HomeMy WebLinkAboutApplications, WC and Licenses fi �-
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� � TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT-2009 �� '
� ...e �. . , . G�I�CCI�OI�/C�I�
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* Please complete form and attach all necessary doc�ri c ' � 1� 8� 6 ?OQq
� � Failure to do so will result in the return of yo�i�a,��li�atio�p'�c �
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� NAME OF ESTABLISHMENT: ��,s.��,-,?, �-a,�� TEL. '
' LOCATION ADDRESS: ;�9�- �2,�,� S'� Gv. y�.,,�,»a..,r�� �2,�-. Q 2..4 ,�
� MAILINGADDRESS: S/ � /?2s� �Sr (,� .�=/,���,,� jL2sr. ��.�� a
OWNER NAME.ax-+� � �7•vGs TAX ID (FEIN or SSN)•
CORRORATION NAME (IF APPLICABLE):
' MANAGER'S NAME: TEL. #
' MAILING ADDRESS:
� POOL CERTIFICATIONS:
� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this farrn.
1. 2.
i
i Pool operators must list a minimum af two employees currently certified in basic water safety,standard First Aid and
� Community Cardiopulmonary Resuscitation(CPR). Please list these empioyees below and attach copies of employee
certificatians to this form. The Health Department �vill 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 axe required to have at least one fiill-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Cod� for Food Seivice Establishments, 105 CMR 590.000.
Please attach capies af 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 f'ood establislunent must have at least one Person In Charge (PIC) an site du1-ing hours of operation.
1. 2.
HEIMLICH CERTIFICATION :
S
All food service establishments with 25 seats or more must have at least one employee nained 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.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING: � '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
_B&B $55 _CABIN $55 r MOTEL S55 �a
—mN �5� _CAMP S55 _SWIIvIl�1INGPOOL �80ea.
_LODGE S55 `TRAII,ER PARK $105 _WHIRLpOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
_0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT $30
_>100 SEATS �160 _COMMON VIC. �60 _WHOLESALfi $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
—<�0 sq.n. ��0 _>25,000 sq.ft. $225
VENDING-FOOD �25
_<25,OOOsq.ft. �80 _FROZENDESSERT $40
_TOBACCO �55
NA�ZE CHANGE: �io AMOUNT DUE _ � 55,�Q
****'"PLEASE TURr OVER�L�V'D CO'VIPLETE OTHER SIDE OF FORM �
**.*x
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ADNIINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED 5TATE WORKER'S COMPEN5ATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED '�D �- �,��
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 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 ar
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS �
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days
pnor to opemng.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected
and opened. �
POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count `
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE I
� E
�
CATERING POLICY: I
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hows 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 sea.ting with waiter/waitress service),must have prior approval fromthe Board ofHealth.
OUTDOOR COOI�TG:
(}utdaQr c��king,preparatiQn,s�ispl�.y of any food product by a retail or food service establishmem is prohibited.
;
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
�
ALL RENOVATIONS TO ANY FOOD ESTABLISHN�EN'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.
� DATE: � ��� SIGNATURE: � ���'�
^� �i.,t.��'[-` �iz
PRINT NAME&TITLE: � �-) ���-� `} � ` '
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- JAfV, 2b, 2009 3:49PM HART INSURANCE N0. 824 P, 1 �
ACORD�, CERT�FICATE O� LIABILlTY INSURANCE oii�s�z�a o
I ;ovuc�t THIS CER7IFlCATE IS ISSUED A5 A MA7"fER OF INF014MATION
� HART INSURANCE AG�NCY, INC- ONLY AND CONFERS NO RIGHTS UPON ni� c�Rr��icasE
243 MA1N STR�ET HOLDER. Tl�iIS CER77FlCA7E DOES NOT �11END. EX7'F_ND OR
ALTF�Z THE COVERAGE AFFORDED BY 'fNE POLICIES eELOW.
PO BOX 700
; sUZZARDS BAY,MA 02532-4700 � ��su�Rs�a�w�coveRaGe NAIC�
' �Eo Irish Willage Restaurant and Pub,lnc. �AISURERA, Ci NITE SYATE INS RAN E 23809
512 West Main Street �asuReR e:
� West Yarmouth,MA 02673 ,Nsua�c:
�Nsur�a
�N$URER E:
� OVERAGES
j 7HE POLICiES Of tNSURANCE LISTEO BELOW FIAVE BEEN ISSUED TO Tl1E iNSURED NAM�D ABOVE FOR YME POUCY PERIOA INDIGA7ED.NOIWITM57ANDING
� ANY REQU11tEMENT, TERM OR CONDITfON OF AIYY CON7RACT OR 07FIER DpCUMENT WITH RESPEC'�'TO NVFi1CH THI&CER7IFICATE MAY 8E ISSUED OR
' MAY PERTAIN,7HE INSURAPtC�AFPORDED BY 7HE POUCtES bESCRIBED tiEREIN IS SUBJECT TO A��7NE 7ERMS,�%CLUSION$ANJ CONR7ITIONS OF SUCH
POLICI£S.AGRREGA7E LIMIT$SNOWN N1AY HAVE BE�N REDUCED BY PAID CLAIMS.
'R D POl�CY NUM6ER PGY PWxY EXPRATiOH LJMIiS
� O�NERAL WIBINTY EACH OCCURHENCE S
CpMM£RCU1l3ENERALIWBILITY PREAII oca+ ee $
ClAIdAS MADE �OCCUR MED E1�P ene Cer�+on) S
PENSONA1.8A0'VINd�1RY i
GENERAL.AGGREGATE E
G�N'tqGGREGA7EUMITAPPLIESPER; . PROpI1Cs$-Cp►ApAp,�AGG S
�L� PRO- LOC
° AUTOMOBLE UABit.tTY COM61NE0 SI�dGLE LIMIT a
� ANrAUTO (�+�1�)
ALL OWNEO AU70S
80DILY I/i.WRY s
sCHEDVLED aU'fos (Px peison)
MRED AU70S ' BO�ILY INJURY
NON-0WNED AI,T�O8 (Per a0dderq 8
PROPER7Y OAM�GE s
(PeraaGGenU
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'� GARA6E LIABILRY ` ALJTO ONIY.EA ACC DEM' _
ANY AU70
OTNER 7MAN ��c a
AUTO ONLY� ACaG S
E7[CESSlUMBRELLa LIABlU7Y EACN OOCURRF.�E S
OCCUR a C},qIMB biADE A6GiR�GATE S
_ S
oEDUC1'IBLE s
RE7£N7�ON '''t:
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� �,,,pwO����"""'a WC6842932 04/01/08 Q4/01/09 srA u. orH-
ANY PROPR1E70R1pARTNE�IEXECU7ryE E.l.E11GH ACClOENT a 500 000
O��CER+eaEMBER DtCWDE07 g,�,.Ot�yFASE•EA EMPLOYEE S SOO OOO
uyes.aoswiee�n�eee �
SGECIAL p v�stoN.s nebw E asrnsr.PouCr uMIT s 500 000
o��rt .
�SCRP'nON OF OPERATipNS!LOCATIONS t YEHICLES r��(d.�pp�g qpDED BY ENRDRSEMENT/SpEC1AL PROVISqNS
�Ot2�
a��r�ovr�o
° JAN 2 7 2�09
:ERTIFICATE HOLDER � CANCELLA'C10N
SlIOY�O/Wv OF'7xE nBOV!D6SCiqBED POiJC�S BE CANCflLED BEFORE 7'►�E EfLPIRATION
TOVIM OF YARMOUTH vA�TM�oF,THE{95yM0�BURER WILL ENDEAVOR T'p MAIL 30 onrs wameN
1146 MAIN STREET �e rn n�c�enAcnrE Noir�x war�eo ro Tn��,eur R�o.uRe To uo so s►w�
S YAi2M0UTM, MA Q2673 �!p�����������Y�D U�N TNE INSURER,rrs nr,�Nrs oR
R�+RES�lI7ATNE.R,
AUZMOR�D RFI+RE�NYATNE
►CORD 25(200�/08) O ORATIOf�f 1988
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„ .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLTMBER: #pg_p46 FEE: $50.00
� This is to certify that John J. Hynes, Jr., Pres. d/b/a Beachway Motel
498 Route 28 VVest Yarmouth MA
� HAS BEEN GRANTED A LICENSE TO
� OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D aud 32E as amended,and is subj+ect to the pmvisions ofthe Laws ofthe Commonwealth ofMassachuseits relating
thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2009 unless sooner suspended or revake�.
January 28 2009 BOARD OF HEALTH: .��/t S���y (?����
�aurtee .�.J�'xtlil�c►x,j `U�ice C'1ta�nuuc
* 14 Units; 14 Bedrooms ��J�ItatUltl�(:C�fl�
1 Manager's unit;3 Bedrooms �►�.
�,..t`'!�'..�•��
ruce G.Mutphy, S.,CHO
Director of Health
i
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� � � TOWN CjF YAT� IVIOLJTH Health
� Divisiot3
_
11�6 RQUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 '
�air,,,,�,o �� Building
Telephone(50$) 398-��31, Fax{508) 760-3472
Division
November 8, 2007
Irish Village Holdings LTD
dlb/a Beach�Vay Nfatet
498 Route 28
W�st Yazm.outh,MA 02673
Re: 2008 Motel Licenses
Dear Motel Owner:
As you are aware, the Town of Yarmouth is working to facilitate the motel license process to
encowage the appropriate utilization of motel properties. To that end, the licensing procedure
has been reworked, and additional materials developed.
Enclosed please find the following materials relating to your 2008 Motel License:
• Application for LicenselPermit
• 2008 Motel Census
• Motel License GuidelineslProcess Flowchart
• Motel Use Inquiry Form
Please complete the application and census according to the instructions provided. Please note
that applic��ion���erials are to be filed with the Health Division by December 14.2007.
The Motel Inquiry Form is being provided for yow convenience, should you have a question
regaxding the current utilization of yaur property far norr-trartsient use.
