 12, 2004 to )uly 12, 2005, 12,01 AM, standard time at the insured's mailing address. � � ;� [3] Coverage A. Workers' Compensation Insurance - Part One ofi this policy applies ta the Workers' Compensation ; Law of the following states: Massachusetts ', E B. Employer's Liabifity Insurance - Part Two of this policy appliesto work in each of the states iisted ' i in item [3]A. The limits of our liabiliky under Part Two are: � ' � Bodily Injury by Accident - each accident $500,000 � ', Bodi]y Injury by Disease - each employee $500,000 , ' Bodily Injury by Disease - pokicy limit $500,000 ' � I C. Other States Insurance - Part Three of this policy appfies to all states, except any state listed in ' item [3]A. and the states of No�th Dakota, Ohio, Washington, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: ' ; See Extension of Information Page - Schedule of Endorsements ' _____--- ------ — � —_�.__ __.._._..w_ ' [41 Premiunti The Premium Basis and, therefore, the premium wi1! be determined by our Manual af Ruies, � Classifications, Rates, and Rating Plans. Afl required information is subject to verifkation and change by � .--audit. (Continued on anather page) _� �� _ _�",__ ._------_.___ ', �j �_�� -�j ��, ��'� � � �;�r/ ; J Total Estimated Poficy Premium s 1,340 �� TotalSurcharges/Assessments s 38 ��„��.� ?otal Estimated Cost $ 1,378 i1�/TERNAL USE �� Page - 1 - Informatron Page M�A : SAWC529218 WC Q04001A Date : 06/29/2d04 MAiVOTE P.O.BOX A-H,WiLKES•BARRE,PENNSYIVAN�A 18703 �� : � . , �� __ --=_� The Co�nnmonwealtl�of Massachuset�s � � DepaR�ne�rt of Indust�rial Acciden�s --_ - -= N�I�irlMf�i ' _ _ -= 6I/0 Washengwn Stree� �"'Floor -�,�r Bosto�,MQss. 02111 � Workera'Com�sahoe I�s�a�ee Affidav�B�il ' leedrical Co,haetors �: �� ,�� G- r� l��- addtess• 7� �- d �"�` pf2' � � �i� 1�� - . �vd d� � �y�j-Gr'�l �, work site locaa�rfuuu address�_ ❑ I am a homeowner performing alI work myseif. Proje�t Type: ❑New C�strucli��]Re,�nodel I am a sole 'etor and have no�e w in an c� ❑Buii ' Addition ❑ I am an employer pc�oviding wa�s' "at f�my�ployces woiicin�g on this job. � �r .d�'�,� r«� ��: �- - - -- �: -?� r ��f ��+ � t - �LG� 6`3 F � �'�` `�CrG� r � �� cs� qv� f� ; ❑ I am a sole proprietor,geaeral ca�tracMr,or�omeewte�(urdt oRt)ancl have hinad ihe contractors listed below who have the following wotkas'comPensahon Polic�: � � , � � � � � �� : ni�e�Y: � aaadnearv�: , , �= dt�r: eie��: Fa�u�e�s secvt ow�aa�e as reqafred�rder 3a1Ma 2SA�t MGL LS2 aa Ia�d b tMe�p�i�a�f crt�id pnfl�es K a�ae�b t1,3M.M a�dl�r eae yaus'ie�tieen�eat as wx8 as dvi pebltla id tbe feret�ta 3'I'Ol'WORK ORDER aid a Sre e[t1N.N a day apiaat�e. 1 odvsla�d that a apy of tib�taleae�t my be fer�vardal/e the Omae of lm�a�f IYe DIA tor averaae vra'16etde�. I do l�errby cerfffy xndcr e peiwa aw�pe�of per,�ary that die urfor�dtoe provdded eboae is b�re d n+ect , Signat�re Date �� Print name G 1 d i��IJ' D�/l��C�� Phone# d�o ' �� b f�1 efficial ese anly ds not�vrite�t6is are.a b 6e aaplefed by dty or!nm�1 dty or te�vn: per�N�ioede# �IB�Departoeet �� ❑cked�if fmme�ale reapsme b reqaQsvl �'s O�oe �HnMk D�t�mt e�attct PeTsen: P�e�li � t��-�) 1 I , ` � . � ' TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A F�OD ESTABLISHMENT PERMIT NUMBER: #OS-181 FEE: $30.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: � CoBerg Realty, 73 South Shore Drive,Bass River,MA Whose place of business is: Beach House at Bass River Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2005 BOARD oF HEALTH: Be�r�rt`h. (�''o+�clo�s,/�`h. ' � n��, v�e�� s�a�v� �4��.,�, R . �y i i.aoos Bruce G.Murphy, H,RS.,CHO � Director of Healtli THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-058 FEE: $50.00 This is to Certify that CoBerg RealtcT d/b/a T�each Ho�se at Bass River 73 South Shore Drive Bass River 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 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 adopted by the Board of Heatth,and e�cpires December 31,2005 unless sooner suspended or revoked. May i i,Zoos Bo�oF�al,�: ��►. �o�o.�, �bf�5. - ��, v�e�� R�t�. 8� � ��s� RrvR�v. ruce G.M hy, , S.,CHO Direetor of Health , C�e.�(OT? �P�6�`" _ �°`�R�o TOWN OF YARMOUTH BUARD O1F H� L'�',�k�� I� � � !� � �!!' � D o, "�'y APPLICATION FOR LICENSE/PE,I�I I =,, �1 4 jQ� 2 2 2004 F, ,.,s „ •.. �• �, �:. * Please complete form and attach all necessary dc�c�itn '` � December 1�9��TH DEPT. Failure to do so will result in the return of y�ur a plication packet. A I �� r .l��f �?. �C� LGL,eL ' r �� , E ' � � -3rJ 4/ 1/' , MA�LING 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 th�s form. _ __ - --- -- - --- _ _ -- - __ -- 1 - -__- -.___ -- ---_ 2. - i PoeZ ug�rators anu��list a anin:mum of two er:Zptoye�s currently certified in basic water safety, standard First Aid '. and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must ' provide new copies and maintain a file at your place of business. ; 1. 2. 3. 4. FQOD PROTECTIQN MANAGE�- GERTIFICATIONS: ' 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.(}00. 