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Home My WebLink AboutApplications, WC and Licenses i -_•< ; " J?,c�00„I�__.__ '°� ►� TOWN OF YARMOUTH BOARD OF HEAL � „ � � !� ,� � � n ` � APPLICATION FOR LICENSE/PEFS��'�Z . ` �� . o , ' �• � �' , �: � "� DEC 2 3 2008 * Please complete form and attach all necessary docwr�ents by�'ecember S 2008. Failure to do so will result in the return of your application packet �I"#-a �;��-��. � NAME OF ESTABLISHMENT: �.n,yL-w o�A � o�n. f �� TEL. #�''�b�l ��d )� � LOCATI4N ADDRESS: G�'(a � ��;� �r-- �-, . .J��,��-� �,,� �� MAILING ADDRESS: S%,4 � OWNER NAME: TAX ID (FEIN or SSNI- CORFORATION NAME (IF APPLICABLE): , MANAGER'S NAME: �(/�',-�j,q� �V�1N/� TEL. #��17 )L,�7/ �I G o� j MAILING ADDRESS: � M'�,�b�i Q � �;�,.rC,•.� ►�AO� ��17 1 � , POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Poal Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. , 1.�i-�� c 1�.�I N— 2. _ _ Pool operators must list a minimum of two employees currently certified in basic water safery,standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR). Please list these empioyees below and attach copies of employee certificatians to tlus 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 requued 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 590.000. 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 Rt your establishment. i I �• 2. � ! ;__ PER$ON_1N_CHARGE: _ _ __ ___ _ — _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1• 2. I , HEIMLICH CERTIFICATIONS: All foad service establishments with 25 seats or more must have at least one employee trained ui the Heimlich Maneuver on the premises at all tunes. Please list your emplayees 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 eopies and maintain a file at your place af business. 1. 2. 3. q.. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� _B&B �55 _CABIN $55 �MOTEL $55 �D --�I3 Z —�NN SS� _CAMP �55 �SVJiMMIlYG PUUL �80ea. �6�� _LODGE S55 _TRAILER PARK $105 LWHIRLPOOL $80ea. �/`��o ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE RfiQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER1vIIT# _0-100 SEATS �85 / CONTINENTAL �35 � ,3 NON-PROFTT' �30 _>100 SEATS �160 _COMMON VIC. $60 �WHOLESALE $80 RETAIL SER��ICE: —RESID.KITCFiEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<�0 sq.h. �50 _>25,000 sq.ft. $225 VENDING-FOOD �25 ' _<Z5,000 sq.ft. S80 _FROZEN DESSERT �40 _TOBACCO �55 vA�zE cxA�cE: sio AMOUNT DUE _ $ 250.o0 *""**PLEASE TURti OVER AND COMPLETE OTHER SIDE OF FORi'I**"'** � � . -_ l AD�STRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 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�v! NO MOTELS AND OTHER LODGING ES�'ABLI�HMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 of residence elsewhere. ; Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an i 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 CNIR 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(�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 WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ; closing. '' � FOOD SERVICE � CATERING POLICY: ` Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required ' Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ` Health Department. ' FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-�COMPLETED RENEW.AL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. � , ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN � k DATE: /„r _ �,y — ��_ SIGNATURE: PRINT NAME&TITLE: ioi2i!os � ; _ �� _ f� — . 1 � _ , .. ,p� �\ The Commonwealth o Mas h f sac usetts Department of Industrial Accidents , � N1�raNi�IJ�is 600 Washington Street, fh Floor Boston,Mass. 02111 Woricers'Compensation Insarance AtSdavit;Bnilding/Pl�mbi�glElectricat Contractors i�forr�� P�se�It1NT ie�bi+r name_ I�K�P�It i e�.}�3 +c� t?� ��p�J(� j/L A � address• �� Iv,-�-I N 'ST � citv � _ yf�L2 M O f'r E}-- siate• /L/ �}— zio• O,�GtS�.�� hone#f�Q��Q �Q�`L work site location(full address)• ` ❑ I am a hom�wuer performing all work myself. Project Type: ❑New Constiruction�Remodel ❑ I am a sole proprietor and have no one working in any capacity. �Building Addition � I am an e.�nployer ptoviding wo;kers'compensation for my e,mployees worlcing on this job. oommav�ec �� —t ): '� ��,�, ,�'� � �tC3 S � _ �— d7tT pi�7�t � . address: �..p g0� �`-�-S � clty' �� 1�; p7f1 � • u�ane#- ce' A S O - �� .. . ... �. . :.;. . . ,:,,; ._., ,;: ,>::�-i �.r=,�.. . <:; : .,..._;. . ._. . ..r";:. ., , ..?..� .,..r: ,. �. ;�:.a , ,�t.`w*C<F�A,;%a;:�:1.,,`�� t w.`;,. ❑ I am a sole proprietor,geaerai coatractor,or�omeowner(cirde one)and have hired the comractars listed below who have the following workers'compen�ation polices: somo�av name- address: ciiv: nhoue#. �ace ca . ;.; , # : , ��, ,, , . � .< .,, ; ... . , :-..��;��p":.�. -: a�ouv�ame- �'as• c�+►. �#. , . —., -- — — — # — ��.. �.,�., . . :.. _ ., �: .: . ;_ �.._ -°�; ..�r. `^�:� > .;i:= r--,�- e '�'�=:,t r*,' - � Failrre b seeare cweraEe as reqaited aedv Satl�a 2SA�f MGL 152 ea Ind t�tre ia�a�f eri�ial pe�aNip of a 8�e tp b S1,3A6�Ab aadlor °�YaR'�P►'��t n wr8�s dN p�apks ia thc forn sf a STO!WORK ORDER a�d a 8ne ef 5109.OA a cepg�[Ws�ta�mt t�ay be fonrarded�s the b18oe�la�q�of t�DIA tar e�verage veripqtlse. ��me. 1 aedashad that a !do henby certfjy wede e P�+s� peejrrry tket the iwfor�nalloe provlded aboae fs h►rre awd onmrt G>C/'�pensldes n ��tl1� t�ate �2 ��'�` - • Print name _ �I��/A 7�- U`,/U � Phone#.�� 3G/�'! �!�S(`Z_. a�c1a1 asc enly de sot�vr�te fm this area t�be compieted by.dly or 1rwa.o�cial city ar tow¢: �� BnidieE Depart�eat ❑cbeck Kimmediale re�ame is t+eqaired OSdrefmm s O�oe caetact �� (��°' phone#' � i � i � � [� � r5 ,� r !�� ,_� i�� - � — �E� 2 3 ZOOg i – NOTICE z �� ^r W HEaL,-�, ICE � � � TO � a TO :, EMPLOYEES �` EMPLOYEES `W � y� �,� Su The Commonwealth of M�ssachusetts � DEPARTMENT OF INDUSTP;IAL ACCIDENTS 6(!0 Wash�ngton Street, Boston, Massachusetts 02111 617-727-4900 — http://�vww.mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring vv�th: MARTFORD UNDERWRITERS INSURAt�E COMPANY � NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6S60U6-0694C06-5-08) 08-16-08 TO 08-16-09 POLICY NUMBER EFFECTIVE DATES � DOWLING & OWEIL INS AGCY 973 IYQ(�UGH RD 21� FL PO BOX 1990 � HYAMVI S MA 026U1 � NAME OF INSURANCE AGENT qDDRESS PHONE# o� BRENTWOOD MOTOR II�I INC 961 ROUTE 28 � S YARNIOUTH � MA 02664 EMPLOYER ADDRESS � � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE � MEDICAL TREATMENT ^� T'he above named insurer is required in cases of personal injuries arising out of and in the course of �� employment to furnish adequate and reasonable hospital and medical services in accordance with the �� provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the � injured employee. The employee may select his or her own physician. The reasonable cost of the services � �� provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably ' connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has ananged for such attention at the NAME OF HOSPITAL ADDRESS ooT,ee WZOP1G02 TO BE POSTED BY EMPLOYER THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMUUTH BOARD OF HEALTH PERMIT NUMBER: #09-032 FEE: $55.00 This is co Certify that Brentwood Motor Inn 951 Route 28 South Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the suthority granCed to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws afthe Commonwealth ofMassachusetts rel�ting 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 31,2004 unless svoner suspended or revoked. Januarv 9,2009 BQARD�F HEAI,TH: .�fe�eet S�: J�..IV., C�c�(atman (.Raatl+�e .�. �felli�'� `U�ice C'�arvrniar� '�46 Units;46 Bedrooms. .�Ji�t��.��l�t.� �:GPXR 1 Manager's Unit. �tll�(��QtEtlt��../v, ��J'..i�auy'ea ru e G.Murphy H,R.S.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-131 FEE: 35.Q0 In accordance with re�arians promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby granted to: Brentwood Motor Inn, 961 Route 28, South Yarmouth, MA Whose place of business is: Brentwocsd Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Tawn of Yarmouth Pernut expires: December 31, 2009 BOARD OF HEALTH: ,`1�e�¢,It S�, `J�..lv, C'f�a�etntatt ��e .�. ��ih�x `Uice C!�aixrnan `.Ra��cE `.�.�Kou�n, C� llruc��teer�uurn, ✓`2..1V. Fue�yn:P- January 9,2009 Bruce G. Murphy,MP . .,CHO Director of Health � i . , . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-059 FEE: $80.00 �rhis is to Cerci�y tbat_ Brentwoad Motor Inn 961 Route 28 South'Yarmouth MA IS I�EREBY GRANTED A PERMIT � To Operate a Public, Semi-PubGc Swimming or Wading Pool ! At Brentwood Motor Inn -INDOOR POOL 961 Route 28 South Yarmouth, MA This pemut is granted in conformity with Article YI of the Sanitary Code of The Commonwealth of Massachusetts,and + expires December 31.2009 unless soaner suspended or revoked. January 9,2009 BOARD OF HEALTH: .`�f,¢�¢tt S�q,� �..lv.� (�ttUtt �1G4f�X0 �.�� [Ce �Q11YJ/KXfL �FPJIf��.�qttl�tttl�� :[PJYR Qruz(�er�acurz, f�..A�. � Bruce .M y, , ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN QF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-026 FEE: $80.04 This is to Certify that BrentwUod Motor Irul 961 Route 28, South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GNING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relaring thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner revoked. January 9,2009 BOARD OF HEALTH: �E¢�¢tl S�� ..lY., ��IXIItat� Cf�Q�clee .�E. J�(�e'�ihex `viC¢ C'.��ci�!ldtcuc 5�e��.�cun, e�ex� ��r�a�um, J2.,lV- ru G.Murphy,MP , .S.,CHO Director of Health i � r .� QQ.EI.►TW�� 2> ' s °`�Y��sc TOWN OF YARMOUTH BOARD..,-: �;�; G��C5 L � M � D I � APPLICATION FOR LICENSE . � s Y �►�� _� � °�P�AR 1 3 2008 ' ..�.. �:�-�� .. � - * Plea,se complete form and attach all necessary�ocuments by ecem er 2007. r Failure to do so will result in the return of your application pa ��L"rH aEp7', � �� .�� * � i NAME OF ESTABLISHMENT: �R�iC/9 �j (�'� TEL. � �- ��/� ? L4CATION ADDRESS: G�'�, / ,�}i�/ �T . ' MAILING ADDRESS: �»c . 4WNER NAM�: N M I RUCT - TAX ID (FEIN or SSNI• ' CORPOR.ATION NAME (IF APPLICABLE): ' MANAGER'S NAM�: �G�-f-f/,5� �U y,�� TEL. # �� /- 7Go� MAILING ADDRESS: ,.,p ,P�Ii L�`�/u' /�2�' �JilJ C � 1�l�1- ��9,��-11 'f � ,_._,__ � POOL CERTIFICATI4NS: ' 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. dt/��-�'�- ��'y� 2, j � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and I Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee ; eertifications to this form. T�te �ealth Depertfnent will not use past years' reeo�ds. 1'0� cnt�s� provide new copies and maintain a fite at your place of business. � � t. �� /p- �U�wl�- 2. MI�'�-F- 1��c1 I� 3. 4. � I i __. _ __. _ __ . __.__. _ . _ I i FOOD PROTECTION MANAGERS - CERTffICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food � Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Flease attaeh copies of certificationto this applieation. The Health Department wiH not use past ye�rs'rPcords. � You must provide new copies and maintain a file at your establishment. t 1. 2. � i ; PE��9I�T IN��-IAKGE: , Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � 1. 2. � � i HEIMLICH CERTIFICATIONS: All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and � attach copies of e�mployee 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. j ; � 1. 2. � 3. 4. RESTAURANT SEATING: TOTAL # � F OFFICE USE ONLY � LODGING: � LICENSE REQUIRED FEE PER'b1IT# LICENSE REQL?IRED FEE PER'1�IIT� LICENSE REQLTIRED FEE PERVIIT= � _BBcB S50 _CABiN SSO / MOTEL S50 �$-OSa �INN $50 _CA?41P S50 �SVb I'_�IING POOL S75ea.��Q-'O79' � ^LODGE �50 _TRAILERPARK S100 I VvHIRLPQOL S75ea.�—�'L— � FOOD SERVICE: ! ___ . �__ _- . � LICENSE REQUIRED FEE PERMIT� LIC£1�TSE AEQLTIRED FEE P£RAZIT* LICENSE REQliIRED FEE PER411T= _0-100 SEATS S75 �CONTINENTAL S30 �Bd67 _lv'ON-PROFIT S3� >100 SEATS 5150 CO;�Il�ION VIC. S50 `��IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'� LICENSE REQLTIRED FEE PER'�AT= LICENSE REQL�IRED FEE PER'�III'� '' i _<50 sq.1�. �45 >35,000 sq.f�. 5200 _VENDIIvG-FOOD S20 _<25,000 sq.ft. S75 _FROZEN DESSERT S3� _TOBACCO S50 �TA.�CHANGE: S10 AMOUNT DUE _ $ a 30,00 ***•'PLEASE TL'R.