Questions regarding non-transient use or the Motel Inquiry Form should be directed to the
Building Division, 508-398-2231, ext. 261. All other qu�stions should be dir�ted to the Health
Division, 508-398-2231, e�. 24L
Thank you in advance for your cooperation.
Sincerely,
nice G. Murphy,Director of Health
<._ � J�} a
�,�-�-, � �/i�'t�-,-x.,.�..�.���,..� .
mes Brandolini,Building Commissioner
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� �°f:aR�.o TOWN OF YARMOUTH BOARD OF HEA,�,��""�� Q � � ' � �
� -�� APPLICATION FOR LICENSE/P�R�T Z��7 �
r; ..�:� �, o� ¢ �;� D E C 1 9 2006
* Please complete form and attach a11 necessary�do�i�n "��iy Decem er
n �'A�� d�PT.
Failure to do so will result in the return ofy�dur apphcation pac .
Nt�ME OF ESTABLIS��V�NT: �C�c.11�. TEL. # Sc��?/-e.oa
LOCATION ADDRESS: y/9� �2�,,.,,�,.s i.,,r 'Lj�-9y
MAILING ADDRESS: S�t�
OWNER NAME: �r�� �, 11� �` �l�(�,,�5 �� TA�T�(FEIN or SSNI- _
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: ,i'� G�y.,�e� TEL. # s ��- ?��-��
MAILING ADDRES S: 5 �g-n�-�
_
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
;
' 1• 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a fde at your place of business.
1. 2.
3. 4.
' FOOD PROTECTION MANAGERS -CERTIFICATIONS:
j All food service establishments aze required to have at least one full-time employee who is certified as a Food
� Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
; Please attach copies of certification to this application. The Health Department will not use past years' records.
j You must provide new copies and maintain a file at your establishment.
I
l. 2.
�
; PERSON IN CHARGE:
j 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.
i
l. 2.
3. 4, '
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERMIT# LICENSE T2EQiJ1RED FEE PERMIT# LICENSE REQUIEt�'D FEE PERMIT#
_�B sso _c,vg�r �so I MOT'EL $so 07�c�
INN $50 _CAMP $50 _SWIIvA�IING POOL$75ea.
LODGE $50 _TRAII,ER PARK $100 WHIItLPOpL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQITIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $I50 _COMMON VIC. $50 WHOLESALE $75
RETAII.SERVICE: —RESID.KTfCHEN $75
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQUII2ED FEE PERMIT#
y<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20
_Q5,000 sq.R. $75 _FROZENDESSERT $35 TOBACCO � $50
NAME CHANGE: S10 AMOUNT DUE _ $ � .O O
'*=""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••"*
�
;
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town af Yarmouth is now required to hald 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
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
;
OR i
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
k
...... _ .. . . _ .. .____ ._. _ _ _ . . . _ _ _ ..�
. _ ._. __. .. _ . . _ . .
MOT'ELS AND OTHER LODGING ESTABLISHMENTS �
TRANSTENT 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 ha.ve 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 (30) days, and an
aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest uflit as a residence or
dwelling unit shall not be considered transient. 4ccupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amendeci, sha11 generally be considered Transient.
POOLS �
i
POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected `
by the Health Department prior ta opening. Contact the Health Department to schedule the inspection five(S�days
pnor to opening.
POQL 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 therea.fter. �
POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or cavered within seven(7)days of �
closin�. -- ____ . __ __ _ _ _ _ _ _ ,
FOOD SERVICE
CATERING P4LICY:
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.
;
FRUZEN 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: f
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
�
e
_ _
— - ----_ �
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, 2006.
ALL RENOVATIONS TO ANY �OOD ESTABLIS�-IlViENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
I
DATE: �vI 2z �d� SIGNATURE: ;
PRINT NAME&TITLE: I
10117/06
�_ - •
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i Ac�Ra� c-��Ti��cA-r� o� ��Ae��ir�r in�su�►�c� ����,
' '''�D1�� 11117l2006
HART INSURANCE AGENCY, 1NC. ONLY ANQR pNF ��s�Q���p�aRTM����°E
243 Mi41N STREET HOLDER, 7HI8 �ERTiF'ICATE ,ppE.a, NpT AAAEN�, EXTEND OR
PO BOX 7'OQ ALY�R THE COVERA�E AF�4RDE0 B1f 'THE PaLICI�S QELOW.
BUZZARDS BAY, MA 02532-070Q �Ngu�R,g q�ORoiNc3 c;ov�RA�E
��D Irish�Iiage Rest'au.rant and pub.Ina ►Nsu�a,,: q���� URaN E C PANY ���
Siz West M�in Street 189z
If�WiER B.`
West Yarn�outh,MA 02673 ��&q�
INBUREk P.
1 URER E:
COVERAGES
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MA1Y PERTAIN,THE INSURANC@ AFFpRDED BY 7HE POLIGES DESCRIBED FIEREIN IS SUWECI'TO ALL TH�TERMS,EXCLUSIONS ANp GnNDlTICNS QF$UCH
POUCIES.AGGREGATE LMIU'1'S 61i0WN t�,qY HAVE BEEN 1iEpUCED eY PA�CLA�{NS.
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snouin�tr oR n�naove oEsc�e�o Pcucies ee eiweet�c s�c�nie ocr�twx
' TOWN OF YAi�MQUTH ti^�TM��,n��sua�a nrsua�R wni�a�►voR�ro�u�. 3o DAYS WRJ7TEN
1146 RT 28 NoncE'ro t�cr���No�wwEn To'1ne�r,6YT FAIWRE TD DO SO SI1AlL
S YARMOUTH, 1YIA 02�� ��N������n��K�NO UpON TIIE NBUpHl,�'f$I�NTg pR
� SENTkTI{l�a,
AY7NORR�REi�RESlNT
ACOIiD�5(2Go11a8) �
• O ACORC?��p�tPS3�d1TlON 1988
THE COMMQNWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-028 FEE: $50.00
,
�� This is to ce�vty mat Irish V'illage Holdings LTD d/b1a Beach Wa Motel
498 Route 28, West Yarmouth; MA
HAS BEEN GR;ANTED 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 canditions,ffid to the rules and regulations in regard to said MoteLs so licensed as adapted
by the Board of Health,and expires December 31,2QQ7 untess sooner suspended or revoked.
March 27.2007 BOARD OF HEALTH: B ut�. /��., .
��s� �'�v..��i�e��
a�t�B�, �►�,�
�����
� �v���� R.�.
ruc�G.Murphy, R S.,CHO
Director of Health
� _ �, �o c d
�
� ;'`R.� TOWN OF YARMOUTH BOARD OF HE . '���; [� � � � " � �r� �u
� o_, � � ''y � APPLICATION FOR LICENSEIPE�R�T=2�06 - �(�N 1 , 2006
`` . . ..,s t. � 9
* P lease comp lete form an d attac h a ll neces§�iy documents by Dece ber 31 2005.
Failure to do so will result in the return ofyour application AL'�i"H DEPT.
NAME OF ESTABLISHMENT: � � ���'j TEL. #__ Sd� z 7 / -olo�a
� LOCATION ADDRES S: ��'B' !'��--iyv ��'-- � y e��r,�,�� ,•.,,e9--�z� 7
{ MAILING ADDRESS: ..�'t._.�. •�6c;
I OWNERNAME: f''� G ��. 2 7�-s�' T ..or
� CORPORATION NAME(IF APPLI LE):
� MANAGER'S NAME: p � .vL TEL. # .S' Q-�- �� ^���
MAILING ADDRESS: S !Z r2�ir s t L�� G1�� �'z ,/��¢ i�zlr 7.�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by 5tate law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
L � `i��-�� �' S 2.
Pool operator�must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Healt6 Department will not use past years' records. You must provide new
copies and maintain a file at your place af business.
1. 2_
3. 4.
�
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
, 1• 2.
i PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2.
HEIl'b��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�ae�i eopies of employee certifications to this form. The Health Department witl not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3• 4.
RESTALTRANT SEATING: TOTAL#
OFFICE USE UNLY
LODGING:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50 I MOTEL $50 �aQ�
_INN $50 _ �CAMP $50 I SWINIlVIIlJG POOL$75ea. �'G b�G�
�LODGE $50 _TRAILER PARK $50 WHIRLpOOL $75ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# :
�0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 �COMMON VIC. $50 WHOLESALE $75
RETAII,SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 i
_Q5,00�sq.$. $75 _FROZENDESSERT $35 _TOBACCO $25 �
NAME CHANGE: $10 AMOUNT DUE _ $ �''`�� ;
- ;
f1 fe A R RpLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM•"•"" �
_ �
!
t '
ADMINISTRATION �
�
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is naw 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
Compensation Insurance. THE ATTACHED STATE WORI�ER'S COMPENSATION INSURANCE
AFFIDAVIT'MU5T BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED t� �� Qj' � �X' � i
OR � � t �,�Jti�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ��
Town of Yarmouth t�es 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. ',
f
SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- !
10 DAYS PRIOR TO OPENING FOR THE SEASON. ;
ALL RENOVATIONS TO AN� FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW k
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BdARD OF HEALTH PRIOR TO ;
COMIV�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. i
�
�
1
ADDITIONAL REGULATIONS
�
POOLS E
�
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY: i
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post f
Consumer Advisories. �
CATERING POLICY: �
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requireri �
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the j
Health Department. �
I
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 ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the ;
above terms have been met. �
i
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 prohibited.