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 fite at your establishment. L 2. �E��^N�C�-iARC3�: Each food establishtn�t must have at least one Person In Charge(PIC)on site during haurs of operation. �, 4 L S l�. �7 ut� G. � '� HEIMLICH CERTIFICATIONS: All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich-�� Maneuver on the prernises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee eertifications 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. , �►ESTAURANT SEATING: TOTAL# OFFICE USE O�LY LQDG[NG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PBRMIT# LICENSE ItEQUIRED FEE PERMIT# _6&B $50 _L�BIN $30 1MOTEL $50 �� _INN $50 _CAMP - $50 _SWIMMING POOL$75ea. _LODGE �50 TRAILER PARK SS0 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT�{ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TO-100 SEATS S75 �CONTINENTAL S30 �6`�'"�� NON-PROFIT S25 >100 SEATS SI50 COMMON V1e'T. $50 WHOLESALE $75 RETA[L SERVICE: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'f# i _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 <25,000 sq.ft. S75 _FROZ.EN DrSSL'RT �35 TOI3ACC0 S25 N.��CHANGE: �to AMOUNT DUE _ $ �O•�� *""**PLEASE TUR1Y OVER AND COMPLETE OTHER SIDE OF FORM**""* ( a ''. 1 '` e � � � � . . g�.�.�►.,. ,,. f . ADMINISTRA.TION y '�. Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of anq 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 ' AFFIDAVI7'MUST BE COMPLETED AND SIGNED,OR I '� _. � . . . 7..,� � , � _ 4. ,� . , . ., . � _ . � � ` , , , : > ,�� °. ' CERT. OF lli1SURANCE 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 � � NO'�I�F•Pe�nitsxun,a�n�aall £r::�r�J��;e�_I �a[�pr..p�...h��-3?: i'�'��'�Ll��'"��'��',�.�-�s,'�'�-d�i'�- ' . �X_ _ , 'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003. SEASONAL ESTABLISH�VIENTS 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 C�MMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i � � - i . . f ADllITIONAL F UI�ATION POOLS ` ---- - ---__=—___—_ _ __ _ - _— �_ —. � ---_ _ ---------� _T�__ POOL OPEI�IING:All swimming,wading and whirlpools which have been closed ior�he season must be inspected ' by the Health Department prior to opening. �'UU��'VA'T�;K 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 CONSUMTR ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisaries. CATEI�iNG 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. � � �� +J-n�cee�-�--- ; � - -- ��-- � � �� _ —Froze�r e� r�� stc��:-��e�y basis__by a�t�t�_�tified lab._ Test results must be sent to the Health � Department. Failure to do so will result in the suspension or revocation of your�zen Desse�t�er�nit � ' ., --- i above terms have been met. : OUTSID�C �'�:5� Outside cafes(i.e.,outdoor seating with waiter/waitress service},�have prior approval from the Board of Health. OUTD(}OR COOI�i�, � Outdoor cooking,preparation,or display�f any food product by a retail or food service establislunent is prohibited. ; , , „_ ' : � ,��a€°�, � � � I � . ,,..e,: � � � � �� 3 �� : ��-�� ; „�. ,�_. _ -.�-� _ _.�,: �� ; � _,��.. �... . � .,x� . _ n a _ ,,, � . . .., £ .•„ _. � �� _ � »��: � '� �` � � , . . . .. ._, . �., , ... , . .. ( 10/22/03 HEALTH DEPT. � i � � , .•• �/�UA�R D� �arkers' Comoensation and Emfllover's LiabiGtv Policv NorGUARD Insurance Company ; INSURANCE Policy Number BAWC426075 � � O � � Renewal of BAWC324710 � NCCI No. [25844] Policy Information Page Endorsement _._-------._ __ _ __-----._._....__.�.__._._____��_ �---.___..__ �____.- ---.___,.__�_.—_.. j [i] Named Insured and Mailing Address Agency � BASS RIVER RECREATION, FNC. E.A, KEILEY OF MASS. � 73 South Shore Drive 45 Wingate St., Suite 402 � � Bass River, MA 02664 Haverhill, MA 01832 i Agency Code: RIEAKEII Federai fmpfoyer's ID Insured is Corporation ! ' Risk ID Number 000441036 � [2] Palicy Period 3 From July 12, 2003 to Juiy 12, 2004, 12:01 AM, standard time at the insured's mailing address. - , ; Er�dorsement ! Endorsement #1, effective on the date shown below, 12:01 AM, standard time, changes the i 4isted items. A11 other terms and conditions of the policy remain unchanged. ; WC890415 - PAYROLL - Eff, 07/12/2003 � � WC000308 - PARTNERS, OFFICERS, AND OTHERS EXCLUSION - Eff. 07/i6/2003 ' ,_.._ _ . .____._._._._,...___._.__�_, _�______.._.�__._..___._�.._ __,�.__._.__._._______�_�____.._ __. � [3] Coverage __._____, � A. Workers' Compensatian insurance - Part One af this policy applies to the Workers' Compensation ; Law of the following states: Massachusetts � B. Employer's Liabiiity Insurance - Part Two of this policy applies to work in each of the states listed , � in item {3]A. The Hmits of our liability under Part Two are: ' 8odily Injury by Acc�dent - each accfdent $SQ0,000 ' � 8odily Injury by Disease - each employee $500,000 7 8odi)y Inje�ry by Disease - policy {imit $500,000 I C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of IVorth Dakota, Ohio, Washington, West Virginia, and Wyoming, ' � f i � D. This policy includes these endorsements and schedules: ; See Extension of Information Page - Schedule of Endorsements � _ .___.__ _ __.__.�.._�_. __ ____ �_..