\OVER�\D CO�iPLETE OTHER SIDE OF FOR�Z'•*"* �"�. ,�" _ t , 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 Ins�xrance.;_ THE .ATTACHED STATE WORKER'S COMPF.I��ATION INSURANCE ' AFFIDAYIT_N�U�T BE GOMPLETED AND SIGI�TED, QR . .: s° . _ CERT. OF INSURANCE ATTACHED I _ OR I � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� ' � i i Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK ' APPROPRIATELY IF PAID: YES� NO ' MO��I.S AND OTHER LODGING ESTABLISHMEl'�TS t � '` r ; ; TItANSIENT 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 custornarily associated with motel and hotel us�. ' ; Transient occupants must have and be able to demonstrate thax they ma.intain a princ;ipal place ofresidence elsewhere. � Transient occupancy sha11 generally refer to continuous occupancy af not more than thirty (30) days, and an ' ' aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or ' dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy ' Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Trausient. � * NOTE: Enclosed Motel Census must be completed and returned with this appiication, � POOL3 �', ; POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected , i by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days j pnor to opening. �� ; POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �' by a State certified lab, prior to opening, and c�uarterly thereafter. �, POOL CLQ�ING �very ou.�d�or i��,ro�nd swimming,pool must be drai�e�or.cov�ered wit�qseven�?,�days of closing: : :. ` • � � �I FOOD SERVICE '�I CATERING POLICY: I� ; Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depariment by filing the required I Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the , i 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 urrtil 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. I OUTDOOR COOKING: ' ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. I II _______ — - __. _ _ ___ NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. � ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIVIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW j EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT PLAN. I � � � DATE: � . I ,� - O � SIGNATURE� I � I PRINT NAME&TITLE: ��t-�-f�. C� �11',�� i 4 10?p 1)', � � ?'he Commonwealth of Massachusetts Department of Indusirial Accidents ; > N�.'�If�1�1l�f i 600 Washington Street, 7�a Floor i Boston,Mas� 02111 � Workers'Compeeaatioa Iwsdra�ee Affidavih Bniidiag/Plambi�g/Ekctrical Coetractors � .�e�'�iint: . : �1"kBVT it��lr ; �: �� adclress• citv state• zi� nhane# work site locatimi(fall addressl_ ❑ I am a homeow�r performing all work myself. Project Type: ❑New Constructia�❑Reanodel ' ❑ I am a sole pmprietar and have no one working in any cap�ity. �Building Addition ' ❑ I am an employer providing wa�lcers'compensati�for my employ�working�this job. comoa�ar�e: . .. . address: cltv: niwte N- ca. # . ; - � . . . , , . > ...;, _ . - , __ _ ti , .��_.�.. .. . -�<�>�-.:.v�:�.�� ❑ I am a sole proprietor,g�eral co�trxtor,or�omeo�vwer(cirde ow�)and have~lrired tbe contractors�listed below wha have tbe following workers'compensation polices: comu�wv�e• addr�ess- citv: nYo�te#: iss # ,: , . .: ;:; > a- . . � . _ � �<,:. ;�_;., , , �: �a�v�e• ad�• citv: uLo�e#: , _ , , � _ . . � � f. F�x r ae�+e av.�s�reg�eA w�r$eetlo,2Sa�f 11l�L 13t aalt�t�r 1� �'�f a�l�al peia�s�t a�e al�f�?�.'�slli a�/x� ese yan'imptba�ammt u we9 as civi pe�aNia in t6e form o[a 3T0r W01tK ORDEA aad a Hne ot316o.M a day agaiost�e. 1 addees�d t6at a ca�y ef H6��ny 6e[orwarded b t!e EHNoe o[lava�ef tYe DLR[�r eovsnge ver�atlN. I do ber+eby cerdfy ratd e pai�es 1 peea of peryirrry tkat t1Ys i�jonri�ion providel arbone is d�re�d com�ct i Date E�� — 1� " �� Print name -�- Phorn#� 2. effi�cial ase osly aa eac.vrice 1�t�is u+ea to be co�ple�d by dly er 6sv►n s�efai city or bwa: per�if/iieeme# �Buidins Dcpu�eat Ql.kea�Board ❑eLedc if�ale tapeme is reqaired �Sdeetmes'a�ffiee �lfakk De�rUe�t coatact paaoa p�x#; QOtlKr c��+) � � VDAC THIS IS A QUOTE , NOT A POLICY � WORKERS COMPfNSAT10N H�Fonn . AN D EMPLOYERS LIABILITY POLICY ' QUOTE PROFILE - VERSION 01 POLICY NUMBER: (6560UB-0694C06-5-07) RENEWAL OF (6560UB-0694C06-5-06) INSURED'S NAME AND ADDRESS � WORKERS COMPENSATION BRENTWOOD MOTOR- I-NN INC INSURANCE PLAN _ 961 ROUTE 28 p/R (WCIP) # MA S YARMOUTH MA 02664 POLICY PERIOD FROM: 08-16-07 TO 08-16-08. TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 362 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 284 � - TOTAL ESTIMATED PREMIUM 654 TAXES AND SURCHARGES 14 DEPOSIT AMOUNT DUE 668 Empioyer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit �4000o Each Employee INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY Adjustments of Premiums shall be made ANNu,4��v **************,r**********�***** Deposit Amount Due: $ 668 ******,r*********************** POLICY NUMBER: (6560UB-0694C06-5-07) DATE OF ISSUE:06-21 -07 WC ST ASSIGN: MA � OFFICE: ORLANDO DA HTFD 05G PRODUGER: DOWL I NG & ONE I L I NS AGCY 76RNJ . - THE COMAZONWEALTH OF MASSACHUSETTS ; TOVVN OF YARMOU'i'H BOA1tD OF HEALTH PERMIT NUMBER: #08-050 FEE: $54.00 ' I ; This is to Certify that N&M Trust d/b/a Brentwood Motor Inn 961 Raute 28 South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regularions in regard to said Motels so licensed as adopted : by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. March 13.2008 BOARD OF HEALTH: .��eit��t��..lV., ��tAGtt , - ��QA .�.J�E�I�A�G�_��QLCe�,I�AtJYl7ttltL ' *46 Units;46 Bedrooms. . ��✓��L��ti 1 Manager's Unit. � � �.�� i � � � £ , B ce G.Murphy H,R.S.,CHO Director of Heal _ _ . _ , TOWN OF YARMOUTH ' BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT ` PERMIT NLTMBER: #08-167 FEE: $30.00 In accordance with re�arions promulgated under authority of Chapter 94,Secrion 305A and Chapter I 111,Section 5 ofthe eneral Laws,a permit is hereby granted to: ' N&M Tiusf, 961 Route 28, South Yarmouth, MA Whose place of business is: Brentwaod Motor Inn � Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: .�fe�en SR�, J�i..N., C'R�awenur�t �� ,�£. 3�,�PiFlr�i `17ice C'�iacvr�nacn J`ZrrlfEe�ct 3.��u+varri, e� � ��J2..N- ; March 13.2008 ' Bruce G.Murphy, H,R.S.,CHO Director of Health � _ ; . ( r w . i � THE COMMONWEAI.TH OF MASSACHUSETTS TOWN OF YARMOUTH B�ARD OF HEALTH PERMIT NUMBER: #08-079 FEE: $50.00 This is to Certify that N&M Trust d/b/a Brentwood Motor Inn 961 Route 28 South Yarmouth MA IS HEREBY GRANTED A PERNIIT To Uperate a Public, Semi-Public Swimming or Wading Pool At Brentwood Motor Inn - INDOOh POOL 961 Route 28 South Yarmouth, MA This permit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. March 13 2008 BOARD OF HEALTH: .�¢�It Sf�� ..1v., ��(Xt�cl�luClt C'f�aycee,e .�. 9CeP,�i�c `�ice C'F&xvunar� JtaB.eact�. J`3.�cacun, C'� e � C�i(�eee�t�a�em., J2.,.�v. � � Eise�rt - ce G.M hy , ., Director of Heal THE COlVIMONWEALTH OF MASSACHUSETTS z_ TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #08-032 FEE: $75.00 Tlus is to Certify that N&M Trust d/b/a Brentwood Motor Inn 961 Route 28, South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE 1N THE BUSINESS OR PRACTICE OF ' " - GIVING OF �TAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subjecCto the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occuparion so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner revoked. March 13,2008 BOARD OF HEALTH_ .��L 5�� ..lV.� �I�trttaft C'hicr�c�e� 3�.��i�'t iXie�c `t7iee C'f�ai�u�uut � �tr�e�et�. `��ov.un, C'�e�e� ' tlruz�eerzdEaum, J2..�v. J. Bruce G.Murphy, . .,CHO , Director of Health 1 i ..• I S ' . 4,�� :: �� G3C� C� C OMC� D °`�R o TOWN OF YARMOUTH BO ' r � A��`H �� MAY 1 4 2007 o ,., "'-`i APPLICATION FOR LICENSE/P ' + ��A07 r .,– .,I.t �%: �� ' � H ALTH DEPT. * Please complete form and attach all necessary docum De er , . Failure to do so will result in the return of your app��n packet. . . NAME OF ESTABLISHMENT: 8aeen,�u/ao� �A��e i,NA/ TEL. #�S.3�Ff��' 8�'I`Z LOCATION ADDRESS:��'/ ,G>,r3 t/J Qr . 5'0 : T— y.�til o c 1T/� MAILING ADDRESS: c��i �,a_:� �z- C��,aQ n�r,,e�-�- , OWNER NAME: T�X T�f (FEIN or S�1�,)• ^ CORPORATION NAME (IF'APPLICABLE):_ �/ ..� M T�L,uc T { MANAGER'S NAME: ,�� r�c�Yn�/f TEL. # MATf,ING ADDRESS: SRn,�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operatar,as required by St�te law. Please list the designated Pool Operator(s}and attach a copy of the certification to this form. l. 2. Pool operatars 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 certificaxions to this form. The Health Department will not use past years records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. — FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are r�uired 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, 1Q5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use p�st years'records. You must provide new copies and maintain a file at your establishmen� 1. 2. PERSON IN CHARGE: Each food establishment must have at lea.st one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIl�ILICH 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 iist your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' , OFFICE USE ONLY � LODGING: ! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERM[T# ' B&B a50 CABIN $50 �MOTEL $50 j ( _INN $50 `CAMP $50 I SWIlVIMIIdG POOL$75ea. E _LODGE $50 _TRAILER PARK $100 �WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUtRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# 0-100 SEATS $75 �CONTII�ib'NTAL $30 NON-PROFIT $25 >I00 SEATS $150 COMMON VIC. $50 WHOLESALE S75 ' RETAIL SERVICE: —RESID.KTTCHEN $75 ; E LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMI'T# LICENSE REQUIltED FEE pERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _45,000 sq.ft $75 _FROZEN DESSERT �35 TOBACCO �50 G — � NAME CHANGE: �10 AMOUNT DUE _ $ a�3 0�QO ; ••'•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"""' � I i f � i � ADMINISTRATION � � , Under Chapter 152, Section 25C, Subsection 6,the Town of Yartnouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MU5T BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � 4R : WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth tu�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 ' 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 ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. POOLS POOL OPENIlYG:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to ogening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and qua.rterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool tnust be drained or covered within seven(7}days of ; closing. � E 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 obtamed at the Health Department. � FROZEN DESSERTS: ' Froaen 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 rnet. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ouTnoox coa�vG: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtTRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. , � ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW '� EQiJIPMENT, ETG.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i ; TO CONA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i ; DATE: 5 ./'� - c�`7 SIGNATURE: � PRINT NAME&TITLE: " �� iomio6 1 y ; � The Commomveahh of Massachusetts De�aent of Industrial Accidents > MAfa�Ni�� 6/1� R'ashington Strree� 7`�'Floor Boston,Mas� 02111 ---- wurkas'com cio■I��s�oe.�al�vi�s.0 ni�ke�al cu■aaetors _. .. a ._ , ,. , ... , ..� � , , , � �• `�fL�•►-�,ao p _ addr�ss: �(o/ /li��l-tr�/ S' T �itv �: ��9�2/�to V i ff- �te- Nlt�- ao• �6 Ctn�ane�e('S 0�a�� r2 work site locati�(foll addressl- p �am a homeo.,�pert'oiming au wo�k m,�self Frajecc T,�pe: p xeN,Ga�,caao pRean«ie� I am a sole 'etor and have no a�w in an Buil . qddition ❑ I am an e.mployer pmviding w�keas'cwmpensatio�f�my e�ployees worlcing on this job. �: ��. �E�' I`�'Ct�-�t ❑ I am a sok pinprietor,g�eni c�tractor,or homeow�r(crrde ou�e)and have hired the co�ctars listed below who have the following work�s'compensation polices: �� r rr - � .. � . . . . �� . . . . � . . . � . . . � _ � .� .. . . � . � .. . ��:..._ � � . .