DATE: �� v SIGNATURE: �
PRINT NAME&TITLE: � �' ���"'`� "' �� �
i
�
�
� o9izs�os �
;
;'
�,
� s
. .�
771 -'3305
�ICaRDT* CERTIFICATE �F LIABILITY INSURANCE DA7E(MMIDWYYYI�
osr�si2oos
� PRODUCER ON)Y�,4Nd�CON ER5 NOE Fi1Gti'S UPON HE J CERTR I�FI AT E
HART INSURAMCE AGENCY, INC. MOLDER. THIS CERTIFICATE DOEiS NOT ANIEND, E)(TEND pR
� 243 MAIN S'fREET p�.�"�� '�� �Qy'E►iqC�� ,qppOROE;D 9Y TH� POLICIE$ BELQW_
PO�OX 700 '
BUZZARDS BAY, MA 02532r0700 INSURERS AFFORDING COVERAGE NWC#
' iNsu�o Irish Village Motel INSUR�RA AIM INSURANCE COMPEIIVY 2g
512 West Mai�Street INSUftER B: '�
West Yarmaur.h,MA 02673 INSURER C: � '
INSURER D: ^
INSURER E: �
coveaaces '
THE P LICIES F INSLIRA►yC�USTEa B�LOW HAVE BEEN ISSUED 70 71iE INSUR�O NAMED ABOVE FOR TFIE POLICY PERIOD INDICAT�D.NOTIMITHSTANDING
' ��CGNDITkON OF ANY CONTRACT pR OTHER OpCl1MENT y�itTH RESP�CT 70 WHlCN TMI:� CER71F1CATE MAY BE ISSUED qR
MAY PERTAtN,THE INSURAN�E AFFpRp�p BY THE P4LICIE3 DESCRIBED I1ER�IN IS SUBJ@CT TO ALL THE TERMS,EXRLUSIpNS AhIP CONDITIONS OF SUCH
� POWCI�B,AGGREGATE�IMIYS SMOWN MAY FIAY�BEEN REDUCED BY PAID GLAq�AS•
114SR ADD'L�— P EFFECTPIE POLICY EIIPIRA7fON '�����
�7R POLIGY NIlMBER �Ry
GENERAL LIpBILiTY EACFi E1fx'LIRRENCE $
COMMERCIAL GENE:RAL LIABILJTY PREMIS!?fi En occunnca S �
CIAIMS MADE �OCCUR MED EXi�+ y ane parson) $ y
PER80NAL&ADV INJURY 8
GENERALAtlOREQATE 8
� GEN'L AGGftEGAYE LId11T APPLIES PER: P�p�JC7S-COMPIDP AdG. S
� � POLICY PRO- �� . . . .. ..
�
� AUTOMOBILE IJABIWTY COM81NI=t)31NGLE LIMIT
� ANy AUTO c�e�a�ln :
� ALL OWN�O AUYO$ � - � � �
BODILT INJURY =
SCHEDULED AUTOS (Per persm)
HIRED pUT05 B(�pILY INJURY
NON-0WNEpAUTOti (Pxacckientl �
�� PROPERT'f pAMA�� �
(Pw sedtbd)
GartnGE upBiurv �+UrO OPILY-Ea ACCIOEN'C a
_TI qNY al,ITp OTHER 7HAN �'A� $
AUT'0 OMtY: AGG S
EXCE9S/UMBRELLALIABIWTY EACH p(:(�URRBNCE S
OCCUR � CWMS MADE - � AGGR�GATE S
I
_ a
�EDUCTIBLE �—
� RE7EN710N s _—,—�„�,._.. S
� VYONKER6 COMPENbA710N AND wC E�TATU- QTH- 3
A EMPl,0YER9��uieu�rr WMz8004199012D05 041011p6 04/01/07 Y ,.,,,,,__
�ANY PROPRIETORIPARTNERlFXE:CIJTIVE E.L EACH A[x10ENT S �jQ�()Q�
j OFFICERlMEMBER EXCLUDEd'!
Iy E.L DISEA$E•EA EbIP�,OVEE S rJOO C�OO
If �,����� B�4 P1S8AS@-AOLICY LIMR s 5QQ QQQ
SP�CIAL PY10wSiDN6 dow�w
OTHER
i
i
� OE6CRIPTION CF OPEiiAT10N9 r LACATIONS I VENICLFS f E7LCW$IpNS ApplD 9Y pNDORSEMENTJ SPECIAL PROYlSIONS
� I�e: �eachway Mat�l, 4u8 Main Street,West Yannouth, Alla. 02fi73
CERTIFlCATE HOLDER CANCEUATION
-�,....,�._
BHOULD ANY OF THE ABOVE DESGI�ED pQL�CIES BE CANCELLED BEFORE TX!�l(pIRA710N
TOVVN OF Y�RMOUTF! bp�TM���TME ISSUIN6 INSURER WW_ENqepyOR TO AAAIL 30 DpyS wRrREN
1146 R7 2$ Nat�eE TO 7F+��n��ca�no�pot qaaeo�C�niE I„�F7,BYT FAILIIRE TD DO SQ SHAL�
S YARMOUTH, MA 02644 �+Pose Nn oauw►rionr os uaeum oF 1 UPON TH�MJSURER,IT9 AGENTS 01t
REPRE9ENTATNES. �
Aunioeaeo�r�
i
aCORD 25(2001lOS} � �ACORD COl�OR,4TION 9 988
Z0 3�tid h�d 3�Nti�If1SNI labH 99�L65L895 Z5�ET 900Z18Z/90
�
- �. , .
THE COMMONWEALTH OF MASSACHUSETTS
' TOWN OF YARMOUTH
BOARD OF HEALTH
;
PERMIT NUMBER: #Q6-056 FEE: $50_OQ
This is to cerafy that Irish V�illage Holdings d/b/a Beach Wa Motel
498 Route 28 West Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornuty with the authority ganted to the Board of Health,by Chapter 140,Sections 32A,32B,
i 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
' thereEo,and upon such terms and conditions,and to the rules anci regulations in regard to said Motels.so licensed as adopted
� by the Board of Health,and expires December 31,2006 unless sooner suspended or revoked.
� June 27,2006 BOARD OF HEALTH: ,Q �' ' �. �j��, /��.�
� c��/��el���/� , NC✓r./.����u�����G�/�ust
� Qo�Bl�6i�. LTi�Of�lt� (i�¢�I�
p����
�4.t.� !�'�d�-.�.,�, R./V.
ruce G.Murphy, H, .5.,CHO
Director of Health
I
�
I
I
i
�
i
, � b
� o�°'Y`�
� � ;� ��o T N F YA UTH
1 � - `'3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4
j �M�`TACHE�� Telephone (508} 398-2231,Ext. 241 — Faat {508) 760-3472 `� � � � � M � D
' ,�y� �RPORAli0�6
j B OAitD OF I-€ Et� LTH .JUL Uh ZOOS
HEALTH DEPT.
�
To: A112005 Yarmouth Board of Health License/Permit Holders
From: Yarmouth Health Department
Re: Tax Identification Numbers
Date: June 1, 2005
The Massachusetts Department of Revenue is now requiring that the Health Department furnish
to them detailed information regarding all permits and licenses that we issue. One of the required
details is to provide a ta�c identification number, whether it be an establishment's Federal
Employer ldentification Number (FEIl� or, in the case of an individual's license, a Social
� Security Number (SSl�. This information will be used by the Health Department purely for
administrative purposes only.
Would you 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,
please do not hesitate to ca11. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The
telephone number is(508)398-2231, e�rt. 241.
Establishment: �Gz��1 � M�u��� FEIN or SSN: � -� �
: > � �!
Location Address: ��� �� �
��`� !�.
�,- �
Signature: ��t/ �Li� �
Print: ��s, ��� ���'(u u c� �< M Title: c" � �'1
��
� Printed on
; � Recycled
`� Paper
- ` (,��'6�� 2�A'�'�j 8��c:H-un�wr
2 0�:aR�o TOWN OF YARMOUTH B'DAR�O [�� s � [� � � � �
o._. �'y e APPLICATION FOR LIC �'��� " 2 � �„A� 2 � 2005
�: , .;;r � �y: �
�r� r\� ` t �' .
* Please complete form and attach all neces "` � o °�'ents by D ber 31 2004.
Failure to do so will result in the retu ' your application p ��-TH DE�'T.
NAME OF ESTABLIS�-IMENT: .F3 ,�A("h/G,/A� 1`?D T�L TEL # 77��03q,,,�
LOCATION ADDRESS: �q8 � TE �8
MAILING ADDRESS: Sa�ne_
OWNER/CORPORATION NAME: �ass W �4�C�.�G,
MANAGER'S NAME: �Sa�� TEL. # s Q��
MAILING ADDRESS: �Saa��e-
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. !'Soss k/ l"I�Cr.tr�l�' 2.
Pool operators must list a minimum of two empio ees currently certified in basic wat�r safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
; employee certifications to this form. The Health Department wilt not use past years' records. You must
provide new copies and maintain a file at your ptace of business.
1. �DSS �i✓ ! %�C.urCl��/ 2. /�c���� ! / [ I c(,Cl�si
3. 4. 7
,
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 59Q.00Q
Please attach copies of certification to this applicaxion. The Health Department will not use past years' records.
� You must provide new copies and maintain a fde at your establishment.
1. 2.
PERSON FN CHARGE: _ _ _ . _ _ _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at 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 file at your place of business.
1. 2.
3. 4.
RESTAiJR1�NT SEATING: TOTAL#
OFFICE USE ONLY
LODGING: '
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMfT# LICENSE REQUIRED FEE PERMIT#
BBcB $50 CABIN $50 I MOTEL $50 �S� (�a'
_INN $50 _CAMP $50 � SWIIvIlvIn1G POOL$75ee. �'O '��
LODGE $50 TRAII,ER PARK $50 WHIl2LPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 '
>100 SEATS $150 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_<50 sq.& $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ /o�S�O O
'"••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••'*•
r
�' __ -
r
ADMINISTRATION L
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's .
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE !
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �- ';
�
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ''
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annua.11y from January 1 to December 31. IT IS YOUR RESFONSIBILITY TO RETURN ;
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. _
�
SEASONAL ESTABLISHIV�NTS ARE TO CONTACT THE HEALTH DEPARTMENTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASQN. !
1
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 COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
i
ADDITIONAL REGULATIONS �
�
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected F
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter. (
:
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing. �
FOOD SERVICE
CONSUMER ADVIS�RY: �
Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products aze 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.
;
FROZEN DESS�RT�: - _ - _ _ _ _ _ �
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 waiterJwaitress service),must ha�re prior approval from the Boazd ofHealth. �
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. i
DATE:� d� SIGNATURE: � �
PR1NT NAME& TITLE: oss �CDu G� i
10/22/04 i
�
;
C
: :
.