�.r__ ......___w________..___. (4] Premium ` The Premium 8asis and, therefore, the premium will be determined by our Manuai of itules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by ' audit. (Continued on another page} ��. : '�otal Estimated Poticy Prem€um � 1,436 Total SurcharpesJAssessments � 44 , Total Estimated Cost $ 1,480 IN7 RNA�JSE__Ql Page- i - Endorsement MGA : BAWC426076 WC890600 ' oace : o9�oztz�as P.O.BOX A-H,WILKES-BARRE, PENNSYLVANIA 18703 a THE COMMON�VEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-054 FEE: $50.00 This is to Certify that CoBer�Realtv Tn�et d/6/a Be.�ch �Lce at Bass River 73 South Shore Drive, Bass River,MA HAS BEEN G�ZANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authoriry grantcd m the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is s�bject to the provisions of the Laws of the Commonwealth of Massachusettsrela#ing thereto,and upan such terms and conditions,and to the rules and regcilations in regard to said Motels so ficensad as adapted by the Board of Health,and expit�es December 31,2004 cuiless sooner suspended or revoked. M�rch 10_2004 BOARD OF HEAI,TH: Be��!. �, I�.$. ' /�#�ic�/ylc�S` e�er�etl, ?lscs��+c Rad�.rt 4. B� G�1� el�...�l�J.y R.tY. ,�.g.��.�w R.n+. B .Murphy,MPH, O Director of Healtli TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT FERMiT NL3MBER: #04-168 FEE: 30.00 In accvrdance with n��ions promulgated uuder authority of Chapter 94,S�tion 305A and�h�rpter 111,Section 5 of the ai Laws,a pernut is hereby granted to: � CoBerg Reaitv Trust, 73 South Shore Drive, Bass River, MA Whose place of business is: Beach House at Bass River Type of business: Continental Brea,kfast To operate a food establishmerrt in: Town of Yarmouth Pertnit expires: December 31, 2004 BOARD oF HEALTH: Bssr�rxiuc�1. �, �/.$. ' ��.�t, v�ef�,� �t�t�.a�, e� ��, �.lv. ,�a"� �,, a.�v. f MflTC�1 1�,2Q04 Bruce G.Murphy,MP , .,CHO D'uector of Health � � P�. y - -�°^°-�'�_,_ _ �.��.�_ �.- r , �'Gi Ch F-�tJLL'��. eD ��o�� f� � � � � �! (� D � TOWN OF YARMOUTH BOARD OF HEALTH�+, �� ° APPLICATION FOR LICENSE/PERMIT- 1999 �j� N 0 V 0 5 1�99 * Please complete form and attach all necessary documents by December 31, 1998. Fail HE �l':-s ' EPT. the return of your application packet. ' ------------------T�--------------------- ----------- ----�:L---------------------------------------L--#--3 s�-� C�! LOCATION ADDRESS� �? s�- s'�� . 1�/kcr�� w�. M ii ING ADDRES S� C RA N ER' N L. # ��'F �'Y MAII,ING A.DDRESS• �3 f�• �'�`-u-� �K �rs �.��- �OOL �ERTIFICATIONS: 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 ttus form. 1. 2. Pool operators must li�t a minimum of two em p"loyee"s currently certified in basic water safety, standard First Aid and Commwuty Cardio�ulmonary Resuscitation(CPR). Please list these employess below and attach copies of employee certifications to ttus form. The Health Department will not use p�st years' records. You must provide new copies and maintain a file at your place of business. 1. 2- 3. 4. HEIlVILICH CERTIFICA'�IONS: 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-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 t'rte at your place of business. I 1. 2• - 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# --------__.. _----- ----�_�_ ____ -----_- - _ � _— -- --- _ _- --- -- _ f3F��-t3��fl�� _--- --- _ � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 , �MOTEL $50 �� _SWIl�iMING POOL $SOea. ' WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQU�RED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT # 0-100 SEATS $75 �CONTINENTAL $30 � — i >100 SEATS $150 NON-PROFIT $25 _ _ __ _ __ COMMON VICT. $50 WHOLESALE $75 ; RETAII.SE�tVICE: ' LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 ^<25,000 sq.ft. $75 FROZEN DESSERT $25 ?25,000 sq.ft. $200 �AME CHANGE: $10 AMOUNT DUE _ $ � •*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•*" i �'� - � �.-�. ��"i . ,. _.._ . ` � , � ADMINISTRATION ° UNDER.GHAPTER 152, SECTION 25C, SUBSECTION 6,'THE TOWN OF YARMOUTH IS NOW REQtJIRED �O HOLI}�ISSt3A-�tC� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A � PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'5 COMPENSATION � INSURANCE. THE ATTACHED STA'�E WORKER'S COMPENSATION iNSURANCE AFFIDAVIT 1VIUST 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 4F YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TF� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY � DECEMBER 31, 19�$. - _ . __ _ _ ---- —. _ __ _ _ _ _ --- , SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENT FOR INSPECTION � 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. � ALL RENOVATIONS TO ANY FOOD ESTABLISF�vvIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIl'MENT, ETC:), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ! ADDITIONAL REGLILATIONS ; POOLS � POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR f THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND THE WATER TESTED FOR ' PSEUDOMONt75, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLO5ING: EVERY OUTDOOR