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Home My WebLink AboutApplications, WC and Licenses " ' 3�,a�.k� ` � � �•Of:a'?� TOWN OF YARMOUTH BOARD OF HEALTH `�( � � � � � �n s D ? o � ''�C APPLICATION FOR LICENSE/PERMIT-2007 ' . o �. . _ , �� N0V 2 2 2006 r , * Please complete form and attach all necessary docum�nts 1�y`°�ec�mbe 3�EZ�QC�a H ��PT. Failure to da so will result in the return of�your`�ppYication pack . NAME OF ESTABLISHI�iENT: � EL. # LOCATION ADDRESS: O� MAII,ING ADDRESS: �/ _ �� ,� f OWNER NAME: iU A� - �a �'��/��--��:�a CLi� d�e�TAX ID (FEIN or S SN): � CORPORATION NAME (IF APPLICABLE): 'S NAME: %l�'�.�.�- iJ : v ` TEL. # l�03�� —c9�6 2� 1vt�II.ING ADURE5S:_3� ��d�ro�� 5;�. �,�,��, N'�j� �,�� 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. l. 2. Pool operators must list a minimum of two employees currently certified in basic water sa.fety, standard First Aid and Community Cardiopulmonary 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 prnvide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments a.re 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 est�blishment. l. 2. PERSON I1�F C�IARG£:— __ _-__- — __ ___ 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-cholcmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY : LODGIlVG: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR�D FEE PERMIT# _B�B $50 �CABIN $50 �'O7'0��' _MOTEL $50 INN $50 CAMP $50 SWIIvIlvIlNG POUL$75ea. LODGE $50 _TRAII,ER PA12K $100 _WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAII.5ERVICE: —RESID.KTfCHEN $75 LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIltED FEE PERMIT# y<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $SO NAME CHANGE: $10 AMOUNT DUE = S 52>�0 0 '•"••PLEASE TURN OVERAND COMPLETE OTHER SIDE OF FO�•�*�. �_,,�� \ �4 � ` ADMINIS'TRATION � � � , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or r ewal 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 INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT, OF INSURANCE ATTACHED � 4R WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordina.rily 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 rnore than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest u�it 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 OPENING: All swimming,wading and whirlpoals which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count _ by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta.med 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 ha.ve been rnet. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: ---_ Outd�or�QQking,_preparation,�r displa�of ar�f�d prsd�c�-b��rgtail c��ae��ic�-�s�ab�isl�e�t is p�eh�ed: -__- NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RET[7RN TI-�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 EQUIl'MENT, ETC.),MUST BE REPORTED TQ AND APPROVED BY T'HE BOARD OF HEALTH PRIOR TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DAT'E: �� /�-' O� SIGNATURE: �i'X' • J�G��{,/,>t�,_; PR1NT NAME&TITLE: �D�.G'r''-fi �.c,�a f�e�.'1 — ��✓P,,Q�_ro'L° � io�i��o6 , . . • � The Comsronweahb of Massachusetxs � Department of Industrial Accidenls �� > N�eiNiw� 60D Washi�gton Stree� f""Floor � Boston,Mass. 02111 -- worlcers'com uoe Lsar�ce I�qx e,. .., - u Affidavit:B�ii . t,� ,.. � _.� , w z- �r �, �_ Co�tractors .g . v. „� m „ � r . , . �uA ,�: .