� .
- —=---� ?7ie Comnionwealth of Massacl�usetts
� _ -
� = - = Depart�neat of Industrial AccidenLr
+ -_ — �i/i
_ - --- � 6f16 Washington Stree� 7��'Floor
�,,, Boston,Mass. 02111
workus'com�ao■Lsvawce A��,�B�ii • bi��/Eleelricai co■aYeMrs
�,< �.,. ..-
�_ ,o,�.,�_. � ,.. ,
.� _ _, u ,_ -, .
.. � ,. � , ��.� . , � ._ . _. �.
nam�_ �r,ss �c/ �`Ciu�o�� ,7)BA .:BEACif1.J�IY /%DTE'L
address: —t q� ���- Z+�S'
, �i�v ��sf I�Q rm o� `�� s�te• H -n• OL��3 nhode# �O&�� 77S D 3��
work site locati�rfnll addressl:
p I am a homeo„�ner i�erfo�ing au wa�k m,rselt: Projed T,�pe: ❑xeW,ca�vcaa�pRemoae�
I am a sole ' and have no o�e w ' in an ' . �Bui1 ' pddition
❑ I���P�Y�PrD�idin8 waa�ke�s'compensatio�f�my employees working a�thi�job.
��: ,54�� _ ,_ _ _
,
�; S a..�r
�r: S�r•ne � �
�
� ❑ I am a sole proprietor,g�eral coitracMr,or�omeo�ec(circlt out)and have hued the con�cWrs listed below who have
the following worlcas'compensation Polices:
c_�: ��.
#�
, �m�ez
� �u:
�• ��,
-- _— --- —
------- -
___ __ -
� -
FaOemc r aec�re a�era�e as nqired uder 3ectlK 2SA�tMGL 1S2 m lad a tl�e��t�twid psfNia�f a�e�p b S1,3N,M a�d/�r
Ne�an'�t an wea as dvll peatlda ia tie fira sta 3T0!WORK ORDER a�d a mte e[S1M.N a day apiet ie. 1�d t6at a
apy�tib�fale�t my 6e firwat�dal!s He Omce of Im��t tre DIA far oswrase vqillntly,
r���y�„ay�y,�„ e �penrhiea of pe�jxry tJrat dYe urforui4llon provdded abnv�e ia d�re aad corr+ecb
�'� �n d/ /`�a y o S'
Priut name O SS � c u�"c� L Phone# J'-O�'�775-Q.3��
e�ial ese only do aot wrlte it tW am te be aa�plaed DY dty'ar Irwa s�al
c�'°r te�r°' Per�ocase# I�Reid�e�t
❑��r�ax.��.���.�a ��
��o�
���
��� ��'
I -. :� ��Ib3� �Ia�`�
OF_Y'9R * � �
�_ ,r: o TOWN OF YARMOUTH BOARDµ� �TH
o _. .";y APPLICATION FOR LICENSE. � -2004
r , ,;? ,� NOV 1 2 2003
* Please complete form and attach all necessa ,.`- cuments by Decem ���•DEPT.
Failure to do so will result in the return � our a lication ac
� �� PP P
__
N��E OF ESTABLISHMENT: �EpCMf�lAY rio�r"E� T # ��S-03q9
LQCATION ADDRESS: 4 q 8 Rte 2�
�Vt�L�iG ADDRESS: �a m�
QWNER/CORPORATION N�ME: ��ss Wo MrCu.rdy
MANAGER'S NAME: ��rne. TEL # -s Qrn r
M�.AI�,ING ADDRESS: sam�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Poo�Operator,as required by State law. Please list the designated
-Poo�(3p€�a#�r�s}�-s��c�-�-cc�py of the certiftcation t�this form.
1. �oss 1� M C Cur-olv 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuseitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department witl not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. �oss Gl /`?rC'ure�,� 2. �'laz�/ /`?Cfit✓'a��
3.�icrltiarri zS`f�vens 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
- _ _ _ _ _ _ _ - _ ,
FE��lv=�i,�iAR�E:-_ _ _ _ _
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fite at your place of business.
1. 2. '
3. 4.
RESTAU�ANT SEATING: TOTAL# .
QFFICE USE ONLY
IADGING:
LICENSE REQUIRED FEE PERM[T# LICENSE REQl1IRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
_BBcB $50 _CABIN $50 �MUTEL $50 ��=6�3
- _INN $50 _CAMP $50 � SWIMMING POOL$75ea. �'�� �
LODGE $50 TRAILER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�t LICENSE REQUIRED FEE PERMIT#
_0-10�SEATS S75 _CONTINENTAL $30 _NON-PROFIT S25
>100 SEATS $l50 _COMMON VICT. a50 _WHOLESALE $75
$�TAIL SERVICE:
LICENSE REQUIRED EEE PERMIT# LICENSE REQUIRED FEG PERMIT# LICGNSE REQIIIRED FEE PERMIT#
<50 sq.ft. $45 _>25,000 sq.ft. $200 _VGNDING-FOOD $20
_�"25,000 sq.ft. S75 _FROZEN DESSGR'P �35 _TOBACCO �25
NAME CHANGE: $to AMOUNT DUE _ $ I Z..S •OO
**"**PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM***"*
�
.. - .• !
ADMINISTRATION
Under Cha.pter 152, Section 25C, Subsection 6,the Tovm of Yarmouth is now required to hold issuance or renewal .
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insuranee. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �'
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
�
E
CERT. OF INSURANCE ATTACHED �
�
Q$ �
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 v� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN `
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION�-10 �
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO, ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING; NEW �
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
�
ADDITIONAL F ULATIONS
�
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed fbr the season must be inspected I
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter. €
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
�
FOOD SERVICE
CONSUMF.R AI,VISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATEIZING PQ I Y:
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.
FRn ,F.N DF.C�_F,RTS�_ _ ______ _ _ _._ _ _ _ �
-_ _ _ _ _ _-- --
--- _ - - - - _ ,
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSID� C FF'�
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOOR C04I�N :
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
I
I
DATE: �' /I fcJv D3 SIGNAT'URE: � �
PRINT NAME& TITLE: s ` ' c c� E
10/22/03
� •• � ,
_ The Co►nmoawealth ojMassQchusetts
� � Department ojlndustrial�-�ccidents '
� ; OJ11C001/OVCSIIofdl/t
� 600 Washington Slreet
� •� Boston. Mass. 02111
� " "�y Vh'orkers' Compensation Insurance Affidavit
Annlicant information: Please il�TTe�.'i+� '
namr: �os s �i� ��C l,�D:� .�.t�/� ��Q�1�1tts� ��te�
ls�cati�n: ��� �fe- Z�
cit� ��Sf Yarmm�elv2, �'1 f} C9��� 3 ehone q ,�8'� �7�.�`�3 p `/
� I am a homecwner perturming all work myself. ,
� f am a sole proprizror�r.� ha�e no one��ori�in_ in am�capaciry '
� I am an emplo�er pro�idins:w�orkers' compensation for my empioy�ees w•orking on this job.
companl• name• �iE��lY�J/gY �b7EL
address• ��?vrl� _
ciEj•: .5 a r»C. phone 1!• .S a�n e
insur�nce co Aolicy# ____—
� I am a sole proprietor. ;enerai eontractor, or homeowner(ci�cle oneJ and hace hired the conaacton ►isted below ��ho ha�e
the follu��in_ ��orkzr�� ,ompensation polices:
comQany name•
��dress•
ri..,•• Rone M•
insur�ncc co �olic}�1
eomoanv name• —
■ddr se• -—
Sjty: ehnee M•
ineuranr��n_ pp(��*
�
Failu�e to seeure coverage as required under Secnoo 2SA of MGL lS2 ea�iead to tbe iepaidoe of criei�fl pe�dtles of a ti�e op to 51�00.00 a�d/or
oae yean'imprisonment a�w�ell a�civil penddes io the torni of a STOP WORK ORDER aed a tise uf SIOOAO a dar K�iost ma [a�denla�d t6at a
copy of thi�statement mav be fonv�rded to the ORice of Invatiguiont of t6e DIA[or eoven�e verifiatio�.
1 do hrreby cenif}�under r ains and penaUies ojperjury that tht injorn�ation providtd ebovr is ttwe and eorr�et
Signaturc �' /l�atr �d3
,
Print name ss ��uv'c� one M �oF�77.�'O3 9 9
.. o(Ticiat use onlv do not w�ite in this area to be completed by eiry or towa eAleiil
city or town: y�M�IIT$ _ pertnitAiceeu k nBuiidiog Departmeot
�Liceasiog Board
�cheek if immediate response i�required 261 QSeiectmen's Ofiiee
�HnItA Department •
contact person: phont N;_ �508} 398�2231 ezt. nOther
.n. .��. ' :]t�,� .
�
�
� „ . .
1 THE COMMONWEALTH OF MASSACHUSETTS
; TOWN OF YARMOUTH
� BOARD OF HEALTH � �
PERMIT NUMBER: #04-013 FEE: $50.00
This is to certify r.t�t Ross W. McCurdy d/b/a Beachway Motel
498 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 Boa�d ofHealth,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 upan 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 31,2004 unless sooner suspended or revoked.
Decetnber 3 ,2003 BOARD OF HEALTH: Beicfa�rrin �. �,/��1. '
n�c�a/�c.�` � �/ice���s
Rod�t� B�x�„ �
_ ___ - -- _--.- _ _ d/�Sl�_R./1 --- --
ruce G.Murphy,MP , ,CHO -
Dir�of Health
THE COMMONWEALTH OF MASSACHUSEITS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-024 FEE: $75.00
'rhis is to cercify that Ross W. McCurdy d/b/a Beachway Motel
498 Route 28. West Yarmouth MA -
IS HEREBY GRANTED A PERNIIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beachwav Motel -OLTTDOOR POOL
: 498 Route 28
This peimit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires Decetnber 31.2004 unless sooner suspended or revoked.