� . . � � . � � . � ... r �: . . . � . � . . . . . . Faihu+e U sece+e erMaa�e a�reqai�+ed uder Sec�f�a 2SA�f MGL 1S2 en Ieal b tYe irpaitlu�f ai�id pe�aNia�f a�e tip b S1,3N.N a�d/ir �Y�'�p�t as we�at dvr pmkfea ia tie 6�ra eta 3T0!WORK ORDER a�d a Sae�tS100.N a day a�aiet tie.1�d t6at a ' c�py�f fib da�t my 6t forwat�ded b He Oma�[It�tl�ae�1!e DIA fit avvage veN�atlea. I lo ber�eby cerdfy rardu`Nie sn�1 of perjwry tJY�dYe nr�fonn�to�prov�dad aboNe ia dwe a+►d c�om� , /" `� Date S - /� - D� , Print aV'Gre'�+L l A �-f-C/}�K�/'�- Phone#�'1_ g� 3 L��- �(� officiai ose osly aa eec.vrice t�this uea ta ne aoPkted 6Y eity er 1rwn.�elai c�'°r tewa= pe�iomee/ p�� ❑cLeck if�medide rapsase is req�ed �� ' �Sdec�'s Offioe �ct peis.a: �g� �� t,�:�e smc zaao) E E[ f 1 � • �� i i NOTICE N - W NOTICE � � TO = 9 To � � � a �, EMPLOYEES � �T EMPLOYEE5 ��o�M SV�y��v The Commonwealth of M�ssa.chusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21, 22&30, this will give you notice that I(we) have provided for payment to our.injured employees under the above mentioned chapter by msuring vv�th: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06183 ADDRESS OF INSURANCE COMPANY (6S60UB-0694C06-5-06) 08-16-06 TO 08-16-07 POLICY NUMBER EFFECTIVE DATES _= �� DOWLING & ONEIL INS AGCY 222 WEST MAIN STREET �� PO BOX 1990 - ' � HYANNIS MA 02648 � NAME OF INSURANCE AGENT ADDRESS PHONE# � o,� BRENTWOOD MOTOR INN INC 961 ROUTE 28 o� �- S YARMOUTH o.�� . -�— MA 02664 � EMPLOYER ADDRESS �� m-� _ �-= EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) , DATE �,--. a= MEDICAL TREATMENT _ "'� The above named insurer is required in cases of personal injuries arising out of and in the course of "�" employment to furnish adequate and reasonable hospital and medical services in accordance with the �'� provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the �— injured employee. The employee may select his or her own physician. The reasonable cost of the services = provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably `- connected to the work related injury: In cases requiring hospital attention, employees are hereby notified that the insurer has arranged far such attention at the ; � F NAME OF HOSPITAL ADDRESS ' 00,59, W2oP1G02 TO BE POSTED �Y EMPLOYER ; � � . , , � � THE COMMONW�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUNiBER: #07-054 FEE: $SO.QO This is to ce�tify that N&M Trust d/b/a Brentwood Motor Inn 961 Route 28 South Yarmou _ MA HAS BE�N GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confonnity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, ' 32C,32D and 32E as amended,a�d is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and ugon such terms and conditians,and to the rules and regulations in regard to said Motels so licensed as ado�ted by ihe Board of Health,and expires December 31,2d07 unless sooner suspended or revoked r��y is.Zoo� Bo�oF�ai.�: B �. �LI.�S., • S ��, .�, v�e�� R�t� 8�, Gl� � p�til��t ti4.��d�, R.N. Bruce G.Murp y, , S.,CHO Director of Health _ _ __.._ TOWN OF YARMUUTH BOARD OF HEALTH PERNIIT TO OPERA�TE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #07-176 FEE: $30.00 In accordance with re�ulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�;eneral Laws,a permit is hereby granted ta _ N&M Trust, 961 Route 28, South Yarmout MA ' Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31, 2007 BOARD oF HEALTH: L� �. �y�,�, /j�j,$,, • dle��6r�1s, ./V., ?/rce G�l�i�ti,sa,ri Rvl,wht�Bnou�, G''l�a ' � P�A�l�� 1�C�'�,��, R.N. i � Ntay i g.aoo� Bruce G.Murphy, ,R.S.,CHO Director of Health ' � ' - � , - � THE COMMONWEALTH OF MASSACHUSETTS � T(?WN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-034 FEE: $75.00 � This is to Certify that N&M Trust d!b/a Brentwood Motor Inn 961 Route 28, South Yazmouth,MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the pmvisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the iules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�cpires December 31,2007 unless sooner revoked. May 18.2007 BOARD OF HEALTH: � �. , /fif,�., . e�e�y��ls�ls, �ice L�lu�� R�t� B �'t� � ��t�t.�l�lc`��.�r� �1*�(�' . RJV. Bruce G.Murp y, S.,CHO Director of Health _ _ _ _ _ _ _ THE COMMONWEALTH QF MASSACHUSETTS TOWN QF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-088 FF,E: $50.00 This is to certiiy that N&M Trust dib/a Brentwood Motor Inn _ 9b1 Route 28 South Yarmout _ MA IS HEREBY GI�tANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Brentwood Motor Inn -INDOOR POOL 961 Route 28 South Yannouth,MA This permit isgrant�in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires Deceinber 31 2007 unless sooner suspended ar revoked. Ma�r 18.2�? BOARD OF HEALTH: L� �t�t�. ��., . a+�� i�i, �dce�savint�ss i � Rc�deht� B�ocusi, ele�a ' p�sc�//��c�'S�ta� i �0su�!�' , R./V, ' � � ruce G. urphy, ., � Director of Health [ c. .� � ��'?. ,�. �f;�R.�o TOWN OF YARMOUTH BOARD OF H�T�`� � � � � � M � D 32 - -'�� A P P L I C A T I O N F O R L I C E N S E/P �' �� M q Y 2 � 2 0 0 6 �,.. �/s « s,;vb` �"�� "�� * Please complete form and attach all necessary dc�ments by ecemb r��(1�(� pEPT. Faulure to do so will result m the return of your apphcation pac . NAME OF ESTABLIS�IlVIENT: e 6 ° TEL. #S��, GI S"-��l 2 LOCATION ADDRESS: ' MATT"ING ADDRESS: � OWNER NAME: �'�Tff lf�-, ��1'�iv'/-� T.AX ID tFEIN or SSNI: .� - �{�/ f CORPORATION NAIV�(IF APPLICABLE): f MANAGER'S NAME: /VGr¢f l�- f�vYiV'� . TEL. # � � St'- �j�`Z� � MAILING ADDRESS: _ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list th�designated ; Pool Operator(s) and attach a copy of the certification to this form. ' ! 1. f�L3�/Q �Uti/�i�i 2. f 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 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. ; l. /1kC,h i c� 1-�-rle.l,� 2. /�f�E'-LJ /�?i�l�— �-�''iv�_�` � � 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= � Protecti�n Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. � Plea.se attach copies of certification to this applica.tion. The Health Department will not use past years' records. You must provide new copies and ma�ntain a file at your establishment. ; l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge{PIC) on site during hours af operation. 1. 2• f f HEIlbE��CH 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 emplayees trained in anti-chokmg procedures below and at�ae�i-cc�pies 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. � i ! 1. 2. ' 3. 4• , RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# $&B $50 CABIN $50 �MOTEL $50 O6'�`� INN $50 CAMP $50 I SWIlvIlv1Il1G POOL$75ea. O�O'�g 4 iLODGE �50 _TRAILERPARK $50 1 WHIRI,POOL $75ea. �06-0.3�/ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMTf# 0-100 SEATS $75 � CONTINENTAL $30 �DG''�I� NON-PROFTT' $25 >100 SEATS $150 �COMMON VIC. $50 WHOLESALE $7S ', RETAIL SERVICE: LICENSE REQUIItED FEE PERMT'P# LICENSE REQIJII2ED FEE PERMIT# LICENSE REQtTIRED FEE PERMIT# _<50 sq.ft. $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_ a� *•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••"" .- _ _ � {� � � ADMINISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or 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 AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR , � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1/ Town of Yarmouth taa�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 Januaxy 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIKED FEE(S)BY DECEMBER31, 2005. SEASONAL ESTABLISF�VIENTS 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 EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO ; COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � � ADDITIONAL REGULATIONS � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ! closing. � FOOD SERVICE � CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw 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 hows prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. ' OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ' OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmerrt is prohibited. � � � DATE: �� SIGNATURE: � /'` �� _ � PRINT NAME&TITLE: { o9izsios � i � � _ � ` I ` .� � � The Commonwearlth of Massachusetts Deparh�nent of Industrial Accidents ; �e NAt�tli�s : 600 Washington Street, 7��Floor Boston,Mass. OZlll Workers'Compeasation Iesara�ce ASdavIr Bnilding/Plumbing/Electrical Coetractors s..:.;:..��..�.,��..... 1'�1'ie�ibiv i i�........�,. �. � n� �R.Enl T i,�'oz9�3 ��>n,f r'�(J'�../ address• qCo / /�/l/�7'r�./ � - citv� M!'/K T/fi" state• /1��- �iit_E� ��L P�e- #— �-�,� '�X - g��`Z- ' work site lceation(full addressl- ❑ I am a homeowner performing all work myself. Project Type: ❑New Ca�struction�Remodel ! ❑ I am a sole proprietor and have no one working in any capacity- ❑Building Addition � I am an employer providing warkeis'compensation f�my employees worlcing on this job. i comosav eame: �G'�CI"� /�O�"Z`!� !/�/N . '�- , �aa� C/��/ /1�l�-i�J �i� - i : ._o____ ! � � �j. y�,z..,�v-u r--c-�- ,��- . �#: � ��-.-�� .�� i , �. ' �� # �� - - oS' � , �,>" : s�.. ,.� _:� . '�-�:�»r�.�, _f" ❑ I am a sole praprietor,g�eral coatractor,or Lomeowa�(cirdt onc)and have lut+ad ibe contractors listed below who have � the following workers'compensation polices: com 'v��• -- address• I citv �#• # � igs ca. ;.<, ,:. cumta�nv�e• - f addras• � i citv- �#' ' co. # , � � � �� -: �� ... .�� .� , � t , �w�_<,;: . � .� v .,- � Fa�ore te sccQe arvvage as req�ircd�ider Sali�a 2SA�'MGL 1S2 caa Ia�d to t4e i�doa�f erWeai pnal�a sf a��b i1,3N.N aad�ir •ne yea�s'imprboa�ent�s we8 as c1vY pwMks in t6e ferm e[a 3T0t WORK ORDEA aed a Sne a[S1AO.OS s day a�aimt�e. 1 miderslud tmat a oepy of t6is�a�ement may be ferwarded M t4e O�ce� of the DIA for coverage veri�atlse. ' � I do beneby cer�ify under pains pe�wJtles of rjury that tbe infor�nafio�prowTded abov�e is d�e axd correcR i Signature � � Date �o� C`3 � Ptint name ��7!�- �CJ}�/Cl�l� Phone# 2 e�cial ese only do not�vrite fm this area to be compkted bY cilY er�owa officjsl city er tervn: P��# Q artmeat Bmrd ❑chedc if imme�a�e mpome is reqnired ❑�� t rnntact persen: P��#; �� ' t��-�) � r ,� WORKERS COMPENSaT10N �,� AND EMPLOYERS LIABILITY P�LiCY TYPE AR INFORMATI�N PAGE WC 00 00 01 ( A) ' POLtCY NUMBER: (6S60ll6-t?�94C06-5-05) I+�W-Q5 ; ! I i INSURER: HARTFORD UN�ERWR�TERS INSURANCE CON�ANY { NCCt CO CODE: 80411 , 1' PRQQUCER: INSURED: p��I� g� ��IL INS AGCY BR��ppp MOTOR Ihlhl INC 222 ydE$T MAIN STREET g61 ROUTE 28 pp BOK 1990 � S YARMOUTH MA 02664 HYAPNII S MA 02601 k � E Insured is A CORPORATION Other work piaces�n� �e��icatian numbers are shov�m in the scaed Q nsgu edcs atling address. . 2. The po�icY Period is from 08-16-05 to 08-16-a6 12:Di A.M. � WQRKERS COMPENSATiQN INSURANCE: Part One of the PolicY�PPtii�ta the Workers I 3- A• Nsted here: Compensation l.aw of the state(s) ' MA � �"^� m� ies to work in each state tistsd in i °'s B. EMPLOYERS LlABtL1TY INSURANCE: Part Two of the policY aPP� ; °�= item 3.A. The limits of our tiability under Part Two are: -=! AccideM: � t o000o Each Accide+�t �� Bodily lnjury by 500000 Policy Limit �...-. Bodily{nJury by Disease: � � b Disease: � i 0v0o0 Each Employee Bodily injury Y �— 07HER STATES INSURANCE: Part Three of the policY aPP��eS to the states, tf any,listed here: rC' 4tC 20 03 46A , ,�,� COVERAC� R�PLACED BY ENDORSEI�N'f �� -'� p. This policy inctudes these endorsemer�ts and schedules: � �„�., SEE LISTING OF ElVDORSEN�NTS - EXTENSION OF INFO PA a..- r this icy wifi be determined by aur Manua�ha eub Saudit to'be made p,n�.�A�flating s q. T h e p re m i u m f a P� ""` Ptans. AIi requtred information is su b]e c t t o v e r rt i c a t i o n a n d c �9 Y ur...... � . �� Y=� ST ASSIGN: M� ppTE OF�SSUE: a9-o8-0� RH 05� OF�iGE: ORLA1�70 DA HTFD 76RtdJ NG & p�I L I NS A�Y ; PRODUCER: ��I � 011993 � �� WORKERS C�NM�PENSATION � EMPLOYERS L1ABiLITY PO�ICY EXTENSION OF INFO PA6E-SCt�DULE WC 40 00 01 { A} POLICY NUMBER: (656QUB-0694C06-5-05) f INSURER: HARTFORD Ut�ERWRITERS INSURANCf COMPANY gp411-MA ' � INSURED'S NAN�: BRENTWOOD MOTOR. Ii�t INC ' ANNIVERSARY RATING QATE : 4?