�m � � � �;,�,'��' name_ ack�ess• ciri �JJ�� l.c,i'`h�LCllf� �j e te• /t zio• t�+Z�� (�� '�� '�l�� work site locati�(full addcess): �� ❑ I am a homoowr►er performing all wa�k myself. Project Type: ❑New C�structia��Rennodel I am a sole 'etar and have no o�e w in an ca Buil ' Addition ❑ I am an employer ptoviding worke.cs'compensati�f�my e.mgioyees working�this job. �: ❑ I am a sole praprietor,geaerat coah acMr,or Lomeowaer(cirde out)and have hined ihe c�nh�tors listed below who have the following worlce,rs'compensatian polices: # #; Failere�o aa�ue erMera�e as rcqained uder 3edMa 2SA ef MGL 152 eu le�d b tl�e 8rp��f c�wial pe�allia�f a�ae�b S1,SM.N aidl�r oae yais'isprboameat as weY a�dv�p�altlm ia t�e forat ata 3TOt WORK ORDER aed a Aoe ettl8b OS s dxp apii�t ie. 1 ndnslud tiat a apy ef tYb ataleseat my be firwarded Oo the O�ce oElav�m of f6e DIA fa�average vaMaBes. I 1014a+eby ceKrfy xnder the ias aud pe�es ofP�H�'tAiet�Ye iufonwallo�provided obo�e ia�nre and oo� •-.-- signatore � �1 ��`'� nate 1 L —' /'7� B�a P�� d6 �r---L ` � Phone#�� Z —�� effieh!ste ealy do aot�vrite�thB arra te be complefed by eity ar lnvn�a! ��'�� Per�/�e q I-1B�idine p�t ❑cLeck if immeditEe reapeme b reqaQed �Sdectmea s O�oe �a' Dep�r�mt t*��' ph�e#' __ _ _ __ _ �L:��°-�� f � � � � WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutuai Insurance Company Burlington, Massachusetts �800�876-2765 NCCI NO 26158 POLICY NO. AWC 7016959012006 ITEM PRIOR NO. AWC 7016959012005 1. The Insured Bayberry Village Condominium Association Mailing Address: Go Robert Lupien Keene NH 03431 32 Monadnock Street (No. Sheet Town or Ciry County Slate Zip Code ❑ Individual ❑ Partnership ❑ Corporation � Other Association FEIN Other workplaces not shown above: 2. The policy period is from09/03/2006 �0 09/03/2007 12;01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state Iisted in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 10 0,0 0 0 each accident Bodily Injury by Disease $ 500,0 00 policy limit Bodily Injury by Disease $ 10 0,0 0 0 each employee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates ��e Estimated Per$100 Estimated No. Tolal Mnual of Mnual Remuneration RemuneraGon Premium INTRA 251208 _ __ — ---- - SEE EXT NSION OF WFOR ATION PAGE — Minimum premium$ 274.00 Total Estimated Annual Premium $ 274.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 274.00 � Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $112.00 x 4.4000% $0.00 This policy,inGuding all endorsements,is hereby countersigned by l� O6/21/2006 Authwized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Rider Risk Specialists MA 9015 704 Insurance Agency Inc WC 00 00 01 A(11-88) PO Box 115 Includes copyrighted material of Ne National Council on Compensation Insurance, Ca�aUl77Ct,MA 02534 used with its permission. .. I�,C`��.�u�:.;��D \ � � � THE COMMONWEALTH OF MASSACHUSETTS TOWN�F YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-002 FEE: $50.00 'rt,is is to cerciry that Bayberrv Condos 503 Route 28, West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS 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 Cabins so licensed as adopted by the Board of Health,and e�ires December 31,2007 unless sooner suspended or revoked. December 8_2Q06 BOARD OF HEALTH: B �ut�. , //��,, ' ��s�, �N.'�`, v`�e�� Number of Units: 18 cabins or 22 units and Qo�e?��B�cusy, (� Manager's apartrnent. n�/�a�� 14�us��eest�r��, R./�. Bruce G.Murphy, ,RS.,CHO Director of Health ��.�-.:� ��ED r, = G��?j� `t D�R�`t C.on►Dd, °f�R� TOWN OF YARMOUTH BOARD OF A �� 3� =� � � -. , Y:. ,�� APPLICATION FOR LICENSF� �� 6� ! * � �,�, �� ;�; � � NOV 1 4 2005 Please complete form and attach all necess �':�loc��s by December 31, 2005. Fa,�lure to do so will result in the retu��n�f our a li ati y p p c o n p a c k e t. NAME OF ESTABLISHIVIENT: �rv �.t, '�'�L. #� 6�s3 - 33 a2—o!�z— LOCATION ADDRESS: o S�- . , ,(,( b �-�,-z� MAII,ING ADDRESS: a OWNER NAME: •--� AX ID�FEIN or SSN�• .-- CORPORATION NAME(IF APPLICABLE): —� MANAGER'S NAME: TEL. # — MAILING ADDRESS: �_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator s) and_attach a copy of the certification to this f,�rm__ 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 �file at your place of business. 