December 3 ,2003 BOARD OF HEALTH: �e��rr�stt�. ��,JJN$. e�Ca�
� nc.�c�Mo�1� ?/r'��ai�rxa�
Rodw�zt�. B�, �
- �Sl�, R.N.
. B
R
Director of He�altli �
1
� �., � � . B�wAy
, oF_Y'�R � . �= � �,�i:�"'" n i�; r' �
2 ,,. �. TOWN O�'YARMOUTH BOA��I,I� , � E� T� � � , � ,; ,�
_ .o � � ti L� �
o_ _ '�� �1PPLICATION FOR L�CEN5�fP'��1���'��00 �' - .,
� �� •''r �� �6��( ��_�, � � ��Q�
.. ..,,-..
* Please complete form and attach all necessary documents by Dec�h e 31 �QO��, .
� Failure to do so will result in the return of your application pack �-�'==�'�'��-,.��p�€�'��"�•
i
1
! E ST L C �� . # 7.5-a.�
' C RE '
i �1AILING ADDRESS: s4�„+�..
� OWNER/CORP�RATION NAME•
� ' E• oss �_��� ��u TEL � 77.S�-D3��
�
MAILING ADDRESS: �C��n
, �
, -�r, b� u,�d.a,�� i k �Ine.. s�r�r� w1+eH iu� ��e���;
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. b s �✓ ��C r� . 2. /�i G�,r� ,L��'uti7Gs�
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certif cations 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.
j L 2.
; 3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATION5:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
'� You must provide new copies and maintain a file at your establishment.
1. 2.
- - P�R�ON��r�r�G�T---
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�
1. 2.
{ HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURAN'� SEATING: TOTAL#
QFFICE USE ONLY
LODGING:
� LICENSE REQUIRED FEE PERMIT# LICENSE Rf;QUIRGD FE� PERMIT# LICENSE REQUIRGD FEE PERMIT#
_BBcB $50 _CAB[N S50 / MOTEL $50 �6a3
_INN �50 _CAMP $50 �SWIMMING POOL S75ea���
_LODGE �50 _TRA[LER PARK $50 _WHIRLPOOL $75ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,
_0-]00 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 �
_>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE• • I
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_<25,000 sq.ft. $75 _FROZBN DESSERT $35 _"COBACCO $25 �
I
NAME CHANGE: $�o AMOUNT DUE _ $ /z.5. 00
*****PLEASE TURN OVER AND COMPLETE OTHER StDE OF FORM***** I�
r
� y
� .,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Warker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �,
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND AT"fACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i
APPROPRIATELY IF PAID: � NO
YES
NOTICE:Permits run annually from January ] to December 3 i. I i'IS YO�.TR R�;SPUNSIBILIT�'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002.
SEASONAL ESTABLISHIUIENTS ARE TO CONTACT Tf�E HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
I
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
I
TO COMMENCEMENT. REN�VATIONS MAY REQUIRE A SITE PLAN. ;
I
AnnITtONAL REGULAT�Q 1�S k
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected `
by the Health Department prior to open�ng.
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
i
closing.
�
FOOD SERVICE
�ONSUM �R ADVISORY:
Each food establishment wluch 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
requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtamed at the Health Department.
FROZEN DESSEB'TS_. __ - � k
-�rozen�sserts must be teste on a monthIy basas by a State certitied 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 CAF�S•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOK�NG: :
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
.7
DATE: /�cx.�— �� Z--SIGNATURE:
PR1NT NAME&TITLE: �S s � � e u�, G� � `
,
i
i
10/18/42 �I
�
. �, �
�
The Conrmoaweulth of Massachusetts
� � Department ojlndustrial.-1 ccidents
" o OfJlC0o1/�stJoflJiit
' � 600 Washington Street
' = Bnston.Mass. 02111
�
�~ �� w'orkers' Compensation lnsurance Atfidavit
Aoolicant information• pq� �pg��.-�
�m�: � �/4����7 /7�7� L � i 1 oS5 �� �1��tlY"�'[f/
LczCat�n. '`� � b L//G71N ��� J�J� �j�'
�
' � ,3-G� ��.��D�
� t am a homecwner pertormin�all work myself.
� I am a sole proprieror�r.,a, ha�e no one«orkine in am•capacin�
� I am an emplo�er pro�idino w�orkers' compensation foc m��empioyees w•orking on this job.
comoam• name•
��1 d ress:
titv: nhone t�•
insur�nce co. Ro i y t!
� I am a sole proprietor. generai contractor, or homeowner(circle one/ and ha�•e hired the contractors listed below �ti ho ha�e
the follu��in_ �.ori�er;� �ompensation polices:
s9moanv name•
address•
citti•• hons li•
insurancc co. noliev#
s4moanv name•
—--
_ --- -
_ _ _-- — ---
address: _ _ -- -- ------------- i
�': nhoee M•
ine�ra_nss�o. noliev�!
•
Failure to securt coven�e as required uoder Seenoo 25A of MGL 1S2 ca�kad to tbe iepo�itioa o(erisi�i pesdtle�of a Au op to 51�00.00 a�d/or
one years'imprisonmant a�w•ell a�civil penaltie�io Mc form ot a STOP WORK ORDER aad a Ase of S100.00 a day qaio�t ma [r�dersta�d t�at a
copy of tha statemcnt mav be for.varded to the 0flice of Inveatig�tioro of tbe DU for eovera;e veritiudo�.
/do hrreby cerrif}•und tb poins and penal�ies ojperjury that tl�t informotion providtd abovt fs trrit and eorrect
i
Signature !3 /�pt� O�-
Print name ��rs � �CC ur�y Pl+one 1�-5��', ��.S ` D`3��
.. olTicia! use only do not r►�ite in this area to be completed by ciry or town oAteial
ciry or town: Y�M�IIT� _ permit/lieenu M n8uildiag Departmeat
�Liceasiog Board
❑cheek if immediate respoese i�required 261 �Stleetmen'�Oliice
�HealtA Department -
coneact person: phone M;_ �508� 398�2231 eat. nOther
.. ..� :<�,�: �
,
.. -
; THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMI"T NUMBER: #03-023 FEE: $50.00
I
; This is to Certify that Ross W. McCurdy d1b/a Beachway Motel
j 498 Route 28 West Yarmouth MA
�
i 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 ofthe Laws ofthe Commonwealth ofMassachusetts relating '
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said C�bins so licensed�as adopted
by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked.
January 9 ;2003 B0.4RD OF HEALTH: (��'��, i��(li�i, (��
�D.��e�D.. �l/iee
���D�
��Sl�k, ��l.
� � ,7
g - ��d�w�d.y- ",+
�
Bruce G.Murphy,MPH,R., ., O
Director of Health �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
_
PERNIIT NITMBER: #03-044 FEE: $75.00
Tt►is is to certi�y that - Ross W. McCurdv d/b/a Beachway Motel - ` . . ,
49$ Route 28 West Yannoutl� MA -
IS HEREBY GRANTED A PERMIT ;
To`Operate a Public, Semi-Pubtic Swimming or Wading Pool
At Beachwav Motel - OUTDOOR POOL
498 Ma.m Street
West Yarmouth MA :
This permit is granied in canformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires_December 31.2003 unless sooner suspended or revoked.
January 9 ,2003 BOARD OF HEAI,TH: �a7fee.�f, ��, (�ua�c
��D. G�i°'rda�c. 'j11.D.. 2/�ce ��
�o�it�, b�ao�a.a, L�
�a�tick�cc9ar.rrot�
�f� .�lra��,y ��Z.
',_ . 2�r' /�'i✓_'�"�/
ruce G.Murphy, H . ., H '
Director of Health
�.� - t.
� �
; - - --
t -
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The Conlmonweolth of Massachusetts
� � Department of Industrial.-�cciden[s
T o Ofllce ol/eres�l�stl�is
600 Washington Street
�� ' ` Bnston. Mass. 02111
�'~ ��y' V4'orkers' Compensation Insurance Atfidavit
� Aoolieant informallon• pq�sepg��,�y,�
n�m • � C� � F �' /�O rE
Lucation: �f' c1 �' M d r t4 :�T.
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a I am a homeowner pertorming all wor myself. '�—
� ( am a sole proprizror���ha�z no one��orkin� in am•capacit�•
� I am an emplo�er pro�idin�w�orl:ers' compensation for my employ�ees w•orkine on this job.
s2mnam• name•
address•
cit��: nhone M•
iosur�nce co. p�Y#
� I am a sole proprietor. :enerai contractor. or homeowoer(circle onel and ha�•e hired the contractors listed below �tiho ha�e
the follu��in� ��orkzr� :ompensation polices:
s4m�anv name•
address•
citti: nhons M•
insurancc co. Qolic}#
comoanv name•
--_ _—__ _ --
address• . — _
�': ehoee+�•
insurance co. D9��* ;
e
Failure to secure coveraee as requ�red under Section 25A of MGL 1S2 w lad to t0e iepo�idoa oltrioi�l peadtles o(a O�c op to Sl¢00.00 a�d/or
one ywn'imprisonment a�w�ell a�eivil peaalNa in the form of a STOP WORK ORDER aad a(iae of 5100.00 s dar Kaiost ma I a�denta�d tbat a
copy of thH satement mav be fonv��ded to the OfTice of invatiefuom ott6e DtA for eoven;e veritiutia.
I do hrreby cenif}�unde th� rns und ptrtalties ojperjury thal!he injoineotion p�ovidtd a6ove is true and corrtd
Signaturc � /�O IL �2a�+!
Print name o � c��.Cv� r one N 7 7�—G3 9�
.- olTicia!use only do not r.rite in this area to bt completed by city or towa oAlcial
city or town: YA��� _ permitAieeme k nBuildiog Departmeot
pLiceasiog Board
�cheek if immediate response ie required 261 �Seiectmen'�OlTice
�Health Depanmeot
contact person: Pho��p�_ (508� 398�2231 egt. nOther
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� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-010 FEE: $50.00
This is to Certify that Ross W.McCurdy d/b/a Beachway Motel
; 498 Main StreetlRoute 28.West Yarmoutha MA
� HAS BEEN GRANTED A LICENSE TO
� OPERATE MOTELS
� This License is issued in conformity with the authority granted to the Boazd of H�,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
i� Massachuseris relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said
J Cabins so licensed as adopted by the Board of Health,and�pires December 31,2002 unless sooner suspended or
� revoked.