IN GROUND SV�IMIVIING POOL MUST BE DRAINED OR COVERED � WITHIN SEVEN(7)DAYS OF CLOSING. � FOOD SERVICE � CATERING PO II�L CY: I ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH �, HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION , FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE ' HEALTH DEPARTMENT. FR�N DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII.URE TO DO SO WII.,L RESULT IN i _ __ _ THE�i 1CpFNSiON(�R RFVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS -- _ _ ----- - - HAVE BEEN MET. �� OUTSIDE CAFES: ' OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),�'�HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: ` � OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.OR FOOD � SERVICE ESTABLIS��VVSEEIVT IS PROHIBITED. j � DATE: 5IGNATURE: PRINT NAME& TITLE: � — _ — - _ _ — _ y . � _ - The Commonwealth of MassQchusetts ' � W Department ojlndustrial.4ccidents � a ofllceol/eres�losdyis � 600 Washington Street 7 y\�y � � BOS�O//� Mass. 02111 � �� V♦ W'orkers' Compensation insvrance'Affidavit namr: �(! � �1.r � /�� //�.� /G�K� location: !� �G- d 1i►�-f�r� /'�-�'"S`�� it� phone# �C!',• �(�� I am a homeowner pertorming ali work myself. � I am a sole proprietor�� ha�e no one ��orking in am�capacity [�f I am an employer pro�idino workers' compensation for my employees working on this job. C� -_ o m n • n /Y�T-C L�l.i /y'� v/J- .l.1 address: .��- '/-.��K"-� �lil�n.� /J/L/Ol. i • K/7l/!.4 . q• insur�nce co. policy# � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below� ��ho ha�e the follu��in� ��orker� �ompensation polices: ' comnanv name: address: . cil,y: �hone#: insurancc co. Folicy# com2�Y name• _ —-------- --- ---- --- -----—---- address• — ------- ----- — -- ciri: nhone M• insurance co. ,Aoliev M Failure to secure coverage as required under Section 25A of MGL IS2 n�lad to tbe iopaitioo ot erisi�al pe�alda of a 6�e op to S1,S00.00 a�d/or one yean'imprisonment a�w�ell aa civil penalda io the form o(a STOP WORK ORDER and a Aoe of 5100.00 a dar apinrt se. I a�denn�d e�a�a eopy of thu statement may be forwarded to the OfTiee of Inve�tigation�otthe DIA for eoven�e veri8eatiw. /do hrreby ce�if}�under�he pains und penalties ojpery'ary thar ll�t injornwtion providtd abovt is hue and eor►ed Signamre � �/ r��f`� T Print name �Le��02/f ��j��f�Pl�Cr Phone 1f �¢�'��o� ., ofTicial use onh do not w rite in this area to be completed by ciry or town oflleial city or town: Y�M�IIT� _ pennitAfeease N nBuildiog Department �Licensiog Board �eheck if immediate response is required 261 �Stlectmen'e Otiiee — -- - --- � — - -- �HealtA Department --__ ____ _ _ ZS��} 398--2231 eat. confact person: phone p;_ _,_ _ nOther Ire��ised i;05 P1A1 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: 99-199 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: Reach House, 73 So � h Shore l�rive, South Yarm�uth, MA Whose place of business is: Beach House Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 1999 BOARD OF HEALTH:�d� .�ettg�, C'�a.,�� oan G. �ul[ivan, �//., Vice C,hairma ,�066,�� .�w�, c�� a��iel�e�a�ol�hy-.�toope� ic � h[in November 17 , 19 9� ` B ce G.Murphy, MPH . ., CHO Director of Heaith THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-61 FEE: $50.00 This is to Certify that Beach House 73 South Shore Drive, Bass River. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity wid�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 Commonweatth of Massachusetts relating thereto,ac�d upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31, 19�unless sooner suspended or revoked. November 17 , 199� BOARD OF HEALTH: �ii/. .teffa�, ��i.al�ma� �oan� Jul�an� �//., Vice C,�irman � �06�� r�,�w.� c�� d,��s�� ruce G.Murphy,MP .,CHO � Director of Health '°�:�� C�1 C�T�"- .; q � � � rk 1 ��; _......._......._.,. � � ��^ � il �;� �.5i�� TOWN QF YARMOUTg BU ° � � �LTH ' `' " APPLICATION FOR LIC�NS� /PERMIT - 1998 ,1 A N 2 1 1998 i_;��;�-�"}-s i�;�";_'-r *Please Complete form and attach all necessary documents by December 31, 1997:�Fa�ixre to c�Ci�`� so will result in the return of out a lication acket. Y PP P -----------�----------------------------- �_�--- ---��,�-------------___------#___----- - - -- / � ✓L. G D S O �vr E J'� � S. , �-< ------------------------------------------------------------------------------------------------------------------ PO�L C�T�FICATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, - standard first aid and Community Cardiopulmonary Resuscitation(CPR).Piease list these empioyees below and attach copies o�employee certific�tions to this forn�. T��ea�th Department wiil not use past years records. Yoa must provide n�ew copies and maintain a file at your place of business. 1. 2. 3. 4, �jVILICH CERTIFI�ATIONS: All food service establishments with 25 seats or more must have at least one employee traznned in the Heinilich Ma.neuver 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 wilt not ase past years records. Yoa must provide new copies and maintain a file at yaur place of basiness. l. 2. 3. 