1. " 2. �' 3. -- 4. � - __ FOOD PROTECTION MANAGERS - CERTIFICATIONS: A11 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 provicle new copies and maintain a file at your establishment. 1. -� �. �� PERSON IN CHARGE, __ _ - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2 -`--. HEIlI��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 employees trained in anti-choking procedures below and at�ae�i eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. '-" 3. — 4. � RESTAURANT SEATING: TOTAL# — OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 ( CABIN $50 �O�p"AD� _MOTEL $50 iINN $50 _CAMP $50 _SWIlvIlvIIl1G POOL$75ea. _LODGE $50 _T12AILER PARK $50 �,ppp�, $75�. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE I2EQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 �CONIMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIIZED FEE PERMIT# LICENSE REQIJIRED FEE PERMiT# LICENSE REQiJIRED FEE PERMIT# _<50 sq.ft. $45 _>25,OQ0 sq.ft. $200 _V�'NDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 `TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SO. QQ "•*""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••'�"" ��.I� �. � � - ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hald issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate af Worker's Compensaxion Insurance. THE ATTACHED STATE WORI�ER'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 1/ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TI� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPE1v1NG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS��V�NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDTTIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER 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. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen dess�rts mn��t�st�d on a monthly�a�is�y a State certifi�d�ab. Test resuits must be seirt t6 th��eahh 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: /� �, /0S� SIGNATURE: ��--�,�-e..�... PR1NT NAME&TITLE: /�� •Y� '� �-v d� �e!1 �2�-Sur� 8�✓ 09/28/OS �� The Commonwealth o Massachusetxs ==—_-_=—� f � �� Departntent of Industrial Accidenls _ __ �/irw�/MI� � _= 600 R'ashington Stree� 7"�`Floor : � ---�,�` Boston,Mas� 021�1 , wo��°c��aos i�� E,. , ._,_. , n. �..v� . : w �� =v�� *�;��,s��;�� w: �� ..;�� , �: �3�6�� ,. C�d� aadress: S �� /�l,4,/M, �7` � s�y � � • � Y✓�0 Q V � state• � �"` zin• O•�� 7.� ohone# work site loc�ti�(full addressl: ❑ I am a homeowner performing all wark myself: Proje�t Type: ❑New C�tructia��Remodei I am a sole 'etar and have no o�e w in an ca Buil ' Addition ❑ I am an e�npioyer p�+oviding wakers'c�ompeasation f�my e�nployees worlcing�►this job. M: ❑ I am a sole p�roprietor,geseral costract+�r,or�omtawa�(cirdi o�)and have hired tbe caatractois listed below who have the following workers'compensation polices: # � FaY�me M sec�e errera�e a�req�nd uder 3aliaa 2SA�f MGL 152 aa Iaui b IYe idpaitl��f crii�ial pnaNia�f a�e�p b tI,SM.M a�dl�r oee yars'imptb�t as we8 as dvY pe�altla f�tYe fera of i STOt WORK ORDER ud a Sse e[S1i�M s day�de. 1 mderstard t6at a c�py ot tib�fa�my be firwarded 1s the Omee�lave�at fke DIA tor eorerage veri�atMa. I ro benby cerajy xnder dYe pei�rs ewd paeeltlea of perjrrry tNet dYe beforaK�tou provlded abov�e is bare aad oon+ccG si�eure__/� - � • o�su.,e�... � �I'e�S c�r�e(� nan l l�_q l a s P,�;nt� .