March 7 ,2002 BOARD OF HEALTH: s'rf. ��,
� D. G�l�rda.�. .�lee
, �o�rt? ��a�x. �ik
� �a.�tlek�arurot�
.�
ruce G.Murphy, R . HO
� Director of Health
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THE COMMONWEALTH OF MASSACHUSETTS
' TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-013 FEE: $50.00
` '1'his is to Certify that Ross W McCur /a hw Motel
j 498 Main Stree oute 28,West Yarmouth,MA
IS HEREBY GRANTED A PERMIT
{ To Operate a Public,Semi-PubGc Swimming or Wading Pool
,
At Beachwav Motel - OUTDOOR POOL
498 Ma.ui Street
West Yarmouth,MA
This perrnit is granted'm conformity with Article VI of the Sanitary Code of T�e Cornmonwealth of Massachusetts,and
expires December 31.2002 unless sooner suspended or revoked.
March 7 ,2002 BOARD OF HEALTH: ��`r�, i��c. (�.nasi
�e�cya�?�. G�io'rd°'i. 711.Z�.. �l/ice ��a�
,Z'ode�ct� �o�C, �l�k
�a���r�wu
'�fele.�SeEak, �72.
Director of Ha lth � �
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jen�auaa ao a�uLmsst piou o�pa.imbaa nnou si�noura���o unnoZ a� �9 uoi��asqnS `�SZ uoi��aS `ZSI �a�d�u�.�apun
I�IOI.L�.LSI1�iIL1IQ�'
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�
iI • H • � .. � ��
The Commonwealth of Mossachusetts
� � Department ojlndustrial.-�ccidents
; Of/Jce olleres�►ostlyis
600 Washington Street
� ,� Bnston. Mass. 02111
�'" "�y Vb'orkers' Compensation lnsu�ance Affidavit
A�niicant information: P►easePRil'�T'Te�'}Jir '
n m•� � �'�� tr �/�C' �l)lE
location� Lf' C( � f -! C.�_i l4 �T•
- � UJ � (�Z. t# � — � �
�
� I am a homeowner pert�rmin�all w�or myself.
(�j I am a sole proprieror�r.� ha�z no one ��orkin_ in am•capacin�
� I am an empto�er proti idin�w�ori:ers' compensation for my empioyees w•orking on this job.
��pan�• name•
�d�ress•
tjtv• phone q• _
iesur�nce co policy tt
� I 3m a sole proprietor. ;enerai contractor, or homeowner(eircle onel and hace hired the contractors listed below �t ho ha�e
the follo��in� ��orkzr� ;ompensation polices:
sompanv name• --
gddress•
��•• nhone#!•
insur�ncc co oolic�•#
tomgan�name•
-ddr ss•
ciri• ohone M•
insur�nceso J19�Y�
l
Failure to secure cover�ge as required uoder Seenoo 25A of MGL 152 esa lad to t6e i�posidoe oterisi�al pesdtles of a O�e op to 51�00.00 a�d/o�
one years'imprisonment as w�ell as eivil penaltla io the form o(a STOP WORK ORDER aad a fise of SIOOAO a dar a=aiost ma I a�der;ta�d tbat a
copy of thH statement m�y bc forwarded to the ORiee of Inveatiguions of the DIA for eoven`e veritiatfo�.
I do hrreby cerrif}•unde rhe ins and penaleies ojperjury thar t/tt inforn�ation provided ebovt is true and cor►ect
Signaturc „� /�O <�O L'!
Print name o � c��u�'' � one N 7 7.�--03 9� '
.. o(licial use only do not+.rite in this area to be completed by ciry or town oflleial
citv or tow.n. YARMO�TQ _ permitAieense II nBuiiding Department
' — �Lieensiog Boud
�check iC immediate response ie required 261 ❑Selectmen's Ofiice
, �Healts Departmeot
Icontact person: phone le:_ �508) 398�2231 eat. nOther
I
,
� • �
�
' THE COMMONWEALTH OF MASSACHUSETTS
; TOWN OF YARMOUTH
; BOARD OF HEALTH
� PERMIT NLTMBER: #02-010 FEE: $50.00
I
� 'rhis is to Certify that Ross W McCurdy d/h/a Beachwav Motel
498 Main Street/Route 28�West Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity wi�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 u�wn such terms and conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Hea1th,and expires December 31,2002 unless sooner suspended or
revoked.
��n� ,Zooa Bo,�xD oF�.�.�: � ��.
��D. ��. .��
��� �. Ge�
�aa���
� S . .72.
�
ruce G.Murphy, R . HO
Director of Health
�
�
I
i
�
' 4 .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-013 FEE: $50.00
� This is to Certify that R ss . McC / B hw M tel
� 498 Main Stree oute 28,West Yarmouth_MA
� IS HEREBY GRANTED A PERMIT
j To Operate a Public,Semi-Public Swimming or Wading Pool
1
� At Beachway Motel -OUTDOOR POOL
i 498 Ma.in Street
West Yarmouth MA
This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2002 unless sooner suspended or revoked.
March 7 ,2002 BOARD OF HEALTH: (�ra�r��r�. i�aP�i�ez. (�ctx
�cfa.ici.t D. G�imtda.t, ?1L.D.. `j/ie;e L�,ra�
,�aGezt� �rot�c, Ll�rk
�a�rie���rsx�
�fe� .5�, ,�..�1.
ruce - urP Y, , •,
Director of Health
` " TOWIv OF YARMOUTH BQARD OF HE
� G3G � � D � I� D
��.� a�
' APPLICATION FOR LICENSE/PER� � � �''� M AY 1 8 2000
�
; �-�°: �� a� �
'� y C�EPT.
�.
* Please complete form and attach all necessary documents by Decembe`r��l, 1999���ure t H EAI.T= ln
the return of your application packet.
--------�---F ESTAB I------------------ -�'�f7��------------ --l---------------------------------------#--------�--_�-3----_.
L ATI A � � q:n �j� �, -�
LIN ADD y
T �y �'��/rr� `
�NAG�R'S NAMF� r,�c�m� 't'R # �Q6��
-cy � _.
POOL CERTIF ATi(�NC-M_-------------------------- ------_--_---______�._ __________------------_----- _�.
The pool supervisor must be certified as a Pool Operator, �s re�uired by new St�te law. Please list the
designat ool Operator(s)and attach a copy of the certificatian 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 Cardiopulmonary Resuscitation (CPR). Plea.se list these employees below and attach copies of
employee certifications to this form. The Healt6 Department wiil not use p�tst years' records. You must provide
new copies and maiatain a file at your place of business.
1. �c�SS �-�� /�'/r��i"cfs% 2. ��?'/'�'�!�/I e �i l�p�
3. 4.
�-IEIl1�iI.ICH .RTIFICATIONS•
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 wili not use past years' records.
You must provide new copies and maintain a file at your place of 6usiness.
1. 2
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
-------------yM_-------------------_---------------QFFICE US�OI,�V �______._________.._______�___��_.,,�
. ��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 � _CABIN $50
—� $50 _CAMP $50
_LODGE $50 �TRAILER PARK $50
1 MOTEL $50 2 rj� �SWIlVIMiNG POOL C�� $SOea. -
FOOD SERVIC'F• �LPOOL $25ea,
LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 ____CONTINENTAI, $30
>100 SEATS $150 NON-PROFIT $25
_COMMON VICT. $50 WHOLESALE $'75
R�TAIL �ERVI F•
LICENSE REQUIRED FEE PERMIT# LICENSE REQTJIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO
— $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35
`>25,000 sq.ft. $Zpp
i
,
N.A�ME C ANGF• $10
------___.____
AMOUNT DUE = $ `OQ, Q(�
f!1t R R�p�ASE TUR1V OVER AND COMPLETE pTHER SIDE OF FORM
RfII�RR .,.
4
({
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�
r
ADMINISTRATION �` � '
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A �
PERSCON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMP�NSATION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR - ':
CERT. OF INSURANCE ATTACHED :
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID►PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES � NO
NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILTI'i' TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 1-10
DAYS PRIOR TO OPENING FOR T'HE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
,ADDITIONAi REGL�.,ATION�
POOLS
POOL OPENING: ALL SVV�aVIMING, WADING AND WHIlZLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI-�E HEALTH DEPARTMENT, AND THE WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMNNmVVG POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7) DAYS OF CLOSING.
�
FOOD SERVICE
CATERING POLICY� '
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH
DEPARTMENT:
FROZEN DES�RRTS�
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN Tf� j
SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERNIIT UNTII,THE ABOVE TERMS HAVE `
BEEN MET.
OUTSIDE CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �LTST HAVE pRIOR
�
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOI�t�1G:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD
SERVICE ESTABLIS�-IlVIENT IS PROHIBITED. ,r
, r'� � �j
DATE: I fi ��7 tio p� SIGNATURE: ��J��`
PRINT NAME& TITLE: ' �ss C�I�C �r�'� �" �' �`'l
11/12/99
— — -----
_�__._ .__.