4. R�SAURANT SEATING: T4TAL # NON SMOKING SEATS: TOTAL# . OFFICE,U�E ONL.Y __- �.ODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _B&B $SO �CABIN $50 _INN $50 CAMP $SO LODGE $50 TRAILER PARK $50 , �MOTEL $5 98•�o S WIM POOL $�Oea. �WHIRLP04L $25ea. �QOD SERVICE: LIC. REQLIIRED FEE PERM[T# LIC. REQUIRED FEE PERMIT# 0-100 SEATS $75 �CONTINENTAL 30� • ZS >100 SEATS $150 � NON-PROFIT $25 _. _„_„COM. VICT. $SO WHOLESALE $75 B�.1'�iL S�]13YL��'�: LIC. REQUIRED FEE PERMIT# LIC. REQLJIRED FEE PERMIT# _<50 sq. ft. $45 TOBACCO $20 <25,000 sq. ft. $?5 FROZ. DESSERT $35 >25,000 sq. 8. $24Q � AMOUNT DUE — � � f a � ADMINISTR,A,TION UNDER CHAPTER 152, SECTION 25C, SUBSECTI4N 6, THE T4WN OF YAR.MOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL 4F ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPAhtY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMI'ENSATION INSURA.NCE. THE AT'TACHED STATE WORKER'S COMPENSATION I1�tSUl2ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MLTST BE PAID PRIOR TO RENEWAL OR ISSU�iCE OF YOUR PERMTTS. PLEASE CHECK APPROPRIATELY IF PAID: YES 1u0� NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO D�CEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED A.PPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL�STABLIS�IMENTS ARE TO CONTACT THE kIEALTH DEPARTMEl'V'I'_FQR_ __ _____ _ ' _ I�3SPE��'fQN 7-�0�7t+�YS PRI(3R TU E4PEI�iIN�FOl.2 THE-SEA�dI�. — - _ ALL RENQVATIONS TO ANY F04D ESTAB�,ISHMENT,MOTEL fJR POOL (i.e. , PAINTING,NEW EQLTIPMENT, ETC.),MUST BE REPORTED TQ AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVJENCEMENT. RENpVATIONS MAY REQUIRE A SITE PL.AN. ' E , � i f ADD�„�,TIONAL RE�ULATIONS POOLS POOL OPENiNG: ALL SWIMMIN�i'r, WADiNC'ir AND WHIRLPOOLS WHICH HAVE BEEN CLOSED F4R'Y'HE SEASON MUST BE INSP�CTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRI+aR TO OPENING. POOL CLOSING: EVERY OUTDOOR IN GR�UND SWINIlVIING PO�L M�JST BE _ _ _ _ --B?[��V�l�i S�.��.�T(7')IIA�� F�bQSINSa. __ _--- _ ! _ ; FOOD SEItVICE �A�.�.�C'T � •I�Y: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILTNG'THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HQURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. � O�N i�"�SS �TS: FRiDZEN DESSERTS MUST BE TESTED �N A MONTHLY BASIS�Y A STATE CERTIFIED LAB. TEST REStTLTS M[JST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO VVILL RESULT IN THE SUSPENSION OR REVOCATIf)N OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. 5�.��F+..�_�� OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �'�HAVE PRIOR APPROVAL FROM THE BOAK.D OF HEALTH. ; _- � O 1L�'DOQR.Cd��IN�ir. . � OUTDOOR COOKING, PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A j RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. __ � -- ----- ; y _ , � � n� DATE: � SIGNATURE. � z I PRINT NAME &TITLE: ��l/`'�� -��J� �'L�� i � ! t i � I ; I 10/97 � ; ; page 2 of 2 , , � • � "�'��\ The Commoawealth ojMassachusetts � W Departmen[of Industrial.-1 ccidents T ; 011lceol/�st/osdfiis � 600 Washington Street , ,,•' Boston, Mass. 02111 �'" °�� W'orkers' Compensation Insurance Affidavit n.m�: U/L�- S / 2't'/l`��-- l�cati�n: �� 1< i !�f/G � �� it�� u�� l7 �� phone# ��Y �� s�� ( am a homeowner pertormin�aIP work myself. � I am a sole proprietor�.�� ha�e no one ��orking in am•capaciry � I am an employer pro�iding w�orl:ers� compensation for my employees working on this job. comoanv namt: h ��( (Jb�1 �+6� �� _ ___� _� _-___ ddress: ��-- 1 � (�^ W�- ; .: `�" L� �� , �� insurance � V � ��'� i #. ��y `� �U �"� � I am a sole proprietor: aeneral contractor, or homeowner(circle onel and have hired the contractors listed below �`ho ha�e the follo��in��orker� �ompensation polices: companv name: address• citv• phone q• insur�nce ca policy# �m�ny name• a�dress• ciri: ��ee#: _J _ , —�-�� _ —�� insuranscso. oolie,y ff ' Failure ro secure covenge as required under Secdoo 25A of MGL IS2 ea�lad to tbe iopaidoo o(erioi�al pe�altla of a d�e op to 51,500.00 a�d/or ' one yean'imprisonment a�w•ell as civil penaltiea io the form o(a STOP WORK OItDER aed a tine of 5100.00 a day a��iost ma I s�dersta�d trat a copy of thi�statement may be forwarded to the OlTice of Investig�tion�of the DIA[or eoven�e veritiutio�. /do hr�eby cerrifj�under�he poins and penallies ojpery'ury that tht injor►nation provided abovt Is hue and correct Signaturc �` � � l�a�� j Printname ��l�.i=�'j`2� ��P9 � PhoneN �G � � �!7 � .- o(Ticial use onl� do not..rite in this area to bt completed by city or town olffcial � ciry or town: y�M�IIT� _ permiNicenae q nBuildiag Department pLicensiug Board Q eheck if immediate response i�required 261 �Selectmen's ORiee (SUB� 398t2231 pgt. �Health Departmeet contact person: phone q;_ __ _ nOther (rt��is:d i;95 p1A1 � 1� I � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 98-40 FEE: $50.00 This is to Certify that C. Hag,berg dlb/a Beach House 73 South Shore Drive, Bass River,MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth 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, 1998 unless sooner suspended or revoked. Januatv 28 , 1998 BOARD OF HEALTH: C�c`� �e�es, ��i.airmarc �oarc C�. �ullivaa., K.