-26-06 RATE SUREAU ID: OOOQ72144 PREMIUM BASSS ESTIMATED RATES ESTIMATED TOTAL AIW1UaL PER $100 OF ANIVUA� CLASSIFICATION CODf REN�INERATiDN REMUPERATION PREMIUM ; LOCATION 001 01 , FEIN ENTITY CD 001 BRENTWOOD MOTOR INN INC 961 ROUTE 28 S YARMOUTH, MA 02664 CLERICAL OFFICE EI�LOYEES NOC 8810 20800 � .f 7 35 HOTEL: ALL O`fF�R EN�LOYEES & ' SALESPER50N5, DRIVERS 9052 26800 2.08 557 _ �� „ e.r�.. �r� r �� w � . �� .� � O� m�� i I`..f1�1�11� �, �� .��.��r��.��.��.��...��.��+�� I�RIT RATING/EXPERIENCE MOD: 1�1� M�DIFIEa PREMIUM �92 �'�" TOTAL ESTIMATED AfW�NAL STA1dDARD PREMIUM 264 "�' EXPENSE CDNSTANT(0900) �� 0.0300 TERRORISM RISK INS ACT 2002 (974�) i4 � 4.40Io MA WC SPECIAL FIIND kNQ TRUST FUt� 26 �•= TOTA! ESTIMATED PREMIUM �g6 � DEPOSIT AMQUNT DUE 896 DATE C�F ISSUE: Os-O8-05 RH ST ASSIGN: MA SCHEDULE NO: 1 OF LAST 011984 1 ; THE COMMONWEALTH QF MASSACHUSETTS - - - ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-055 FEE: $50.00 This is to Certify that N�hia Huynh d/b/a Brentwood Motor Inn 961 Route 28, South 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 conditions,and to the rules and regulations in regard to said Motels so licensed as adogted by the Board of Health,and eapires December 31,2006 unless sooner suspended or revoked. May23.2006 BOARD OF HEALTH: B �. , ��., � ��s�, ��v��z Ra&�`�. B� �!�k � ��a��. Bruce G.M y, ,R S.,CHQ Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT: PERMIT NUMBER: #06-179 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: Nghia Huynh,961 Route 28, South Yarmauth, MA Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast � To operate a food establishment in: Town of Ya.rmouth I�, Permit expires: December 31, 2006 BOARD oF HEALTH: ,C�e srs�1. o�o�t,/l�l._`n., ' '� all�e�t��'lt�r,�i, �./�., 7/ice e�t�:i/��u'•�st Rol,�tt� Bnou�ss, G'!�Z � A��l��att �4� � , R./V. � . �� Ma�23,2006 Bruce G.Murphy H,R.S.,CHO Director of Health � _ i .-- - --- THE CONiMQNWEALTH OF MASSACHH�ETTS TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT NUMBER: #06-034 FEE: $75.00 This is to Certify that l�ghia Hu�nh d/b/a Brentwood Motor Inn 961 Route 28, South Yarmouth, MA _ HAS BEEN GR:ANTED A LICENSE TO ENGAGE IN TI-�BUSINESS OR PRAG�'ICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the cacrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2006 unless sooner revoked. May 23,2006 BOARD OF HEALTH: B r� �. , M�•, o��t��l:ck, �2lice G�lr�r�iriu.� ' R�t� B u'!� !��tila��R.N. �t�us�j' , ru G. M y,MP ,R .,GHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' BOARD OF HEALTH , PERMIT NUMBER: #06-090 FEE: $50.00 This is to certify that Nghia HuXnh dIb/a Brentwood Motor Inn 961 Route 28 South Yarmouth, MA _ IS HEREBY GRAN�ED A_PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Brentwood Motor Inn -INDOOR PO4L 961 Route 28 South Yarmouth MA I Ttus permit is granted in confornury with Article VI of the Sanitary Code of The Commonwealth of Massachuseits,and e�ires December 31 2006 unless sooner suspended or revoked. May 23.2006 BOARD OF HEALTH: � �• �[�:��•r ' ��"s'�, /1.�, v�e�,�� I � tt�t�. e�, �i►� � n��a�� ; ,4 y' �, a./v. � , • hY� •, Director of Health , , of�qR �`T JS �/�� .- �.o TOWN OF YARM�UTH BOARD Y I�3 � (� ;� � � {� D I �'` APPLICATION FOR LICENS �~=2 OS MAY 0 5 2005 y ��,�: -'/�, * Please complete form and attach all neces e� s by Dece ber 31 2�04 Failure to do so will result in the retu ; f y r application p ALTH b�PT. NAME OF ESTABLISHHMENT: �, � �s TEL #� �q'�- gg(2.._, LOCATION ADDRESS: 9'Co/ M,r�i CJ S r • MAILING ADDRESS: arn . OWNER/CORPORATION NAME� iv r# iw R�q Lr v� T�e.K r � MANAGER'S NAME: ��► ��N f TEL. # i i -7��3 MAILING ADDRESS: Q ��:1�viv e �;r�r vy n�a ��7 i �Et 7�x fD # ; (a 5-�/(QZl�t� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifica.tions 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 MANAGER5 -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 applicaxion. The Healt6 Department will not use past years'records. Yoa must provide new copies and maintain a fde at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site daring hours of operation. 1. 2. HEIlVILTCH CERTIFICATIONS: � A1i 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 tra.ined in anti-choking procedures below and �I 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. RESTAURt�NT SEATING: TOTAL# ; � F OFFICE USE ONLY 4 LODGING: { i LICENSE REQUIIZED FEE P�RMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' BBcB $50 CABIN $50 I MOTEL �50 '�O S�O S7 INN $50 `CAMP $50 �SWIlVIlvIIlJG POOL$75e$. �ds�� LODGE $50 _TRAII,ER PARK $50 �WHIRLPOOL $75ea. ��p ` FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS $75 �CONTII�TENTAL $30 OS� �J� NON-PROFIT $25 I _>100 SEATS $150 _COMMON VTCT. $50 WHOL$SALE $75 � RETAIL SERVICE: 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE pERMfT# LICENSE REQUII2ED FEE pERMIT# f! _<50 sq.ft. $45 >25,000 ft. $200 ° — 39• �VENDING-FOOD �20 � _Q5,000 sq.ft. �75 FROZEN DESSERT $35 iTOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ Z?jO. O 6 � ••"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"••* ' � - — i r 1 ADMINISTRATION ; � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's 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 ar issuance of your permits. PLEASE CHECK APPROPRIATEL�IF PAID: YES�_ NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T'HE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPART'MENT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-�E SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i E f 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 ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE C�NSUMER ADVISURY: Each food estab 'shment 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 requued Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health , Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: � p� - O S SIGNAT`URE: PRINT NAME& TITLE: A-n��I- 10/22/04 .e ..�,._._ --- _- , �� . ==-� The Commo�wealth of Massachusetts ��--__ =_=- - - _ Deparhreent of Indttstrial Acciden�s ---- MifaK�M�i — _ --- 600 Washuegtoa Stree� 7`"'Floor � ,,,J Boston,Mass. 02111 � Workera'Com�eeaxtwa bs�raeee A�davt�Brildi lambi�/ElectricAl Co�tractors � zruw�., .�.->, � .,_ w _. .ti �__ . , ., Y•.,.�, .wx . , ,_. � �� , � .. . . < � �: �vd-vvo��D M n�R i N�v �s: �G� � /r./�iN C r • �itv �o: S��?-i2M oc� 1'�l �te• �C/� a�Q 4,� !�_nhone# .!U� • 3G'i 4'- $Sf(`Z— work site locatiam(fnll address): ❑ I am a homeowner performing all wark myself. Ptoject Type: ❑New Caostruction�Rernodel I am a sole 'etor and have no�w � in any ' . ' ' Addition �] I am an eanpbyer providing wadceas'conupensation fa�t my e.mploy�.s wo�cing ar►this job. �: �� r S f��fi rt�-c -I- �: . ,��, ❑ I am a sole praprietor,g�eral co�tractor,or�omeewter(e�rde out)and have hired the canttactnrs listed below who have the following woskers'cou�ensation polices: ��-' � eliv; ni�are�- � �: ' s.�tv: �� i Fa�^e a sec�ae a�aa�e a.rey.hed.�r sedi..Z?�A.tMGI.Lu n.laa b tl�e hrpaitln.tctiwial peaiia.t:S�e�b sl,sN�N„dfir ose Y�ean'ImPtir�mmt as we�as dH paaltla it tYe E�ra ata STO!WORK OADER a�d a Are dS169.0�a day asaimt ee. 1�dm��d t6at a apy�f Ws�ta�e�t my be f�rwardcd Is He(�ce�[lavatlptlus�f 1Ye DIA hrc�v�rage vrrMeatly. /do beneby cerd'jy w�der e p�aifws of ptr�Wry tJY�t tlie iwfonw�toe provided aboae ta dzre awd onn+e�ct � �� Date S • .� � �0.� Pr;m name /�} �cJ fi� Phone# Sa�� Cl R�— R�l 2 •ffieial ox sHly de'ot�viite ia tW arra te 6e aspleted by dly K,rwa�dnl �'O1'�� perm�/�iceme At ❑ehect if�ed41e neapesae b req�ed �+s� ', ceatict petsea: ph�g� ��t t��a smc som) ' ` � H�F°RD WORKERS COMPENSATION i AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBEfl: (6S60UB-912X778-3-04) RENEWAL OF (6S60UB-912X778-3-03) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. NCCI CO CODE: 80411 INSURED: PRODUCER: KIEU, MINH NGYTET & HYUN, DOWLING & 0 NEIL INS AGC NGHIA DBA BRENTWOOD MOTOR INN PO BOX 1990 961 ROUTE 28 HYANNIS MA 02601 SOUTH YARMOUTH MA 02664 Insured is A PARTNERSHIP Other work piaces and identification numbers are shown in the schedule(s) attached. 2. The policy period is from o7-26-04 to 07-26-05 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA Y� � d� B. EMPLOYERS LIABILI7Y INSURANCE: Part Two of the policy applies to work in each state listed in m item 3.A. The limits of our liability under Part Two are: � �_ Bodily Injury by Accident: � 10000o Each Accident o= Bodily Injury by Disease: $ 50000o Policy Limit o= Bodily Injury by Disease: � 10000o Each Employee m C. OTHER STATES INSURANCE: Part Three of the policy appiies to the states, if any, listed here: � �� SEE ENDORSEMENT WC 20 03 06 �� o� _ D. This policy inciudes these endorsements and schedules: o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE , o� �� 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating < Plans. All required information is subject to verification and change by audit to be made ANNUALLY. � � Y�� DATE OF ISSUE: 07-06-04 WC ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: DOWLING & 0 NEIL INS AGC 22LGR 025344 : � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT NLTMBER: #OS-057 FEE: $50.00 1�is i�to c�ti�y tt�t_ N&M Realtv Trust dJb/a Brentwood Motor Inn __ 9b 1 Route 28 South Yarmout MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Tlus License is issued in conformity with the authority granted to the Board of Health,by Chapter T40,Sections 32A,32B, 32�,32D and 32E as amended,and is subj�t to the provisions of the Laws of the Commonweatth of Massachusetts relating thereto,and upan such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and e�ires Deceinber 31,2005 unless sooner suspended or revoked. May 11.2005 BOARD OF HEALTH: Be��. t''o�P,o,�iyl.�. • ��G�l�e�.�.� �s�, R�v . �4��.�d� R.N. Bruce G.Murphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIV�NT PERMIT NUMBER: #OS-179 FEE: 30.00 In accordance with regutations promulgated under authoriry of Chapter 94,Section 305A ffid Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: _ N&M Real Trust, 961 Route 28, South Yannouth, MA Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2005 BOARD OF HEALTH: Be��rri�_`?S. (�'o+�da�s,/l�$, • /��#�isc�/�lc.�S` e�,ro�, ?/tiae��.L R�ent� B�, G!� ��sl�, R.N. �I.��..�.�, R.N. May 11,2005 : Bruce G.Murphy, S.,CHO ' Director of Health T , i , b � � � i / ` y r ' �°�� - `��a To � N OF YARM � UTH � �(/� +`� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 " MATTACMEES��t Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 � � y��AVOR�TED�b'fl� /O . � -d G" j B O A R D O F H E A L T H _-_.�.�.._.__ � !� C�'r '-� R% - �, � � = _ � To: All 2005 Yarmouth Board ofHealth License/Permit Holders MAY 0 5 2005 � From: Yarmouth Health Department HEa�r� r��r. � Re: T�Identification Numbers Date: March 22, 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 t� 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: Yannouth 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 aze Monday to Friday, 8:30 a.m. to 4:30 p.m. The ' telephone number is(508)398-2231, ext. 241. Establishment:�� =`��IN or SSN: �� Location Address: �� d� `� � 1�� Signature: � , Print: N�� -tI� � U��/V � Title: 0�'(S��i L� . , ; � ��T ' , . �� Prii t- ��S R . ,, � - F. . ��9y f_Yq C,�' � �' ". G� CC� f� OML� D �� ,r R�o TOWN OF YARMOUTH BOARD ��-� o_ .`�y APPLICATION FOR LICE � . " 004 D E C 0 2 2003 r ��,;z _��. �t * Please complete form and attach all necessary documents by December 3 , �Q��LTH I�EPT. Failure to do so will result in the return of your application packet. N MF. OF E T L.iSHMRNT, ` i � �i /Z � TEL #soS� - 3��- S��1 L �Q�ATION ADDRESS: Gl o/ /l�/�%� S T - MAILING ADDRESSj S,�a�� V�I�LER/CORPORATION NAME: J�'�,�,��_�(J yriv�-� ' ��GER'S NAME: �sarn�c. TEL #3�f�C- '��C � � �l 2- ' MAILING ADDRESS: �/ /1//A-rN �i—�_ POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s}and attach a;:opy of tn�certificatiorr ta �tjis�arm: - ' 1.��/�P�/� t-�c1 �r� 2. 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 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 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. . --- ---- ____ _- -- __-- ___ _ ---- -- _ _ _ _ _ - - _ - - -- - _ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. ; 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAUjtANT SEATING: TOTAL# ' OFFICE USE ONLY LODG� LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# _B&B $50 _CABIN SSO 1 MOTEL �50 �v .