A �,��"_.....�-1 _ _ _ _ �
� - �
� `'
The Commonwealth of Massachusetts
� � � Department ojlndustria!.-f ccidents
J
�
_ a 0lllceoll�s�los�►iis �
0 600 Washington Street
. '�,�, ���•` Bnston, Mass. 02111
Workers' Compensation Insurance Affidavit
Aooiicant intormation• p�� p��_.�,
� - _
n m•. � �„°�-- � -.-'?
p - - C
Ltzcation� `T 7' c� l'7 u i/% 1?" r ���. 2C� _
, , ��� a z� � s� � � s -�3 -
(] ( am a homeow�ner pertorming all w�ork myself. �
[�] I am a sole proprieror�:-� ha�e no one ��orkin_ in am•capaciri•
� I am an employer pro�idins w�orkers' compensation for my employ�ees w•orking on this job.
companv namr•
�ddress:
siri••
ehons p
iesurance co. ��y#
� I am a sole proprietor. qenerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu��in_ ��orker�� ;ompensation polices:
companv name•
address•
SL�7r'�
nhons#
insurancc co Rolie� #
com[�anv namr
uldresr
�' nhoes+t
iesurance co ��
,
Failure eo secure coveraee as required under Secnon ISA of MGL 152 ea�kad to t6e iepo�ibon oterivi�al peadtla o(a 6�e ap to 51�00.00 a�d/or
one years'imprisonment»w•ell a�civil penaltie�io the form of a STOP WORK ORDER aad a lise of 5100.00 a day K�inst me. I a�dersea�d t5at a
topy of thy stalement mav be fonvarded to tht ORice of fevnti��Gom of t6t DU for eoven`t veri8ado�.
/do.hrreby certif}•undtr rh poins and penal�ies ojperjury that the injorn�ation provided abovt is trtre and eerreet
Signaturc �°�
- a�� 20 0�,
Print name d s ��C�''�` one# 7�� 'f�3`�`9
•- o(Ticiat use onl� do not Mrite in this area to be completed by eih or fown oflleial
city or town: YARMOIIT$ rmifAicen�e N
- P� nBuildiog Department
Q check if immediate response i�required ❑Liceasiee Board '
261 OSdectmen'e Otiice
contact person: �r08 ❑Healt�DeQartment '
phone N;_ �__� 398�?231 eat. nOther
i
.. .�,: (
f
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
.I�ERNIIT NUMBER: Y2K-57 FEE: $50.00
:
This is to Certify that Ro W Mc � rdy d/h/a RPa�hwav Motel
498 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 of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and canditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked.
Ma 1�9 ,2000 BOARD OF HEALTH: Gc`� �}ef,�e�, �`iairmarc
KoberE.}. 9��own.
abrie6[e�ahol�kc�-JEtooPee
ichaeL Odou�hli.iz
��,
ruce G.Murphy, , .,CHO
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-95 FEE: $50.00
Tlus is to Certify that Ross W McC�rdv d!b/a Beachwav MotPl
_ 498 Main treet� Wect Yarmouth 11�A
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beachwav Motel - O Ti'i)(1 R POO
498 MaLn Street
West Yarmouth_ MA
This pennit isgranted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�ires December 31.2000 unless sooner suspended or revoked.
Mav 19 ,2000 BOARD OF HEALTH: Gc�� .}e��, C�i,,,,az
KoberE.}. /�iouin
a�rie��a�ol���ooPe�
ic�6 ooCou��fin.
t
II�Ce
Director of Health� � '
1
�
_ r����;<<y ��+��
; �`� a � � � od � �
� %1
i TOWN QF YARMOUTH BU.ARD OF HEALTH
APPLICATION FOR LICEN �' � = 1998 N 0 V 1 8 1997
�� '�� � �;:� �..���• HFAL�'1� IJE�'T.
*Please Complete form and attach all necessaiy documents by December 31, 1997. Failure to c�
so will result in the return of your application packet.
�QF'ESTABLISHMENT: _ �3�AC�k/AY MD <`.EL TEL� # 7�5-03?9 .
��� SE S: 4qC I`�a�n S�� W, �armok�k UZ(o73
�I��ADDRESS Sctw�e.-
(�W�T�R/CORPORATION NAME: �oss 4�1. M"Cur�(✓
MAN�GER'S NAME: S a m� TEL.# Sa m�
�AILING ADDRESS: sa M�
POOL CER�FiCATIONS:
Pool Operators must list a minimum of two employees currently certified in basic water safety,
- staa�da�t'd_fi�_��and CQmmunity Card'�opu�monasy_Resu�citation(�PR�.Pleas� list-t�ese--- --
j employees below and attach copies of employee certifications to this form. The Health
Department will not use past years recards. Yoa t»ust provide new copies and maintain a
� file at your place of business.
� 1. n W ("�`Cuu'dY 2.
�
3. �i Y'Q��i a (�i-ffio r 4.
� HEIlvILICH CE�TIFI�TIONS:
i All food service establishments with 25 seats or more must have at least one employee tr�ined in
the Heimlich Maneuver on the premises at all times. Please list your etnployees trained in anti-
choking procedures below ana attach copies of employee certifications to this form. The Health
Department will not use past years records. Yau must provide new copies and maintain a
file at yQur place of business.
1. 2.
� 3. 4.
�
RESAURANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL#
O FIC USE ONLY --
�,ODG�NG:
LIC. REQUIRED FEE PERMIT# LIC. REQLIIRED FEE PERMIT#
_B&B $SO CABIN $50
_,INN �50 CAMP $SO
�LODGE $SO �TRAILER PARK $50 �
�MOTEL 50� q8-1 � SWIM POOL SOe qg—�
,_.,_VV�-IIRLPOOL $25ea.
�O�D SE �:
L�C. R�QtTIRED FEE PERMIT# LIC. REQLJIRED FEE PERNIIT#
0-100 SEATS $75 .,_,_CONTINENTAL $30
>104 SEATS $150 NON-PROFIT $25
_COM. VICT. $SO WHOLESALE $75
BT�.TAIi�
�EB.Y.L�:
LIC. REQLJIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT#
.�<50 sq. ft. $45 TOBACCO $20
_,<25,000 sq. ft. $75 FROZ. DESSERT $35
>25,000 sq. ft. $200
AMOUNT DUE — $ �I C��
t
�
ADMINISTRATION "
tlNDER CHAPTER 152, SECTICIN 25C, SUBSECTION 6, THE T�WN OF YARMOUTH IS
NOW REQUIRED TO HQLD ISSUANCE UR RENEWAL OF ANY LICENSE OR PERMIT
'TO 4PERATE A BUSiNESS IF A PERSON OR COMPANY DOES NOT HAVE A
CERTIFICATE OF WORKER'S COMPENSATION TNSURA.NCE. THE ATTACHED
STATE WORKER'S COMPENSATION I1�SURANCE AFFIDAVIT MUST BE
COMPLETED AND SIGNED.
T4WN OF YAR.MOUTH TAXES AND LIENS MUST BE PAID PRIUR TO RENEWAL OR
IS�SUANCE OF YOUR PERM�TS. PLEASE CHECI�APPROPRIATELY IF PAID:
YES ✓ 1�10�
NOTICE: PERMITS RUN ANNUALLY FR�M J.ANtJARY 1 TO DECEMBER 31. IT IS
YOUIt RESPONSIBILITY TQ RETURN THE COMPLETED AFPLICATION(S)ANB
REQUIRED FEE(5)BY DECEMBER 31, 1997
SEASONAL�STABLIS�-Il1�NT5 ARE TO CONTACT THE HEALTH DEPARTMENT FOR
INSPECT'ION 7-10 DAXS PRIOR TO OPEl�TING FOR THE SEASON.
ALL RENOVATIONS TO ANY F04D ESTABLISHMENT,MOTEL 4R POOL (i.e. ,
PAINTING,NEW EQUIPMENT, ETC,), MtJST BE REPORTED TCI�AND APPROVED BY '
THE BOARD OF HEALTH PRIO�TO COMMENCEMENT. RENQVATIONS 1VIAY '
REQUtRE A SITE PLAN. �
i
I
,�1�.�'�Q.NAL REGULATIONS
POOLS
POOL OPENTNG: ALL SWiMMINCr, WADING AND VV�IIRLP04LS WHICH HAVE BEEN
CLOSED FQR THE SEASON MUST BE INSPE�TED BY THE HEALTH DEPARTMENT,
AND THE WATER TESTED Ft�R BACTERIA BY A STATE CERTIFIED LAB,PRI4R TO
OPE1vING.
POOL CLOSiNG: EVERY OUTDOOR IN GROUND SWINIlVIlNG POOL MUST BE
__------ nR erntFn nR �nvFUFr�wrTH��VEI�T_�����.���..�S�t��--- ---- — __ �
FOOD SERVICE
�T_ER1N�.�PQLI�Y:
ANYONE '�NHO CATERS WITHIN THE TOWN OF YARMOU'TH MUST NOTIFY THE
YARMOUTH I-�EALTH DEPARTMEl�T BY'FILING'I'HE REQUIREll TEMPC�RARY
FOOD SERVICE APPLICATION FORM 12 H�7URS PRIOR TQ THE CATERED EVENT.
THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT.
�7 .N �S��R��
FROZ�N DESSERTS MUST BE TESTED ON A MONTHLY BASIS SY A STATE
CERTIFIED LAB. TEST RESULTS MLT5T BE SENT TO THE HEALTH DEP.ARTMENT.
FAI�,URE TO DO SO WILL RESULT 1N THE SU�PENSION OR REt�OCATION OF YOUR
FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET.
�"I E CAFES:
OUTSIDE CA.FES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),
14ItIST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH.
- �3�Q.� OUi�iN_..,�C: _ -- - _ _
OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A
RETAIL OR FOOD SERVICE ESTABLIS��VIENT IS PROHIBITED.
DATE: I� /'t�v�t � f 9 9,7 SIGNATURE:
PRINT NAME &TITLE: 1?�ss k! M`CuYL��wN„ER,t�ofEAAToR
10/97
page 2 of 2
�
� �
� The Commoawealth of MassQchusetts
� W Department ojlndustrial.-1 ccidents
� ; Ol'1lceof/�s�►osa�is
� 600 Washington Street
' = Boston, Mass 02111
�. V,V .. � . . ��� .
W'orkers' Compensation Insurance Atfidavit
ARR��cant information: p(easepR '"�•
�mr: t�SS �/� �C�� OBA �UCA('NinlA`( I`10i�L
L�c�tion: ��b �0.�h S�- r —
�it� W• I A,t'VY�Ou��/l, M� OZ�O7 3 phone# 7 7J'r-03�Q
� ( am a homeowner pertorming all work myself.