//., Vice l..�irmah Ko�ert.}. 4�rowm, l..ler� adrieLle�a�io[ehy-Jd�ooPes • �e�0' ��. �,; Bruce G. Murphy,MPH,R.S., O Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NIJIVIBER: 98-125 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Secfion 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: C: Hagberg, 73 SoLth Rh�re Drive, Bas�River, MA Whose place of business is: Beach House Type of business: Continental Breakfast To operate a food establishment in: TQwn of Yarmouth Permit expires: December 31. 1998 BOARD OF HEALTH:��f. �et��, C'�t,�„na� �oan � �ullivan�K.1/., Vice l��irmarc Ko�erE.}, p�ro�vn� l�[er� � a�rielle�a�Zo[��ict-.�toopea 'i/ic�el oCo [in i Janu ,arv 28 _, 19 98 � ruce G. Murphy,MPH,R.S., HO Director of Health ,�'�-.-� � �� - ��p�`� l.3 e„��i-.N��s�M�ToR�od�,.� P cX" r,; , � - ;.,� � �riS t�= 4 -- �') TOWN OF YARMOUTH B�AI�"��I�iLTH JAN 1 5 1997 APPLICATION FQR LICENSE / PERMIT - 199 f--l�ALTH D�PT. * Please Complete form and attach all necessary documents by December 31, 1996. Failure to do so will result in the return of your application packet. 55¢��fl� ---- ------- ---- - -------� ---�' -------------------------------- NAME OF ESTABLIS�-IlVIENT: TEL. # — 2> ADD .ro- 6 G 6 MAILING AD RES �- R C RPO ION NAME• -u / MANA ER' NAME: -�- TEL.# �� ' � MAILING ADDRESS: �aL�i ------------------------------------------------------------------------------------------------------------------ POOL CERTIFICATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, . . . . __--- -�- - �i�esuseitatia�°�PR��-1is�t1��- _ - employees below and attach copies of employee certifications to this form. The Heatth Department wil! not use past years records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIQNS: 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. L 2. 3. 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL# ------------------------------------------------------------------------------------------------------------------ . _— __ . _-- — ---- _._ (1FFTf F iTCF Q�IL�---—-- .-------— . � LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# ' _B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 TRAILER PARK $50 �MOTEL $50 �_ SWIM POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# _0-100 SEATS $75 I CONTINENTAL $30 `1 � ' _>100 SEATS $150 NON-PROFIT $25 _COM. VICT. $50 WHOLESALE $75 RETAIL j SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft, $45 TOBACCO $20 , _<25,000 sq. ft. $75 FROZ. DESSERT $35 >25,000 sq. ft. $200 — � O� AMOUNT DUE — �� t 4 - ! : ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSONOR COMPANY DOES NOT HAVE A CERTIFICATE OF WORI�ER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE � COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: PERNIITS RUN ANNIJALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQiTIRED FEE(S) BY DECEMBER 31, 1996. SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY j REQUIRE A SITE PLAN. c ADDITIONAL REGULATIONS i , POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPEI�IING. � POOL CLOSING: EVERY OUTDOOR IN GROUND SWIl�RVIING POOL MUST BE ' DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. - � t FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE ; YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY j 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 $USPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), ; MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. � i : __ O�J __ ___ _ ----- -- - ___ ---- - - --_ _ , OUTDOOR E�OKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A � RETAIL OR FOOD SERVICE ESTABLIS�IMENT IS PROHIBITED. � l �� DATE: � SIGNATURE: PRINT NAME & TITLE: � �� C� �� ; � 9/96 page 2 of 2 1_! , . , � ...._.. •.M-.-q--� The Commonwealth o Massuchusetts � r �� ;'��, L �1 C�a [� f �;.� .... ... � J Department ojlndustrial,-�ccidents � 6�x�� 5 �� 01I1ceol��s�►�s�liis _ o � 600 Washington Street i-��. 1'�,,�yi�,'j�°�• �,� y��y BOS{O/.�Mass 02111 �� W'orkers' Compensation Insurance Affidavit : namc: ll� �V�ie .(�T ,f ��'' . R location: �� )'d�- � �� • �� - � '��y'6 �6 � � I am a homeowner pertorming all wo myself. � f am a sole proprietor��,� ha�e no one��orkin_ in am•capaciry _ I am an employer pro�idins workers' compensation for my emp oyees workins on this jo�j _ __ /r!,',��1��'` om n • n : - '� � �� ' address• � � �t �?��v ��l -��~� � �i. .��'. � f W � ( G61��t � insurance i # � I am a sole proprietor. general contractor. or homeowner(circle onel and have hired the contractors listed below ��ho Ma�e the follu«in��orker�' �ompensation polices: companv name: ' address• ' �i�y: �hone#!• _ insurancc co. policy# com a�nv name• —__— _ _ _ _ address: __. __ ---- - gj,ty• Fhoee#• insurance ca ooliev M Failure to secure coverage as required under Secdoo 25A of MGL IS2 ea�lud to tbe imposition of erioi�l peealtla of a O�e op to S1rS00.00 a�d/or ; one yean'imprisonment a�w•ell as civil peaalNes io t6e form of a STOP WORK OItDER and a liee otS100.00 a day apinst ma I s�dersta�d t6at a copy of thy statement may be forwarded to the Ofliee of Iave�tigatloa�of t6e D1A for eovenge veritieatiw. 