�S _INN a50 _CAMP a50 ( SWIMMING POOL S75ea. �'F�O`�S ! _LODGE $50 _TRAILER PARK $50 ( WHIRLPOOL $75ea. '�� FOOD SERYICE: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 �CONTMENTAL $30 ��7 NON-PROFIT $25 >100 SEATS St50 _COMMON VICT. �50 _WHaLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PGRMiT# LICGNSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENatNG-FOOD $20 <25,000 sq.ft. S75 _FROZEN DESSI:R"C S35 _TOBACCO �25 NAME C NGE: $10 AMOUNT DUE _ $ 230.DO **''**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � r ; � ADMINISTRATION 4 i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal f of any license or permit to operate a business if a person or company does not have a Certifica.te of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIUN INSUItANCE ; .AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR I 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�_ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YUUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003. II SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 II DAYS PRIOR TO OPENING FOR THE SEASON. �'�, ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW II EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' .ADDITIONAL RF'GULATIONS III __._ POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TE5TING: The water must be tested for pseudomonas,total eoliform 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 CQNSL�FR Al)VISORY: 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 Applieation form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. __ �vn��r n�c�c��rrc. --- _ -- - - - _ - -- Fmzen 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. OU'�'DOOR COOI�NG• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: / _ c� _ o SIGNATURE: � � � PRINT NAME&TITL : ,�ll' �� c� �c.l� � v�f 10/22/03 . i , ` � The Commonwealth ojMassachusetts � � Depa�tment ojlndustrial.-lccidents � ; OfAceol/erest/�sd»s ; 600 Washington Slreet ' = Eoston, Mass. 01111 �'" ��y V4'orkers' Compensation Insurance Aftidavit ARnlicant information: P►essePR11�7"L�.'Wa nam�: �R�i�C/i W`Di�I� c�i�I� ��Nnf Ls�cati�n:_ ��o/ 19/I f3i/V � �tt� �Ti � Y�r�//✓1D t/ T!T ehone� �—b� " 3cl� '— ��/`2-- � ( am a homecwner pertorming all w�ork myself. � f am a sole proprieror �r.� ha�e no one ��orkins in am•capaciry � I am an employer pro�idins workers� compensation for mv employees w•orking on this job. comnanv namr. lddress: ciri�• phone q• iesurance co. po��y p � I am a sole proprietor. :enerai contractor, or homeow�ner(circle onel and ha��e hired the contracton listed below ��ho ha�e the foll��in_ ��orker� ,ompensation polices: '; �mR�v name• address• citv: �hone fl: insurancc co. oelic�•#! s9m a�ny namr address: citY: ohQee It• insuraes�so. _�ty if t Failure to secure cove�a;e as«quired under Secnoo 2SA of MGL 152 n�lqd to tbe iepaitioa o(erisi�l pt�dtles o(a ti�e ap to 51�00.00 a�d/o� one years'imprisonment��w•ell a�eivif peaaltia io the form of a STOP WORK ORDER asd a tiae o�S100.00 t dar a�ainst ma I a�dersta�d that a copy of thh statement mav be fonwrded to tbe ORice of inveuig�tiom of the DIA tor eoven�e veriBqdo�. I do hrreby cenif}�un��he poin and prna! ojperjury that ll�t injormation p►ovided obovt is due and conect S�gnaturc � �� Print name f9- U �f- one N .S7S7�g " 3GI 4�� 4`�/2 .. o(Ticiat use onl� do not w rite in this area to be compteted by titv or town oflfeial city or town: YA��IIT� _ permitAiceese M n8uildiag Departmeet �Liceosiog Board ❑cheek if immediatt response i�required 261 �Seleetmen's OfTiee �Health Departmeot • contact person: phont p;_ �� 3��31 ext. nOther .. .�. <a,,: THE COMMONWEALTH OF MASSACHUSETTS TOWN UF YARMOUTH BOARD OF HEALTH PERNIIT NLTMBER: #04-025 FEE: $50.00 This is to Certify that N 'a Huynh d/b/a Brentwood Motor Inn 961 Route 28, South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO � OPERATE MOTELS Tlus Licen.�e is issued in conformity with the autharily granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such tetms and conditions,and to the niles and regulations in regard ta said Motels so licensed as ada�ted by the Board of Health,and e�ires December 31,2004 unless sooner saspended or revokaci. January 27.2004 BOARD OF HEALTH: Be��. ��/��. ' /��u'c�a A�l�`�1at�xa�, ?l�c�s�ra�t�� Ro1�t� ,��ou� G!�►�(a � �� R.N. ruce G.Murphy,MPH .S HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-09? FEE: 30.00 In accordance with re�ulations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is hereby gi-anted to: Nghia Huynh, 961 Route 28, South Yarmouth, MA Whose place of business is: Brentwood Motor Inn Type of business: Contine�tal Breakfast To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2004 Boau�oF�al,�: B�.�j�:��. C�'� �l.$. � ��ac�s� v� �� a�t� a�, e�,� �s�„ R.�r. , January 27.2004 Bruce G. Murphy, H, S.,CHO Director of Health t J , ; . . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BC?ARD OF HEALTH PERMIT NUMBER: #04-045 FEE: $50.00 This is to Certify tl�t Nghia Huvnh d/b!a Brentwood Motor Inn 961 Route 28, South Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Pubtic, Semi-Pubtic Swimming or Wading Pool At Brentwood Motor Inn - INDOOR POOL 961 Route 28 South Yarmouth, MA This pernut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�tpires December 31.2004 unless sooner suspended or revoked. January 27,2004 BOARD OF HEALTH: Be�a��. �j� �/.�1. ' P�� v�e�� Rode�rt 4. B�, � �� Sl� R.N. Dll'CCtOF OMHCRI�Il� � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLIMBER: #04-019 FEE: $75.00 'rhis is to certi�y that Nghia Huvnh d/b/a Brentwood Motor Inn 961 Route 28, South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in confarmity with the suthority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments ther�o,and is subject to the provisions of the Laws of the Commonweahh of Massachusetts relating thereto,and upon such tecros and conditions,and to the rules and regulations in regard to the carrying on of the , occupation so licensed as adopted by the Board of Health,and expires Deceinber 31,2004 unless sooner revoked. ' January 27.2�4 BOARD OF HEALTH: 8�.�$. �'��,A�$. • P�� v�e�� R�t�. e�, e�,� d/� �&, R.N. , ruce G. MuiPhY,MP , ,CHO Director of Health ' i i (•/L:�"/`�J�� C (��JJ i' , " ' {/'� 4 Of�--�'Rk (S tJ V � D � �. .y TOWN OF YARMOUTH BOARD OF HE � � � � � o� - " `'� APPLICATION FOR LICENSE/PER t - 3�, `� �� 9 2��z r ,, ,,;? � � ��• * Please complete form and attach all necessary do` � �'A� t �_ " ecember 1{-�9f,��T� DEPT. Failure to do so will result in the return of yo�. ., pp ication packet. NAMF nF F�TARt T�HMFNT• � c�1 �A��IZ E TEL # 5ag �3�74'- fc''E'.Z/ I.nC'ATinN ADDRESS• �6 / ��J � MAii.iNG ADDRESS• �MG nWNF.R/CnRPnRATinN NAMF.� 9LI�Gfl�f1 /,�lJ y�cl�'-F MANAGER'S Nt�ME• TEL. # MAILING ADDR�SS• S�Ic`-. POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to t�iis form. W�u.. 6cT c�t,-nW G��o�1 p2.to(z �tv oPeNING- 1. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. __��;��'J�fi��-iti�E:-- -- - - -_._ . _ _ _ Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2• HEIMLI 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 all times. Please list your employees trained in anti-chok�ng procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new eopies and maintain a file at your place of business. 1. 2. 3. 4. RFSTAURAI�TT SEATING: TOTAL# OFFICE USE ONLY . LODGING: LTCENSE REQUIRED FEE PERMIT# LICF,NSE RF,QUIRBD FGF. PERMIT# LICENSE REQUIRFD FEE PERMIT# B&B $50 _CABIN $50 �MOTEL $50 �O� 'dOb INN $50 _CAMP $50 �SWIMMING POOL 1S3�0/a LODC�E S50 _TRA[LER PARK $50 I WHIRLPOOL 6J?�G FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $�5 �CONTINENTAL $30 �� ._NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RTTAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,Q00 sq.ft. 5200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZBN DF,SSF.RT $35 _TOI3ACC0 $25 �VAME CHANGE: $�o AMOUNT DUE = S a3�.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i � e ` j � 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 h�ve 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 2 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 NOTICE:Permits run annually ftom January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT'I'��E HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ; EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ; ( ADDITIONAL REGULATIONS POOLS � POOL OPEIVING: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 TESTtNG: 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 C'nNSI7 ER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. C'AT�RNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS• ---�, , � tt�rly bass� by a 5u,.�� es��as�-be-�en�-t��I€a�t� 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. QUTDOOR COOKING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ff- 1�- 0,2 SIGNATURE: � PRINT NAME &TITLE: e 10/18/02 � Th e Conrmon wealth of Massach usetts � � Depa�tment ojlndustrial.-iccidents " ; Of11C001/OYCS�O�l11If 600 Washington Streel , ,,` - Bnsto,n.Mass. 02111 �~ �� V1�'orkers' Compensatian Insurance Atfidavit ARnlicant information: p►essepRil�'1'Ted,'Wir namr ��f-f/�� -�U�iV�- � location• l�Jlt1�/C!'l l�Oc�I� /1/1C�?71�Z� / f� �� (' /�/Jy4P/J � � �it� S � V�/ZMc9 fl�1' �hone� �J�Q'- �� '��Sl l`L � I am a homecw�ner pertormin,aU work myself. (� I am a sole proprieror�r.� ha�e no one��orkin� in am�capacity - Q t am an empi-o�e�pTo�� iit�'f)fK��S'-carfrEsensation for m��eet�im�ees wortcing on this job. - comnanr namr eddress: _ ��t�" nhone M• �urince co. oolicy# � I am a sole proprietor. generai contractor. or homeowner(circle onel and have hired the contractors listed below ��ho ha�e the follu��ins ��orker.�:ompensation polices: s4moanv name: address• citv• . phone k• insurancc co. Qolic}# s4moanv name: — — _ —_ __ _ __ ___ ---____ ------ tddrcss: ' �'� �hoee M• insuranse so. �gn,* ; t Failure to secu�e covera;e as required under Secnoo ISA of MGL 1S2 a�iad to tbe i�paitioe ot eeisiad peadtles of a 6u op tu 51�00.00 a�d/o� ' aae ynn'imprisonment as w�ell a�civil pendtie�io the form of a STOP 3VORK ORDER aad a Ifee otS100.00 a dar apio�t me. [��denn�d ehae a copy of thy statement may be fonwrded to the ORice of InveatiY�qoo�of tbe DU for eoven�t veritiatio�. /do hrreby cenij}�under t �peins a penalti s ojperjury that tl�t injorniation provided above is true wtd corree� Si nature � .- �- 8 �/ !� c�2 Print name f11��/�f}� �CI ��6�- Phone M ��'' �� /9 .. otTicial use onh do not write in this area ro be completed by citr or towo oAleial city or town: Y�M�� _ permifAieeeee k nBuildioe Department cheek if immediate res nse i�re uired ❑Lieensiog Board � � Q 261 OSeiectmen'e Otfiee �Health Departmeot cont�ct person: phone N:_ �508) 398�?231 ezt. nOther _ .. ._� <,,,; � 1 � ' � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #03-033 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General I,aws,a permit is hereby granted to: Nghia.Huynh, 961 Route 28, South Yarmouth, MA Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth _ Permit e�ires: December 3 l, 2003 Bo.�xn OF��,�: �ka�rtea`s� Ze�rh, �avr.xa+� � c�. . D C�.ardoa, 7AG.Z�., �l/tce , __ �a�e� �'n�, �fr�rk �a��auxot� _ r�e(�c.$l�c. �� December 2 ,2002 ruce G. Y, ,R.S.,CHO Director of Health _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLINIBER: #03-012 FEE: $50.00 This`is to Certify that Nghia Huynh d/b/a`Brentwood Motor Inn ' 961 Route 28, South Yarmouth,MA ` IS HEREBY GRANTED A PERMTT ' To Operate a Pub6c, Se�i-Publie Swimming or Wading Pool At Brentwood Motor Inn - INDOOR POOL 961 Route 28 South Yarmouth,MA, This permit is gra��ted in conformity with Article VI of the Sanitary Code of'The Commonwealth of Massachusetts,and exp'ves December 31.2003 unless sooner suspended or revoked. December 2 ,2002 BOARD OF HEALTH: ��`�f. i�ellu�r�c, (�ua�c $'ewc�D. G�t'°r�cl°'t. ?1l.?�., 21�ee ,�a�t�. �iaoaoac, L� �a�rie��e'�exoxott ?