� I am asole proprietor�^� ha�e no one��orking in am•capaciry
� I am an emplo��er pro�idin�w�orkers' compensation for my employees working on this job.
comoan�• name: _
address:
sit�•: �hone!!•
�surance co. Aolicy#
� f am a sole proprietor. generai eontractor, or homeowner(circle onel and ha�•e hired the contractors listed'below ��ho ha�e
the follo�+in� ��orker� �ompensation polices:
comoanv name•
address:
�it�• ohone#!•
insurancc co. ,poli�,y# ,
�m�nv name:
address:
�ltY: Qboee�•
r
insurance co. Ao��1
Failure to secure coverage as required under Seerioo 2SA of MGL 1S2 eat lad to tbe iopai0oa oterisi�al pe�altla of a O�e ap to 51�00.00 a�d/or
one yean'imprisonment a�w�ell aa eivil peealtla io the form o(a STOP WORK ORDER and a fiee of 5100.00 a day a�aiott ma [a�dersta�d that a
eopy of thy statemrnt may be forwarded to thrOtTiee of Inve�tigations of t6e DIA for eovente veriBtatia.
/do hr�eby cerrify�und,er�e rns and penalti s ojperjury tha thc injormation providtd abovt is true and correct
�_/
Signaturc � /� /�o� 199�'
Print name ��s s �� M�Cu�'� Phone N �7 7�-�3 9 9
.- olTicial use onh do not w rite in this ares to be completed by city or town oflicial
ciry or town: YA��� _ pe�miUliceest M nBuildiog Departmeet
�Liceosing Board
�check if immediate respoese is required 261 �Selectmen's ORiee
�Hnith Departmeot
contact person: phone q;_ �508� 398�2231 egt. nOther
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.
. •
THE COMMONWEALTH OF MASSACHUSETTS
TUWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLTMBER: 98-3 FEE: $50.00
This is to Certiffy that Ross W McCurdv d/b/a Beachwav Motel
498 Masn Street West Yarmouth,MA
.IS HEREBY GRANTED A PERMIT
To Oper�te a Public, Semi-Public Swimming or Wading Pool
'At_ Beachwav Mot�l O�TTDOOR P OL
498 Masn Street
_ West Yarmouth MA
This permit is granted in co�formity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
eapires December 31 1998 auless sooner suspended or revoked.
December 9 , 1997 BOARD OF HEALTH: �c�� �e�ee, C�irma�
�oaa� JuG�ivam�K.f f.� �ice C�hairma�
RESTRICTION3 IFANY: None /'CoberE,}. �rowrc �
a�rfeLle�aho[�ht�-../�tooPed �
� �el O� ou�h ' �
�lleCtOlOf��1 � �
, _ _ �. P,x�c�h u�-�4�t��t
Q � ..y. * ° ��31 G�3CC� [� � � [�
TOWN OF YARMOUT�B(�'��(���i.TH
' APPLICATION FOR LICENSE/PERMIT- 1999 �t� O � �9�8
* Please complete form and attach all necessary documents by December 31, 1998. F H A TH D �
the return of your application packet.
-------------------------------------------------------------------------------------------------------------------------------------�--
NAME OF ESTABLISHMENT: 1����'�f�Ay I`'Ia'TE[L TEL. # �7_S-a� y
LOCATION ADDRESS: �F Q'�' T?cr;n �S` �
MAILING ADDRES S: Sa��
UWNER/CORPORATION NAME� i?oss k( 1`1�C.��
MANAGER'S NAME� �o M F TEL #
MAIL.INC7 ADDRESs: .�S'a�n�
POOL CERTIFICATIONS:
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.
� �
l. <�,�» �� � �:�v�s1 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
� Commwuty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
� certifications to ttus form. The Health Departmeat will not use past years' records. You must provide new
� copies and maintain a file at your ptace of business.
,
�i 1. �n5s k[ �`�.cv��,� 2. (`�au-�Qu�►� �`1�l��h
; 3. 4.
i
; HE�ML,ICH CERTIFICATIONS:
� All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-chokuig procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
Yau must provide new copies and maintain a file at your place of business.
1. 2.
{ 3. 4.
�
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
LODGING:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
� — —
INN $50 CAMP $50
LODGE $50 TRAII,ER PARK $50
�MOTEL $50 _� �SV�VIlVIlVBNGPOOL $SOea. Q4-2
WHIltLPOOL $25ea.
FOQD 5ERVICE:
LICEN5E REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
{ _0-100 SEATS $75 + CONTIlVENTAL $30 '
� >100 SEATS $150 NON-PROFIT $25
+ — —
� �
' COMMON VICT. $50 WHOLESALE $75
RETAII.SE�E:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $25
>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ 1 [�,--
"*"�'�'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R R�!R
..{-�-�-- =►
_. _ ;
. ` t
ADMINISTRATION
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TF�TOWN OF YARMOUTH IS NOW REQUIRED f
T�.�OLD I���JANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINES5 IF A
PERSON OR COMPANY DOES 1'�TOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES NO
NOTICE: PERMITS itIJN AI�INUALLY _FRONI- IANUARY 1 T4 DECEMBEl� 3.1.-- IT' I�__YOUR
RESPONSIBII.TTY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTA.BLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR TI� SEASON.
t4L.L RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
i
i
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SV�VIMMING WADING AND WHIlZLPOOLS WHICH HAVE BEEN CLOSED FOR �
, �
TI�SEASON MUST BE INSPECTED BY TI�HEALTH DEPART'MENT,AND TI�WATER TESTED FOR
PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COLTNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIl�IlVIING POOL MUST BE DRAINED OR COVERED �
WITHIN SEVEN(7)DAYS OF CLOSING. �
I
FOOD SERVICE �
CATERING POLICY:
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPARTMENT BY FILING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-�
HEALTH DEPARTMENT.
FR�EN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO 50 WII,L RESLTLT IN
_THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS _ _ �
HAVE BEEN MET. �
OIITSIDE CAFES:
OiJTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OiTTDOnR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHMENT IS PRUHIBITED.
DATE:_�� o v. � �
� 9� SIGNAT[.IRE: �'
PRINT NAME&TITLE: �s�� 1�. ����-c���y C c t`1
�
�
•� �;-� �
The Commonwealth of Massachusetts
� � Department ojlndustrial.-lccidents
� � � 0!/lceol/�res�l�stfiis
�� 600 Washington Street
` Bnston,Mass. 02111
. 7� v'y`'y �
W'orkers' Compensation Insurance Affidavit
ARnticant information: p►�sepR •s�.
n m• �5 S W � - �' M �----�
Ls�C�tion: � C 6 � l i'�l 'tl
�i[� V�l. �Q r`h10��� � � f�2� �� � phone# 7� —C�� � � —
� t am a homeowner pertorming all w�ork myse�f. T—
� I am a sole proprietor�r,� ha�e no one ��orkine in am•capaciri�
� l am an employer pro�idin� w�orkers' compensation for my employees working on this job.
_ _ --__
comnanv name-
address:
citv• phone li•
in�uronce co. yolicy#
� I am a sole proprietor. :eneral contractor,or homeowner(circle onel and ha�•e hired the contractors listed below ��ho Ma�e
the follu��in� ��orl:en' �ompensation polices:
comoanv name•
address•
citv• ohone tf•
insurancc co. Folicy#
tomoanv namr
_ __ ----- — — _
__--- _
a�dress: _ _—__-- —_-----
�'" nhoee#•
insurance co. �Y*
Failure to secure coverage as�equired unde�Secdoo 25A of MGL lS2 a�lad to tbe ioporitioo of erisi�al pe�dtles of a O�e op to S1,S00.00 a�d/or
oae yean'imprisonment a�w•ell a�civil penalda io the form of a STOP WORK ORDER asd a tise of S100A9�day a�riest me. I e�dersta�d t6at a
copy of this statement may be forwarded to the OlTiee of Investiguiooe of t6e DIA for eovenge veriBatiw.
/do hrreby certijj�unde rhe p ns and penalties ojperjury thet�6�injorn�ation providtd abovt is true and eorrect
,
Signature � a2� j��� �g°
Print name �55 c Cu+r Phone N 7 7 5 v03 �' g"
.- otTicial use onh� do not w rite in this area to be completed by city or town otfltial
ciry or town: Y�M��TQ _ permit/lieeese k nBuilding Department
pLiceasiog Board
p check if immediate response is required 261 �Selectmen's Otlfee
QHealt6 Department
contact person: phone q:_ �508� 398�2231 ext. nOther '
Ire��nM i,05%AI
i
� � THE COMMONWEALTH OF MASSACHUSETTS
I .
' TOWN OF YARMOUTH
BOARD OF HEAI,TH
PERMIT NUMBER: 99-3 FEE: $50.00
This is to cerrciffy that Ross W. McCurdy d/b/a Beachwa,y Motel
_ 498 Main Street, West Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confoimity 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 of the Commonwealth of Massachusetts relating
I thereto,and upon such teims and conditions,and to the rules and regalations in regard to said Cabins so licensed as adopted
by the Board of Health,and eaLpires December 31, 1999 unless sooner suspended or revoked.
December 10 , 1998 BOARD OF HEALTH: �c`///. �}a�ee, ��i,airma�c
�oam� �ullivarc, K.//., Vice C.hairmaa
Ko�ert� �rown
a�rielfe�a�of�kc�-�too�nea
a , D
' �el ou��lin
/
Bruce G.Murphy,MP ,R ,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: 99-2 FEE: $50.00
This is to cerafy that Ross W McCurdv d/b/a Beachw�y Motel
498 Main Street,West Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beachway Motel ' -OUTDOOR POOL
498 Main Street
West YarmoutlL MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cpires December 31. 1999 unless sooner suspended or revoked.
December 10 , 1998 BOARD OF HEALTH: �d� �ef�te�, lr�ar',,�mah
• �oaic� �u6�ivan���/•� Vice lr�irma�
RESTRICTIONs IF ANY: None Ko�erf� /�rouia
a�risLla�a�of���-J�tooPaa
�
e ou
Director of H�ealth� � �