1 do hrreby cerrij}�under rhe pains and pena![ies ojpery'ury that tht injornwtion provided abovt is!nu and coneci Signaturc �/�G � � —�r Print name Phone�l 3Q L'�� / ., otTicial use onh� do not..rite in this area to be completed by citv or town offlcial ciry or town: Y�M��T� _ permitAieeese p nBuildiog Department �Liceasing Board �check if immediate response is required 261 ❑Selectmen's ORee �Health Departmeot contact person: phone#;_ �508� 398-a2231 egt. nOther Irev�sed 3;95 P1A1 � � � .• � . NUMBER FEE 97-139 THE COMMONWEALTH OF MASSACHUSETTS $30.00 .... ..?�.... of .YAR1vI0UTH........................ Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .:--........ ..JAIVUARY, 29=... 19.9?.. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter I I1, Section 5 of the General Laws a Permit is hereby granted to: C. HAGBERG, 73 SOUTH SHORE DRIVE, BASS RIVE�t, MA ....................................................................................... Whose place of business is .B��.HOUSE.AT,BA5S,RIVER............................... Type of business and any restrictions ....�INENTAL BRFAi�'AST,,,,,,,,,,,,,,,,,,,,,,, Tooperate a food establishment in ....Y��....................... ............... (City or Town) Permit Expires .... ...Pk�k�.3�.,�19..9.Z. � ��C�•�v�.s. ...� Board .....�M'. . .. of �f�� ,�'L�/:,jj Health :::::��--�� :.=/�-A.j��: .... • PORM 738 A.M. 9ULK�N COMPANV •� ,.///�e� �� NUMBER FEE 97_49 THE COMMONWEALTH OF MASSACHUSETTS $SO.00 •---•-TCIGVIV............... of .---•-YARA�IOUTH-.__......--•---•-----------------••- I Board of Health � This is to Certify that .............C�...NAGBERG.D/B/A_BEACH.HOUSE AT BASS RIVER � --•.................•----...........----•---------- i -----------------------------------------73--SOUTH--SI-IORE DRIVE, BASS RIVER, MA - -•--...----�-------•-------•-••---•-----•........................•---•--...._._,_........ � HAS BEEN GRANTED A LICENSE TO OPERATE � � �� MOTELS � i This License ia issued in conformity with the authority granted to the Board of FIealtli, 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 Massaehusetts relnting thereto, and upon such terms and conditions, and to the rules and regulations in regard to eaid Camps or Cabins so licensed as adopted by the Board of Health, and expires December 31st, 199Z::.. nles sooner suspended or revoked. .............. ��--.... --- M � -� Board •-----.JAI�I[JARY-29-'--.--------19---97 :_:::::� . ��---_�----�.�/--_.. - ------------------�--- of --------- . .. ...-if'=`iJ'' ' '- -- � -- ---�.� Health Original License Fee �`j�xiVC !• ��Zvw�+�.., Renewal Fee By�...................•--•-•- FOFM S 525 A.M.SULKIN,INC.-BOSTON (617)542-5858 TOWN OF YARMOUTH BOARD OF HEALTH _ - �� Q�; ' r APPLICAT�ON__FOR LICENSE/PERMIT_-_1936 �i �C' ' � -- C/� �� ^�� r ------------------------------------------ -------------- NAME OF ESTABLISHMENT:__�L (.� ��2_i •v'v�n`-' �„�j EL. NO.!_� _ __ �-- ADDRESS�..__-� ------- -- - -- ----- -- MAILING AllURESS (IF DIFFERENTj_: ------ OWNER/CORPORATION i�TAME:____.�.__ .- — - MANAGER'S NAME: _ TEL. NO. _ --`.-� MAILING ADDRESS: RESTAURANT SEATING• TOTAL '� �_ NON SMOKING SEATS TOTAL # Under Chapter 152, Sec: 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 Co. does not have a certificate of saorker's r�►��ion.---ins�'ance•.- �e attached State Workers' Co�ensation Insurance Affidavit m�st be aompleted and signed . Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes!_` no _ ----------------------------------------------------- All food service establishments with 25 seats or more must have at lease 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 their certifications._ 1•__._------------------- --- — 2. -- -- 3. _ 4' __ Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and CoRanunity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to , this form. 1• ---__.��-- -- 2' --- --- - 3. _ 4.` ___ __ ------------------------------------------------------------------ OFFICE USE ONLY LICENSE REQUIRED: FEE: PERMIT #. LICENSE REQUIRED: FEE: PERMIT FOOD SERVICE _�MOTEL $50.00 �o__ 0-100 SEATS $ 75.00 CABIN $50.00 __�_ ��OVER 100 SEATS $150.00 � TRAILER PARK $50.00 _ _ , ` NON-PROFIT $ 25.00 ___ INN . $50.00 __��. �CONTINENTAL BREAKFAST$ 30.00 �f-� ---�-LODGE $50.00 CO1�Il�70N VICTUALLER $ 50.00 t' c� $50.00 SWIMMING POOL ( ) $50.00ea. _ _ VAPOR BATH/ ( ) $25.00ea. __ WHIRLPOOL RETAIL E'OOD SERVICE Less Than 50 sq.ft. ,prepackaged candy,gum,soda,chips $45.00 _ LESS THAN 25,000 sq. ft. $ 75.00 � ^ MORE THAN 25,000 sq. ft. $200.00 __.