� S �?Z. Bruce G. wP Y� • •, Director of Health r � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLTMBER: #03-006 FEE: $75.00 This is to Certify that N 'a Huynh d/b/a Brentwood Motor Inn _ 961 Route 28. South Yatmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,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 the carrying on of the occupation so licensed as adopted by the Boazd of Health,and eacpires December 31,2003 unless sooner revoked. December 2 ,2002 BOARD OF HEALTH: ei(ra�tlee� i�i�lf�Car, �aGr.xa�c . ' b'eeorr fasxi�c?�. C�imcdo�c, �K D.. ?/ice � �oBact�. �a'�aaoac. �ik �aduck�KcD� ��S�ak, ��l. l ce G.Murphy, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH . � PERMIT NUMBER: #03-006 FEE: $50.00 'rhis is to Certify that Nghia Huvnh d/b/a Brentwood Motor Inn _ . � 96f Route 28; South Yarmouth MA .. . , HAS BEEN GRANTED A LICENSE T0 � ; , _ OPERATE MOTELS. , - _ This License is issu�in conformity with the authority graated 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 Cornmonwealth ofMassachusetts relating ' thereto,and upon such terms and conditions,and to�e rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and e�ires December 31,2003 unless sooner suspended or revoked. December 2 ,2002 BOARD OF HEALTH: �led� i�e�ac, �alirsrrauc �e�a�D, y�nd,o�c. �D.. 2/tee ��t�. ��, � �a�'�lcD� s�e�e�c Slu�. ,�.'.7Z. ruce G. urphy, ,R.S.,CHO Director of Health - - 2 , � TOWN OF YARMOUTH BOARD OF HE G� C� I� � M I� � APPLICATION FOR LICENSE/PE - MAY 2�. 2002 * Please complete form and attach all necessary documents by De � ,�' �t��es t in the return of your application packet. '`' �� iAME OF ESTABLISHMENT: -Ni urr� ,� �liID7��C' �rViv TEL �S�S) 39Q - S�'r`L LOCATION AD�RESS: q�I` R/�jiu' S'�` ,fZ_vwT� �.2�' '9°arin��ur� ��► r-�.� �. �AILING ADDRESS: �aa,c, OWNER/CORPORATION NAME: Nc'.r�f� �{r�y,�� MANAGER'S NAME: NGr:�i/-� f!vy�vr.� TEL. #�SZ�`)��S"--�4��°2 M.2►.ILING ADDRESS: 9`/� l�i�v �� R.au�,t, .�S( Yar�»a ,r � I�- �,,,7,�l��,�.._ 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. �a� ��b�H-�'�t-� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Dep�rtment will not use past years' records. You must provide new copies and mauttain a file at your place of business. 1. �1f1_��/.�,� t/v�iv� 2. MiNH �/VC�J�'/�`T K�t v 3. 4. FOOD PROTECTION MANAGERS - CERTIF�CATIONS: 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 �MR 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 fde at your establishment. 1. 2. PERSON IN CHARGE: Each food establishxnent must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2. I�IMLICH 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 �file at�your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# i � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 1MOTEL $50 �o��O'!�o _INN $SO _CAMP $50 �SWI1�IlvfING POOL$SOea�6a�� I _LODGE $50 _TRAILER PARK $50 I WHIRLPOOL $25ea. �Qa_;�j�j ! FOOD SERVIe'E: G I LICENSE ItEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE pERMIT# I _0-100 SEATS �75 �CONTINENTAL $30 0 �� NON-PROFIT $25 � >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 ' BETAIL SERVICE: � _ F LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# � _TOBACCO �20 �<25,000 sq.ft. �75 �TOBACCO $20 <50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35 , NAME CI�NGE: $io AMOUNT DUE _ $ /SS,Qp *****PLEASE TURN OVER AND COMPLETE OTfIER SmE OF FORM***** j � : _ --�,, r # . .. . _ _ _�. , ; . � , � , ADMINISTRATION � i � � �"` � � � � � �, � t Un�ler��;��;��i 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any �icense 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 .� i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� � Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ' / - YES f/ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQIJIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-iE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS ;: POOLS � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: � Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze requircd to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZ�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. Failure to do so will result in the suspension or revoca.tion of your Frozen Dessert Permit until the i above terms have been met. 1 OUTSIDE CA�'� ' ; Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Healtti. ; OUTDOOR COOKINGs � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � ; , ; i +; DATE:� � ' OZSIGNATURE: { PRITIT NAME&TITLE: ,�(�� /� f�C1,�,� i � � 09/11/O1 i _. . � '. — i . „ ' � � The Conrmonwealth of Massachusetts � � Deparrment ojlndustrial.-lccidents � o Oh/ceo�l�estl�s�is 600 Washington Street ' �` Boston. Mass. 02111 ~ 'v�y N-'orkers' Compensation Insurance Affidavit ARolicant information: PleasePRiNT'Te�.'�r � nam� �I��17�f� 0 h� �(7Tl)� �/U� lV location: 9�i / /��1N �'r �(� �Q�S — �, • , uT f�- ��s a 3Ct'p" S�S�lt 2 � f am a homeow�ner pzrr�rming all work myself. �I am a sole proprieror�r.,: h��e no one ��orkins in am•capaciry � I am an emplo�er pro��din� workers' compensation for my�empioy�ees w•orking on this job. comnanv �ame• .�Jdress citv: nhone M• insurance co. ��y q � I am a sole proprietor. _enerai contractor, or homeow�ner(ci�cle oneJ and ha��e hired the contractors listed belo� ��ho ha�e thz follu��in_ ��orker� �ompensation polices: s4moanv name• addresss citti•• nhone q• insur�ncc co. ooli �•!i s4moanv name• asldress• �': ehoee M• insurance co. �g�* i Failure to stcure covenee as requ�red under Secdoo 2SA of MGL 152 n�Ind to tde iopo�idoe ot crisi�al peaaltles o(a Ou ap to 51.500.00 a�d/or oee years'imprisonment as w�ell a�civil penalde�io the form of a STOP WORK ORDER and a(iae of SI00.00�day ataiost ma 1 s�dersta�d t6st a copy of thH statrmen[may be fonvarded to the Ofiiee of Inveatiguions of tbe DfA for eoven;e verifieatb�. /do hrreby cerrij}•under the poins ond penal�its ojpery'ury that tht rnjorniotion p�ovidtd above is tnte and contct �,Signature ate /�/1�4� -�-� - �2. X Print name��/,��L t�5,iit Phone Mr.'�O��" �� - fi��`Z. � .- o(Ticial use onh do not write in this area ro be tomplettd by eiN or town oAkial ' city or town: Y�M��T� _ permitAieen�e N nBuilding Departmeot �Lieeasiog Board �cheek if immediate response i�required 261 �Seleetmen'�Oliice (]HnItA Department cont�ct person: phone p;_ �508� 398�2231 ext. nOther ' ` � � . . • .� THE COMMONWEALTH OF MASSACHUSETTS $� ; TOWN OF YARMOUTH BOARD OF HEALTH . PERMIT NUMBER: #02-046 FEE: $50.00 'rhis is to Certify that N 'a Huvnh dJb/a Brentwood Motor Inn 961 Main Street/Route 28, South 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 tlie 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 3l,2002 unless sooner suspended or revoked. May 24 ,2002 BOARD OF HEALTH: r`��. �e�fli�rat, ,�kal�axa� " ?�. l�i�. 7 D.. 2/ice ,�o8art� �aota�c. (� �a�uu�7N�ez.xoti� #e�le�c S�ak, ,�7d. A Bruce G.Murphy, S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #02-158 FEE: �30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: Ngh�'a Huy�h, 961 Main StreetlR��t�28, Sou h Yarmo� h� MA Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31,2002 BOARD OF�AL'rH: ��: zelli�(ce�i. �avu,�a�c �c fa.xi�c�. C�,oado�c. 7�D.. ?/�ee ,�o�e�tt� ��otaMc, L� : �a�stek�ez�w� `�efe�c kak, ��l. Mav 24 ,2002 Bruce G.Murp , R.S.,CHO Director of Hea th � � - i � ' , � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-082 FEE: $50.00 This is to Certify that Nghia Huynh d/b/a Brentwood Motor Inn 961 Maiu Street/Route 28 South Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Brentwood Motor Inn -1NDOOR POOL 961Ma�n Street Soutii Yarmouth. MA This permit is granted in conformity with Article VI of the Sanitazy Code of The Commonwealti�of Massachusetts,and etcpires December 31_2002 unless sooner suspended ar revoked. May 24 ,2002 BOARD OF HEALTH: `s� i��i. D. �mcalo�c, .�iee ,�a�ett? bao�ac, � Paa�r��D� ?fele�Sl�ak. �?Z. , Director of H�ealtl�i � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-033 FEE: $25.00 This is to Certify that N 'a Hut�nh d/b/a Brentwood Motor Inn _ 961 Main Street/Route 28 South Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS lfiis License is issued in conformity with the audiority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws, and amendments thereto, and is subject to the provisions of the L,aws of the Commonwealth of Massachusetts relating tliereto,and upon such terms and conditions,and to the rules and regulations in regard to the cazrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner revoked. May 24 ,2002 BOARD OF HEALTH: ��led s��, �ellil�i, ��a�cc ��ra�o�,cyio7d.aMc�Z�.. �/lee �a�rick 7�er�xot� ��s�. �� Bruce G.Murphy, .,CHO ' Director of Health � f r _ .�--� .��- � . ,� ' ` • � TOWN OF YARMOUTH BOARD OF HEALT G`�� Cr� (_� C �` LS DD APPLICATION FOR LICENSE/PERMIT FE� Q 4 2QO2 * Please complete form and attach all necessary documents by Decembe 2 . e��-;��it i the return of your application packet. � ; • � �$� � AME OF ESTABLISHMENT: /tl ' TEL. # - � D S: - MAI ING ADDRE S: E: I l' ��rerFR�c ue�,tF• �'��- . TEL # MAILING ADDRESS• S��-�'�'J� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool e tor(s) and attach a co the certification to this form. 1. `r�� 2• ool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation{CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provi new copies and maintain a fde at your place of business. 1. �/ 2. 3. 4. FOOD PROTECTION MANAGFRS - 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. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2• HFIMLICH 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-chok�ng procedures below and atta.ch 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# OFFiCF. USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 I MOTEL $50 02�I INN $50 _CAMP $50 I SWIMMING POOL$SOea. ^�� LODGE $50 TRAILER PARK $50 �WHIRLPOOL $25ea.�02-b0( FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 �CONTINENTAL $30 �02-02I NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETA_ SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TOBACCO $20 CL5,000 sq.ft. $75 TOBACCO $20 _<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35 NAME CHANGE: $1 o AMOUNT DUE _ $ /�S.0 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'�** kz . y � 6 ✓ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: /' YES i/ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT'THE HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS ', POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected ' by the Health Department prior to opening. �! POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food 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. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te 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 of Health. � OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food ice establishment is prohibited. �c��,,, � � DATE: � � �C1 SIGNATURE: ' i C PR1NT NAME& TITLE: (� �.y�. N� 09/11/O1 ' 4 �,�,,, ,t ,., � : The Commonwealth of Mossachusetts � � Department ojlndustrial.-lccidents � a OI1Ice oll�stJ�s�liis 600 Washington S�reet ' ,•� Bosron, Mass. 02111 �~ '�� W'orkers' Compensation Insurance Affidavit n m• � �on: � av/V • �t� /'V�� l101 A� � ��a=�, ��77�"�"/�7 1/� phone q ( 5�� I am a homeowner perturmin;all w�ork myself. � ( am a sole proprieror �� ha�e no one��orkin_ in am•capacin� � I am an empio�er pro��3ing w�orkers' compensation my�empioyees w�orking on this job. an • � e• dres : /1/ ' �` � titv: ��.- 7D`t0� //, O/ �� phone q•�� (1 j� insurance co. �� /�l ., Ao�dSY#`�'�LL�� S"� � � � I am a sole proprieror. _enerai contractor, or homeowner(circle onel and hace hired the contractors listed below �tiho ha�e the follu�+in� ��orker� �ompensation polices: s9mpanv name• address cttt" phone q• insur�ncc co. polic}'# com�2nv namr addresr tih�: nhoee 1!