__ FROZEN DESSERT �` � SOFT-SERVE ICE CREAM $ 35.00 TOTAL DUE $ �V� TURN OVER TURN OVER TURN OVER TURN OVER PAGE 1 OF 2 r ADDITIONAL REGULATIONS: � n ', �6 ✓, t � CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST N07.'IFY 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 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 REVOCATZON OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE , BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE) MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. FAILURE TO OBTAIN PRIOR APPROVAL I FROM THE BOARD OF HEALTH WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FOOD SERVICE ANI) COMMON VICTUALLER PERMITS. '' OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD ' SERVICE ESTABLISHMENT IS PROHIBITED. EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. � RESULTS FROM POOL WATER TESTS BY A STATE CERTIFIED LAB MUST BE RECEIVED BY THE HEALTH f DEPARTMENT PRIOR TO OPENING. ' 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. REI�VATIONS MAY REQUIRE A SITE PLAN. ' 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, 1995. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPT. FOR INSPECTION 7-10 DAYS � PRIOR TO OPENING FOR THE SEASON. ` APPLICATIONS MUST BE COMPLETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT 'UNTIL THE ABOVE TERMS HAVE BEEN MET. A HEARING BEFORE THE BOARD � OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. � ' DATE � W/L/(�/ SIGNATURE o�G� � � . _ - -__ _ ---_.�__ _-w-��- __ _ - -- - PRINT NAME & Title ___��,�GL.� �__ IMPORTANT: THESE APPLICATION.S N1[JST BE COMPLETED IN FVLL AND SUBMI4TED ON OR PRIOR T�O D�IIt 31, 1995 OR YOU WILL BE SUBJECT �O AN ADMINIS'ZRATIVE HEARING. 11/95 4 ( PACE__� aF a _ __.__ � � 4f f 4 � � � , . �.....'� I� I _.�__ �-- -_. .�l'� � � -- � _ -- - . _ � �` �" The Commonwealth oJMossachusetts � � Department ojlndustrial,accidents � o 011lce o!/er�s�lysdliis � 600 Waslrington Street �, ,,•� Bnston,Mass. 02111 "' "� W'orkers' Compensation Insurance Affidavit _ n�mr: G�c�Z 0��'� -�1�( �l I `cG�v�— L�cation� Z� y �'` �� `� � �it� ��f �� hone q ��'��6� � ( am a homeow�ner pertormin�all w�ork myself. � ( am a sole proprieror �:;� h��e no one �t�orkin� in am•capaciri� � I am an emplo�er pro�idin� w�orkers' compensation for my empioyees working on this job. compan�• name• �1Gf[f"��`- (�Jc'�'�y /�'� ��d'x � �u``'(�'c." . a:i::ess: 7� ) �• /�'� ��' it �(Z"/ G Gv`�L� �, �� . �_� insurance co. �� /v� �glicy# �il� Q G°c �15�5" �5� 3I � I am a sole proprietor. :enerai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed below �tho ha�: the follu�cin� ��orker�� .ompensation polices: �qmoanv name• atldress• ;�y• phone k• inc��r�ncc co Roiicv# sompanv name• addres�• �,y: ohoee It• _ .._ _ .. __ fnsorance cn_ ` �o�ri,� _ D Faiiure to secure coverage as required under Section 25A of MGI.1S2 ta�iad to tht iaposi000 of erimiad peaaltles of a 6oe ap to S1,500.00 a�d/or one years'imprisonmeat as w•ell aa civil penaldea io tht form of a STOP WORK ORDER aod s tioe of SI00.00�dr�y apinst ma I a�dtataad t�at a copy of thy statement may be forwarded to the Ofiice of Invatigatioas of the D1A tor eoven;t verititatio�. I do hrreby eerrijy�under rhe pains and penalties ojpery'ury that Iht injormatinn providtd abovt is tnit and eoirtet Signature ��.�✓�'�� Date ��!� Print name 1��`v�� '►'S°��'i- Phone�l 3��-��b r .. o(Ticial use oniy do not N rite in this area to be compieted by city or towe otiieial - city or town: YA��TQ _ permiNicea�e M nBuildiog Department pLicensiog Board �check if immediate response is required 261 ❑Sdectmen's Otlice �Health Departmeat contact person: phone q;_ �508} 398�2231 ezt. nOther NUMBER FEE 96_8 THE COMMONWEALTH OF MASSACHUSETTS $�jO.00 ..-•-'.�1�j----------------- of .._.__�'.A�MOUTH----•-----.....-----------•---••---.... Board of Health , CLIFFORD HAGBERG d/b/a BEACH HOUSE MOTOR LODGE ' Thisie to Certify that ••-••-•-••••-•-•._....••--•-•••••••-•-••-•-•-••------•-------••-••---••--•---•••--•------------=-•-•---••---••••••------•- .-----73._SOUTH..SHORE__DRIVE_r...S.Y.-----.---- -----•----... ' -------------�---------------�--�----------......_.._._.......---._....-------... HAS BEEN GRANTED A LICENSE To OPERATE ��. �� ' , MOTELS 1�{!ID ' This License is issued in conformity with the authority granted to tl�e Board of Flealth, by Chapter 140, Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such terms and conditione, and to the rules and regulations in regard to eaid C�q�ps or Cabins so licensed as adopted by the Board of Health, and expires December 31st, 19__.�.::_ unle soo r suspended or revoked. � � » / . ae.rV�-�.� �� •-•••••-•-••---- •• •-------------�•---•-••-•-•--�------.....--•••.---•-• Boa ---MARCH--15-'--------------------19_._96 -•-------••--- ----- ------•-•-•-1----- - -----------�� -- r ..................r!..�.�..�.�k'��__._.. .._ . �, of , _..--••••----•--------- - -- ------ -- . . . - ------ ,/ _ . •-----------------•- - �-- - - - Health ~��__'_ �..._��i��I'�.. Original License Fee � _ Renewal Fee B �•_�'=_��--�'� Y••------.... .._.._.....- • •---•-•-•�--_.... FOAM S 525 A.M.SULKIN,INC.-BOSTON (677)562-5858 �� j� I i i E � i I � � I � i i i G s e__ce===e=====e===e==��c��===ee_=c��e��==��e===eee:�c�v��e=�a=v_=��ee=ece==ec�e��=�=e=__=e=av�=��=��=n=e�x=e�===__=a=e_e_e_: ISSUE DATE IMMIDDIYYI CEHTIFICATE UF INSUAANCE --- � � 81111l96 ____________________________________________________________________________________________