• insuraes�so, n�liev 1t t Failure to seeure coveraee as requi�ed under Secnoo 25A of MGL 1S2 ca�(ad to tbe iopaidoa o(crisi�al pesdtla of a 6�e op to 51,500.00 a�d/o� one yean'imprisonment a�w•ell as eivil penalda io he form of a STOP WORK ORDER aod a fiat of 5100.00�dtr apiost me. t a■dena.d ma�a copy of this statement may be fonvarded to the O e of Invatiguiom ott6e DU for eoven`e verifiatio�. I do hrreby cerriJ}•u er e poins a prn 1 ' o rjury that lht injornration providtd above is tn�e and cerieet Signaturc - �-�j��12p�L Print name one Il �� ^�g�� .. olTicial use onlv do no�M rite in this�res to be completed by eitv or towa oAltial ciry or town: Y�M�� _ permit/licease q nBuilding Department �Lieensio6 Board �eheck if immcdiate response i�required 261 OSdectmen'e Otliee �Healt6 Departmeet contact person: pAone p;_ �508� 398�?231 ext. nOther THE COMMONWEALTfI OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #02-001 FEE: $50.00 This is to Certify that Siddharth Siddharth d/b/a Brentwood Motor Inn 961 Main Street/Route 28 South Yarmouth,MA I5 HEREBY GRANTED A PERMIT To Operate a Public,Semi-Pnblic Swimming or Wading Pool At Brentwood Motor Inn -INDOOR POOL � 961Main Street South Yarmouth_MA 'Ig►is permit is grantsd in canformity with Article VI of the Saniqry Code of 11►e Commonwealt�of Massachus�ts,and expires December 31.2002 unless sooner suspended or revoked. Februarv 6 ,2002 BOARD OF HEALTH: �'�"��D xy� .�lce ,�o�e�rt� �ta�c. � �a�rfek'�a�xo� ?� S . .72. Director of H lth � THE COMII�IONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH : BOARD OF HEALTH PERNIIT NUMBER: #02-001 FEE: $25.00 'rhis is to Certify that Siddharth Siddharth d/b/a Brentwood Motor Inn 961 Main StreetlRoute 28 South Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF : ' -GIVING OF VAPOR BATHS This License is issued in confornuty with the authority�to the Boaz�d of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner revoked. Februar 6 ,2002 BOARD OF HEALTH: �a�rlem�s�. i�e�i(cez, �aur�ac�t� �eufa.xi�a 9. l��o7da�c. �?�.. 211c� ,�a�vtt� �ra�c, (�,�cr� �a�itck'�e�r�cot� 'r'�e��i, .� ruce G.Murphy,MPH, .S., Director of Hea.lth � ��.n��, �, i � � ' 1 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-021 FEE: �30.00 In accordance with regulations promulga ted under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a permit is hereby granted to: SidcLharth Siddharth, 961 Main �treet/Route 28, South Yarmouth,MA Whose place of business is: Brentwood Motor Inn Type of business:, Continental Breakfast To opera.te a food establishment in: Town of Yarmouth Permit expires: December 31�2002 BOARD OF HEALTH: �afilea s� xd�, �a�iuxau �fa.x�c D. C�mrd,owc. 'yll.D.. `r/1ee ,�o6e�rt� �raav�c, ,(,�(,e�rk �� S �'.�1. Februarv 6 ,2002 ruce G.Murphy, .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NtTMBER: #02-001 FEE: $50.00 This is to Certify that Siddharth Siddbarth d/b/a Brentwood Motor Inn 961 Main Street/Route 28 South Yarmouth.MA HAS BEEN GRANTED A LICENSE TO � OPERATE MOTELS This License is issued'm conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and up�m such terms and conditions,and to the niles and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or revoked. 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'(.� � �� 5 ' I �!/' i'�! V n � � � � ��/ =��c fn, fi .G: .p,4 `K `Y4� ;�.�... - � k s � � ,. u ,. ..�, _� y,., r. _ _ .. _ = ..- .,. , .h � . -....___ .. �cf..�-.. �,,.v . . . . r � I am a sole proprieror. generai contractor. or homeowner(circle onel and hace hired the contractors listed below� �.ho ha�e ; the follu«in� ��orkzr:� :ompensation polices: ! i � �p�ev name• - � G i address• cih': nhone l�• j . � { insur�nce co. ,�elie�� I s4moanv name: ' j uldress• �f f I S1t1'I eboee f�• ' !f f insurance co. �� a � Failu�e to seeure cove�age as required uader Seedoo ISA otMGL lS2 ea�iad to tYe iopait�oterioi�t!pndtla of a d�e ap to S1,S00.00 a�d/or ! oae vean'imprisonmcat as wdl u eivii peesidt�io the[orm of�STOP WORK ORDER tad a tiae of 5100.00 a day aaia�t sa 1�sdeata�d t6at a eopy of thi�satemeat may be fonvardcd to tbe OI'liee of lavadeationf of tbe D[A for eoven;e veritkaeio�. /do hrreby cerrif}•under�he pains m!pena res ojpery'ury that�he ihjo�niatfon provided above Fs bue a�d eonux Si ature � , -" '� `�_ 8n Ptint name ' � `� p�� • alTicial use onh� do not write in this ana ro be eompieted by eiry or towa ofileial ' ciry or town: Y��DT� _ per�e;tAieeaae M nBuildio�Departmeot �Licensioe Board �cheek if immediate�esponse ie required 261 �Seleetmea'�ORiee (508) 398--2231 �t, OHealth Departmeat - contact person: phoae N;_ _ nOthe� � � •StV '.7<D1�1 � '� � �� YA�� TOWN OF YARMOUTH � o � � � `'� I i•}b R(J[�'I'1? ?h tiC�GTH 1".�R�10['TH �[ASS�CHL;5E1'TS 0?66-t-+�t�l � MATTACMEES � �+�,+Po.,,rob�� Tclephone iSOK) 39R-��37, }i�t. Z41 — Faa�(;0�1 ;9H-Z3�i5 BOARD OF HEALTH � ' I - i � May 12, 1999 i j Siddharth Siddharth dJb/a Brentwood Motor Inn 961 Main Street South Yarmouth, MA 02664 Dear Mr. Siddharth, Thank you for submitting the 1999 application for the rnotel, swimming pool, whirlpool and cominental food service pernuts issued through the Health Department. However, prior to issuing the licenses to y.ou, we are required under Massachusetts State Law, Chapter 152, Section 25C, Subsection 6,to have you complete a Staxe Worker's Compensation Insurance Affidavit form, �r to have you submit a Certificate of Insurance from your insurance agency indicating that your State Worker's Compensation is in effect. The a�davit form submitted with your permit application was incomplete. A copy of the form has been enclosed. The highlighted area shows the inforn�ation tha.t is pending. Please complete the fonn and return it to our office, or have your insurance agency send us a certificate of insurance. As soon as out office receives proof of your worker's compensation insurance coverage, we will be able to issue the licenses to you. � E If you have any questions on the above, please feel free to contact me at the Health Department at � (508)398-2231, e�. 241. Thank you for your anticipated cooperation. Sincerely, �� -� � Mary Ah'ce Florio Principal Department Assistant '; /maf enc. � cc: file ' i � Printed on �r Recycled �; • �.1� Paper ` , ; . � � The Co�rrmonwealth of Mossaclrusetts Z � Department ojlndustrial.-�ccidents � > Of!lceol/�res�Fostfiis ; 600 Washington Street �, ,,•= Boston.Mass. 02111 "� Workers' Compensation lnsurance Aflidavit - , � lf� i��1,�--�'' f' F + � t1 � ��' �'G ,� � � . locatinn� / �/ � ��'�/' �� c�t� � l�� -��.�y"I �c1I li phone� ��i�" �/\ � 1 � � 0 f am a homeow�ner pertorming all work my�self. � 1.am a sole proprietor�^� ha�e no one ��orking in am•capacin• � I am an empioyer pro� i�t�workers' compensation for�y employees working on this job. n • n � . ; . /� '�� '� a s �i C�-�1�-( /V'� �� ► • j' - . . 3� .. � ,��.. - � ..�, r � ..�: ,; , ,: W,: . .� , :�. w. , (y . ,�� .� � - � � �� .e�� a.: �,�,� �;k �e.; .�r� �� , � .. ._. .- '§4' _ k. .,�� ,'�'.i. �- ��s ru". 'a.:tl '"�i ..�i: S i-Z- - . r y t . ' .:l'`e_ , ., �y�� .,>..._ '.':.. ..��.-...�n M':..-...�a. ..:. �:.., . �,. .•>.- - ..., �.,+._._ . . -.._._ . _, ..._ ..__ .. _ __ .. .. ,.. � I am a sole proprietor. generai contractor, or homeowner(circle oneJ and ha�e hircd the contracton listed beiow� �tho ha�e ' thz foliu��in_�� ers�:ompensation polices: ; s�m �. • '��1--�_�..��1��-� �ddress• �•• ohone#• - , insur�nce co Roiicv f! i to�,�v nsme• � add �a• �y: eeoee ii: insurance co noiiev i! � Failure to secun coven;e as required usder Secaon 25A of MGL 132 ea�iad to Ue i�pai�of ui�i�ai pe�altles of a O�e op w S1.S09.00 a�dlor � oae years'imprisoameat as weil as tiril peaalda ie the form of a Sf0!WORK ORDER ted a ti�otSt00.00 a d�r a�aiost se. I��dersta�d t5st a ' wpy of this satemcat mav be forw�arded to tbe Otliee of lavatieatiow ottbe DIA[or eovera�e veriliutio�. !do�hrreby eertif}•uade�r/�e pains�,td p�na!(la ojperjyry that tbt injonaation provid�obove rs tr�ts pa,��tn�,, _ 7 �-�'� �� `'��` I 5�� .;� - 1 Print name \ �-� 1� one�f � oRiciai use oni�� do not write in.this area to be compieted by ciry or towa otfleial � i ciry or town: Y��T� _ • peneftAieetue N nBuildin`Departmeat pu��psioe Bo.�d i �eheek if immedi�te raponse is required 261 �Seleetmee's ORiee (508} 398�2231 �t, OH°'�ce oep.Rmm� • contact penon• phoee M•_ ____ _ nOther ' ; ; j THE COMMONWEALTH OF MA5SACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-55 FEE: $50.00 ��to c�tii'y t�at Siddharth Siddha�rth d/b/a Brentwood Motor Inn 961 Main treet South 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 amencied,and is subject to the provLSions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted ' by the Board of Health,and expires December 31, 1999 unless sooner suspended or revoked. i � - MaY 12 , 1999 BOARD OF HEALTH: �c`� �e�e�� C�iairmarc � �oan � �u[livan� K.�� Vice l.hairmarc � Kobert� �rown� (�leph j adreelfe�a�iof�hi�-�toopee � / pn � i ' fi,aet O�(, �Circ � } i Bruce G. Murphy,MPH,R S ,C � Director of Health � � � . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-183 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: . iddh rth Siddh rth 961 l�� in Str , 4�� hY rm�� h R�A ' Whose place of business is: Brentwood Motor Inn Type of business: ontinental Breakfast ' To operate a food establishment in:_ Town of Yarmouth � Permit expires: December 31, 1999 BOARD OF HEALTH:��/. .�et�e, C'�cr„�n �oan � �alliva��/[.�� ice C�hairman Kobert�}, p�rouire� (�ferh � ��a�rielle Ja�iof��i�-.�tooped � ic�el oCou hliic ' Mav 12 , 19 99 � i � Bruce G.Murphy,MPH, S., O ! Director of Health ' k i V i THE COMMONWEALTH OF MAS5ACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLJMBER: 99-92 FEE: $50.00 'rhis is to cerafy that Siddharth Siddharth d/b/a Brentwood Motor Inn 961 Maui Street South Yannouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Brentwood Motor Inn INbOOR POOL 961Ma�n Street South Yarmout MA 'This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and '' expires December 31. 1999 unless sooner suspended or revoked. j Mav 12 , 1999 BOARD OF HEALTH: �c�� etfee, ��iairmarc ' �oare C�. �ul�vah� /'�,�� ic6 l.�irmare Ko�ert.}. P�rouir�� l,lerh ��adrie��a�iof��i�-�toope� i/ichae�ooCou hlirc � i Director of He�altl� � � f _ ; � THE COMMONWEALTH OF MASSACHU5ETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-37 FEE: $25.00 This is to Cerki'y that Siddha�rth Siddha�rth d/b/a Brentwood Motor Inn ' 961 Main treet ��nth Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformiiy with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments fhereto,and is subject to ti�e provislons of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�ires December 31, 19 99 unless sooner revoked. Ma�2 , 1999 BOARD OF HEALTH: �c�� `�e�ee� C�irman , �oait C�. �ul�iva�z�/C.�� Vice C�hairmaa ! Kobert� �rowa� (�ferh ��adrie�Le�a�ol��i�-.htooPed f ilichae�ooCou �lirc I � i Bruce G. M h MPH R � �'p y, , .5.,CHO � Director of Health i � � � ; , � � ac� �r� � � c� D � TOWN OF YARMOUTH BOARD OF HEALTH MAY 0 4 1998 , + APPLICATION FOR LICEN5E /PERMIT - 1998 �� .` NEA�TH DEPT. I �� * Please Comple#e form and attach all necessary docwnents by December 31, 1997. F � so will result in the return of your application packet. �� -----------F--------------------------- - -- ----T�------------------------�N--------#----- -- ------- �,,��i�3r� ; _ � ING D S � , � � � � � MATT.iNG ADDRESS• Sl-�-�n� ------------------------------------------------------------------------------------------------------------------ POOL C RT FiCATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and Cvmmunity Cardiopulmonary Resuscitation(CPR).Pleasc list these � employees below and attach copies of employee certifications to this form. The Heatth Department will not use past years records. Yoa must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CE TR IFICt�TIONS: 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 ti�nes. 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 maiatain a file at your place of business. 1. 2. 3. 4. � RESAURANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL # -------------------------------------------------------------------------------------------------------------�---- OFFICE USE UNLY I�ODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# � B&B $so c�snv $so INN S50 ,�,,,,_CAMP $SO LODGE $SO TRAILER PARK $50 �VIOTEL $SU 8'S� �WIM POOL C"z ) 5 ea ��"�—,-f, T,�-IIRLPOOL 2 ea. �� OD SE VI . LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# 0-100 5EAT5 $75 �ONTINENTAI, $30 'I Z >100 SEATS $150 NON-PROFIT $25 COM. VICT. $SO WHOLESALE $75 B►ET�Ii� � . ;ItVI " : i 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. $20U AMOUNT DUE _ /,�'J-�'.p� � ` i - _ _ I � . _ � _ .. . _ . y � � � ' ADMINISTRATION ; LTLJDER lC�3APTER 152, SECTION 25C, SUBSECTION 6,THE TOWN�N E OR EURNIIT ` - - - NO�V REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY � "` '�'� �T� OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A 'CER$TIFICATE OF WORKER'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 T()RENEWAL OR ISSUANCE OF YOUR PERM[TS. EASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE: PERMITS RUN ANNUALLY FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL ESTABLIS�iMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT,MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED T4 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � f I 4 � k , k � r A DITIONAL REGUL� IONS � � POOLS ! POOL OPEI�TING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN ; CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, i AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO ', OPENING. � i POOL CLOSING: EVERY OUTDOOR IN GROUNU SWIIVIlVIING POOL MUST BE � DRAINED OR COVERED WITHIN SEVEN('1)DAYS OF CLOSING. FOOD SERVICE ('ATE jNG POLICY: ANYONE WHO CATER5 WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING 7'HE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. ��E� •�-�� FROZEN DESSERTS MUST BE TESTED�BE SENT OLTHE HEAI.TH DEPARTMENT• CERTIF�ED LAB. TEST RESULTS MUST FAILURE TO DO SO WILL RESLTLT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. nUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �„'�HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH• � (,ZI,�TDOOR COOI�ING: OUTDOOR COOKING, PREPAR.ATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS��VIENT IS PROHIBITED. � I��k . �` � ! DATE: �� 4 � � SIGNATURE. � pRINT N�ME &TITLE: � i i ' � 10/97 ', ,, page 2 of 2 � ��. �- -- a �, , � _ The Conimonwealth ojMossac/rusetts � W Department ojlndustrial,accidents � a 011lceo�/eves�los�liis � 600 Washington Street '.�� v�„o` Bnston, Mass 02111 W'orkers' Compensation Insurance Affidavit n m•: TW DII�U' location:_ 9 6�-- �'►y4-i w. s�r �� ^ �4�'(Q�7°� ,phone# �V "�� ( am a homeowner pertormin�all work myself. � � I am a sole proprietor�:;� ha�e no one��orking in am•capaciry � I am an empioyer pro�id� _ worl:ers' compensation for my employees w•orking on this job. om n • n ( address: ��f� �I�/1�. S� sih•• `�� fiQ()-��/ �7� tzhone# ��7 O � �cT � 2. insurance co. ��• �0 x, policy!! a I am a sole proprietor. ;eneral rontractor, or homeowner(circle oneJ and hace hired the contractors listed belo�� `ho ha�e the follu��in� ��orl:er_� �ompensation polices: sQm�anv name: address �i�• Ahone t�• insurance co. policy# : s�mnanv name• tddress• � titv: � � i nboee Il• �, insurance co. A�y� ; Failure to secure coverage as required unde�Secdoo 25A of MGL IS2 eae lad to tbe ioporitioa of erisi�l peaaltla of a O�e ap to 51,500.00 a�d/or ooe yean'imprisonment a�w•ell a�eivil penalde�io the form of a STOP WORK OItDER asd a tioe of 5100.00 a day a=ain�t ma i a�denta�d that a eopy of thH statement may be forwarded to the Otlice of Inve�tigat�ow of t6e DIA for eovenge veriAtatio�. ! /do hrreby cer�ij}�under the puins penalt#e�.aj'pery'ury thallht injormation providtd abovt is true and correct � �/V" i Signaturc ' ate Print name Phone�t ' .- otTicial use only do not write in this ara to be completed by cify ortown oflftial ciry or town: y�� _ permit/liecase M nBuildiog Departmeet pLiceosiog Board Q check if immediate�espoese is required 261 OStlectmen's Otlite pHealth Department ' contact person: phone p;_ �508� 398--2231 egt. nOther [ (re.��sxd 1�9t P1A1 � € a�wr�run 'lI1V FpRl1S1�111L 1�� L�1NY4Y RY 1 [lniton '�L _t�av��:n�yvn vnL� .'l/�l• • CnqPaRs BO RIGNtS UPOR fH8 CRAfI?IcRf6 H{fLDBR, tHtS �BG4I►ICA?R J.A.•DEVIIJCSNT�S �N3URANCE AGCY DQBS NO! AN�NO, 6Xt6AD QR AbtBA fHR COY6�AG6 APPONDHD BY r�g � i 338 BR0�4wAX BOX 664 Pni,iCI8fi A&10M. � MALD�3H NA 02148— .....------ - , � -------------- -...__.......... � , - ------------------ .....I ` 617-324-1809 ___ ��PA�� C08PAAIBS AFPORDING COVBRtIGE ' ...................-----------------..._---.......------- a .L�G�QN �NSURANCE COMpANY ; INSUAdO • � �04�P11NY------------------------------•----------------------------� � � , SRENTWOODHO�OR INN ---•---------------------------------------------------•----..._.__, CO!lP�AY ; BRENTWOOD REALTY TRUST D/B/A � � ; 961 MAIN 3TREBT � � SOUTH YARHOUTH HA 02264 C�1lIPll11Y..----------------------------------------------------------; �i ; � > CAVaRAGBS <:�aau��::e:a:::,::..sso�:��a:�:�:x::.::�:=:i�:::ss�::��u��:e:�:e:::::__=_:=_:====,.sa.:aao��i��us�=::.e=::' �NI� IS r0 CBRTIl4 48AP 4NB POLICTBS pv IpgpR�p�g LI5'CBO BELOY HA�'R BBBN rgg06p �o rHB INSURRD NAMRb ABovE FOR tHE �G�ICY ' � RBRIDD INDICIIt'BA. pOtiiJ}HS?�AUIN� ANy �R OIRBMRN+' PRRN OF CQNO?rIQB (�? AWIf (:OpT;tACi OR Oifl$R I)ofUNBNP t1TTN k'r•3P°"�' rQ MN1CN PNIS CBRfIFICAI'B KAY BE rSSU611 OR K�Y P�RTAIQ tflB IDISDRAl1C� A4�ORUBIi BY T86 P�LiCIBS AES�kIBBD NRR6IN IS SUBJYCr ?'� ? AbL fHo r8RNs, Sir,LpyI0N5, ��0 coNDlrlotis ng SnCN P6btCiRs. LIMIPS S80rrN M�r H�YR "SnN kEDUr.So aY PAiA cL��ri, ' IbtR-------tl'PB�4F�I➢SORANCg�--•---. .......pQLICY !illMRgF----.... -'PQbICY-�$�-----p0�1.Cq R%o .............i--T---------------- ; !-- -------- ----- AAt� (![�rDDIYY) DP�R(MK!DDIfY) �� • - - ------------- --------------------- � � " - - ----- --------------- -------------- -•-----------------------------...� GBN�AAL bI�BI6IPY ,GB�BR�L AGGRBGAt'g ' ( � CONMBRr,iAL GBN LIA�IbIt� PRaD-CONF!OP A�c. � 1 r.L�ixs �An� ( j OC�. �PBRS. 6 �U7, INJpRY ; ; ( Oft�16RS'S & COH}RACtAR'S 6AC8 OCCqpRBACR ; � �PROt6f.4IV6 i?[R DAM1lG� ; � �4NY OAR Y?H$� ; !f D. 6YPBNS6 ` . .AnlOM .......-•- -------------- --��...... ------------- ------....... _tANY �Nf_F�RSnHI-- ----.._.-----� OBIb6 LIABIbIfY I CONb, SINGbk 6llir� ANY 6G44 RGDILY tNJOFY . ' ALL OUNBD AUtOS �� SCNRDU1tD AOTos • iP6R PXRSG�I 8IRB0 AOlOS BO�ILY tYJf1RY � �ON-OYp60 AUpOS {FER A��IqBNt) � - .................... .. ........ PRQP6kfY DAMAG� GABb�C� bI�IBI1I1'Y ----------- ----- -------------- ------------ ------------------ ------------- � ANY AQtO • �rflBBOp1AU"P0�01i6Yi' ' '' � BA�BIICCIOSYP � . .tYC6SS 1IA8FLItY� ------------ --------------------------- -------------- ------------- ------...AGGBBG�r6 ' - - ....... .............. ' [ j OU6RBb1A tORN BACN UCCUAA68CR I ( Otb�R fbDN OM8Ra6LA tOAM AGGA6G9T6 110RKBR5 �OK?� A�D.BMP LIAB.-- ----_....�--------------- -�._,....,--•- ------------- .......----------- --------••---' TH8 PROPRI6t0AlPARiN6RS; ^ .X�STA'f�ITORY bIMJi3 ' A BYB�119'IVB OFlICRA3 AR6; WC3-28�$13 0�l03/98 04/03/99 DISPASBrPOL�rLINI! '.�0,@A� ( � IACL. ( j BICb. � - 'OtNBt ----------------------- ------------------------- ------------- ------------- DISHI►SS-BlIr,H_BMP_ _� iHy,�09 _....� ; � ' � , I i' -DB CAIP'PION 0� ' OPSRAPiONSILOCi►fIUN IYR.HICbBs,+SPt�r,I�!� I4�NS------- ------------•--------._....-•--------- - - ---.-...._....---------; ; ��iRCNTW�c1D �C�ofaR �N� i > cRaflplca�6 H06DBR �_ ' sacztteua�a�eaacsz=e'x:asea��i�es) CAACBLI,ATION <u��e:!_ee':-"--'aai�a��u��een=':v::::::aaaaa�eae�a•� �.. YARH00 1 SAOULi1 �1Nt nq rHB AEOVB (1BSCkt@gp P01ICI65 86 �AACRjjBC 9�fnRE rH� ' @YPI�1lTI0q DA1'R THR,RSOP SNE ISS111NG COMP�FY MIi,1, FN9��yilR '�0 .u.�!:1, TOWN OF YA�HpUTH 10 DAY� fiRIT?RN N�tf ICR TD 'PHr CRRrIFTC�fE NOLD�k NAN3D 'P�� TNR LR°t kU? PqILORK 1'0 NAIL �UCB �OtiC& SF�LI IlIP0;6 AO i�b�,;GAT?ON CF �Y A R HO U T H MA tiIAK�LIr� OF ��Y KIND uPnA TH6 �UHPANY�IT3 16BHTS OB NEi'REfi&NT�1fIYRS. � lIUtHOkILRD pBPRBS6�4,6 ?Y�.................. , ..---------------------; ACO�� ),S-S (3/53� l � ---------------------------------------------------- i i � � t . � THE CONiMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER 98-36 FEE: $25.00 This is to certify that Siddharth Siddharth d/b/a Brentwood Motor Inn 961 Main Stree�, South Yarmouth� MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This Lic�se is issue�in conformity with the suthority granted to the Board of Health,by Chapter 140,S�tions 51,of the Ge�al Iaws,and amendm�ts thereto,and is subject to the pravisions of the Laws of the Commonweaith of Massachus�tts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31, 19 9�unless sooner revoked. Mav 11 , 1998 BOARD OF HEALTH: �c`� .}elfe�� C�iairman �oan.� �u6fi�van� K.//., Vice C.�irrnua Ko�aE� /�rown� C�[er� a�rie[[e�a�Zolek�ooPed ic�ao[O� u�hlin. ruce G.Murphy,MPH,RS.,CH Director of Health . . ._ . . . - -.....•.•�-,--r, TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERNIIT NiJMBER: 98-182 FEE: $30.00 In accordance with re�alations promulgated under authority of Chapter 94,Section 395A and Chapter 111,Section 5 of the Ge�neral Laws,a petmit is hereby granted ta Siddharth Siddharth 961 Main Street, S�uthYarmouth, MA Whose place of business is: Brentwood Motor Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 1998 BOARD OF HEALTH:�d�/. �et�e, C'��►��. . oah� �u[livan,K.//., Vico l.�arrrucrt. Ko�rt�}. �rowa� l.[er� a�ri��a�ole�ry-.J�tooPe� ic O� oa��[in Mav 11 , 19 98 Bruce G.Murphy,lvlPH, .,C ' Director of Health ' i I • � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: . 98-58 FEE: $50.00 This is to Cerafy that_. Siddhasth Siddha�rth d/b/a Brentwood Motor Inn _ 961 M in Street, Sn»th Yarmni�th' j�A HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Tl�is License is issued in conformity with the authority granted to the Board of Heaith,by Chapter 140,S�tions 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 tenms 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. Mav 11 , 19�8 BOARD OF HEALTH: Gi`� ._tettea, ��ciirrnaa �oan � �ulfivaa�K.�/•, Vice l.�ironaa . Ko�rt�}. p�rowa� (..lerk a�riel�e�ako[��ooPed � ichae[ O� ou��G�r� Bruce G.Murphy,MPH,RS. H , Director of Health THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 98-182 FEE: $50.00 This is to Ceraty that__ Siddharth Siddharth d/bla Brentwood Motor Lnn 961 Mai S reet, Sou�h Ya�r_rr�outlL MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wad'wg Pool At Brentwood Motor nn -INDOOR POOL 961Main Street South Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and eXpires_December 31. 1998 unless sooner snspended or revoked. �sy 11 , 19�8 BOARD OF HEALTH: �c�� }etfa�, C�ialrn�an . �oan� �a[livaa,K.�, Vice l.�irman Ko�rt.}. 0_7rown� C�fOrk a�rie��a�ol��./�tooPee ' ��0' �..��. Director of Health � �' 1 � I , ,� CKt�1G�U - _ ,, :.� � �----- � r • . , *�'y� • �i u � �i � ; o---- ' ��'�"�A � i„�. k �f.0� . . i� �`� ��I� � � � �ED 0 5 3��7 TOWN OF YARMO �H �b1� "��IEALTH APPLICATION FOR LICENSE /PERMIT - 1997 ��,,t_TH DE�T. * 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. ----------------------------------------- - ----�--------------------------------------------------------=------- ��ME OF ESTABLIS MFNT• �t� T l��'C(cTD dl��p T�� f�� TEL # ADDRESS: 96�- �'l A-r N � S T �-�,�� . �{�-2Yn lN T�.�. L S N rN � r.k AG R' � �'�a # - AiLING A1�DRFS�• 9 6 I - �'I�a.n �7` So � y�-�'l c�-r�r r� ------------------------------------------------------------------------------------------------------------------ POOL CERTIFICATION : Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and Community Cardiopulmonary Resuscitation(CPR).Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATION • 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. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL# ------------------------------------------------=------------------------------ OFFICE U E ONLY L011GINS�: LIC. REQLTIRED FEE PERMIT# LIC. REQLTIRED FEE PERMIT# B&B $50 CABIN $50 � . � $50 CAMP $50 ; LODGE $50 TRAILER PARK $50 `� MOTEL $50 '� ✓gWIM POOL C� 5 7 �� $ Oea. � �} �3 ; �VV�-IIRLPOOL $25ea. � �1�'3 8 I FOOD �F,RVI .F; � LIC. REQUIItED FEE PERMIT# LIC. REQt1IRED FEE PERMIT# 0-100 SEATS $75 �/CONTINENTA,L, $30 �1-7--�55 >100 SEATS $150 NON-PROFIT $25 COM. VICT. $50 WHOLESALE $'75 R IL �E VI LIC. REQUIRED FEE PERNIIT# LIC. REQIIIRED FEE PERMIT# <50 sq. ft. $45 TOBACCO $20 <25,000 sq. ft. $75 FROZ. DESSERT $35 >25,000 sq. ft. $200 AMOUNT DUE _ ��S;�d � ;