�z�°'l� S �v Pr�e� Pn��#_(a D� �3 S� " o/ � z� sffic�i ase oely a��t..rire i�t�s u�ea m ne c�plaed br e�y�e�.e�dnl aty ar ts�rn: permif/Boease# (�1B�Dewv�e�ent Q�Beard ❑e4eck if I�me�ale rppeme is re9e'� �Sdect�n's O�oe ��t muea��macin� pti�e#; 0016a' ��v�� WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual insurance Company Burlington, Massachusetts (800) 876-2765 NCCI NO 26158 POLICY NO. AWC 7016959012005 PRIOR NO. AWC 7016959012004 ITEM 1. The Insured Bayberry Viliage Condominium Association ; Mailing Address: c/o Robert Lupien Keene NH 03431 32 Monadnock Street (No. Street Town or Ciry . County State Zp Code ❑ Individual ❑ Partnership ❑ Corporation � Other Association FEIN Other workptaces not shown above: 2. The policy period is from09/03/2005 to 09/03/2006 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liabitity Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 10 0,000 each accident BoditylnjurybyDisease $ 500,000 policylimit BodilylnjurybyDisease $ 100,000 eachemployee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. Ail information required below is subject to verification and change by audit. � Classifications Premium Basis Rates Code Estimated Per$100 Estimated Total Annual of Mnual No. Remuneration Remuneration Premium INTRA 251208 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 274.00 Total Estimated Annual Premium $ 275.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 281.00 � Annualiy ❑ Semi A�nually ❑ Quarterly ❑ Monthly MA Assessment Chg. $132.00 x 4.4000% $6.00 This policy,including all endorsements,is hereby countersigned by 07l20/2005 Authorized Signature Date . GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Rider Risk Specialists MA 9015 2 704 Insurance Agency Inc wc o0 00 0�a,�»-sa> Po soX t 15 Includes copyrighted material of the Na6onal Counal on Compensa5on Insurance, Cdt3Uri1CI,MA 02534 used wifh its pertnission. � ,��cl}"'� ;��f �� . • ; THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-001 FEE: $SO.QO This is to Certify that Bayberry Condo Association 503 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS This License is issued in confornury with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such tenns and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and e�ires December 31,2006 unless sooner suspended or revoked. December 9 2005 BoauD oF��,�: 13��.$. �jo�,A�l.`�. ' /��/l�lc`l�e�u�`t, ?/sce E��s Number of Units: 18 cabins or 22 units and /�o�iPlct`�. BhauRst, �� Manager's apartinent. o�e�e�s eQ��i, Q./�. �I�t�t C�'�ieessd��r�, R.N. ruce G.Murp�hy,MP .,CHO Director of Health �C�'�an�.,��ED . : �6�6� � �r��atr C�Ntb �� •O`:�'R�so TOWN OF YARMOUTH BOARD OF HEAL� �� f� C� _` i= � �ti� � r�� : �;� APPLICATION FOR LICENSE/PE �5 .� � '' DEC � � ?_004 * Please com plete f orm a n d a tt a c h al l n e c e s s a r� „; t �l e c e�i r 3 1, 2 0 0 4. Failure to do so will result in the return'. � o on pac eH EAL�i � �.��:, )��, .� �. NAME OF ESTABLIS��VIENT: TEL. # +� LOCATION ADDRESS: . � _ _d �� MAILING ADDRESS: .2 c9- e OWNER/CORPORATION NAME: MANAGER'S NAME: �, # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certif ed 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 cunently 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. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. l. 2. . __ ��RSON�N-£�ARF�-- — _ __ _ _ ___ _ -- Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMI,ICH CERTIFICATIONS: Ali food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# B&B $50 I CABIN $50 ��S-�Ov� MOTEL $50 _INN $50 _ _CAMP $50 _SWIlVIlVIIl�TG POOL$75ea. _LODGE $50 _TRAIL,ER PARK $50 WFIIRLLPaOL $75ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIltED FEE PfiRMIT# LICENSE REQUIItED FEE PERNIIT# _0-100 SEATS $75 _CON"I'INENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIlZED FEE PERMIT# LICENSE REQUIItED FEE PERMTf# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 _�25,000 sq.ft. �75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SI�.00 '"'••PLEASE TURN OVER AND COMPLETE OTHER 5��I$K��D 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 af 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 NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEAL'TH DEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTTIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY• 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 pnor to the catered event. Thses forms can be obtained at the Health Department. �`ROZEi�DESSE�tTSr— _ _ ___ _ _ _._ __ - - _ 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: f,�Z / �' ` Q % SIGNATURE: � PRINT NAME& TITLE:�^l/z°C{ C c�li'f:✓� �v � L.� �l e� 10/22/04 �� `-_i� The Commonweahh of Massachusetts -_ Depart�rent ofindus�rialAccidents � -_ _— �N��1M�s == � 60o w�h��,n sr� �Fioor --�,�� Boston,Mass. 021I1 � Workera'Compeesatioa I�sua,ee Affidavlt:B�it ' bv�/Gleed�icul Co'tractors � . . ,. z; .. , .. .,� - . :y �.�. �__.. _ _� _ �..� ,� 'w= `�'�,��-'`��`` # � �' .�.�� - �� . �� `; �;�� : 4. .r, ,.,. , . name- addnss: �_Pi C// i � � t : zi : work site locati� full address: . p I am a homeo.vner perfomring all wa�k myself. 'Type: ❑xew co�uctio�pt�n«ka am a sole 'etor and l�ve no one w ' m aa ca ' . ❑Buil ' Additian . . ❑ I am an employer providing wa�s'wmpensati� or my emgloy�s wadcing a�this job. �r a�: __ �. ±�: ��- ❑ I am a sole proprietor,ge�erat codracMr,or�omeewoer(circle o�e)a�have lured the c�ntracta�s listed below who have the following workers'compensation polices: �: dtv: _�r�F- � ��ne: �: s�Y: _��• - -- -- — - – -- – # _ _ _- FaBarc M secm+e�e n req�iral�a Salioa ZSA�f MGL 152 e�a kad b IYe L�p�a�f cri�i�d pnaNb�'a 4�e�p b SI,SM.M aidlK �e yeus'imprbenmmt as we,as cM pe�alda ia the f•rn of a 3T01'WORK ORDER aed a�ae d S16S.YA a day apiint�e. I nde�staud tiat a cepy ef thb stahment maq 6e fer�vaMcd oe t6e 011ice ef lav�as of t6e DIA tor a�vaiAatlea. I do heneby cerfffy rrnder tAie pa�fiis mi�l peealBea of prrjrry tJYet tJie iefor�rellon provided aboae fs bxs ao�d oarnct �� llate Print name Phone# efficlal ese only ae eot�vrite L tlds area te 6e oomplded bY eitY sr�efficfal dly or te�vn: �q ��'�� ❑check if jmme�ale neapeme is reqeired ��E Bsard �Sdectam's U�ee �De�at�ewt t��• phex#' 5��.,`"�� : e � � WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY "�� INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI NO 26158 (800j 876-2765 ' POUCY NO. AWC 7016959012004 PRIOR NO. NEW BU5INESS ITEM 1. The Insured Bayberry Viilage Condominium Association Mailing Address: c/o Robert Lupien Keene NH 03431 32 Monadnock Street (No. Street Town or C(ry County � State Zip Code ❑ Individual ❑ Partnership ❑ Corporation � Other Association FEIN Other workplaces not shown above: 2. The policy period is from09/03/2004 to 09J03/2005 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation fisurance: Part One of the policy appii�s to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $ 10 0,0 0 0 each accident BodilylnjurybyDisease $ 500,000 po��y�imit BodilylnjurybyDisease $ 100,000 eachemployee C. Other States insurance:See Endorsement WC 20 03 O6 A ' D. This policy includes these endorsements and schedules: SEE SCHEDULE � 4. The premium for this policy will be determined by our Manuais of Rules,Classifications,Rates and Rating pians. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Cade Estimated Per$100 Es6mated No. Tofal Annual of Annual Remuneratlon Remuneradon Premium INTRA 251208 SEE EXT NSION OF INFOR TION PAGE � Minimum premium$ 268.00 Total Estimated Annuai Premium $ 268.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 275.00 � Annually ❑ Semi Annuaily ❑ Quarterly ❑ Monthiy MA Assessment Chg. $136.00 x 4.9000% $7.00 This policy,including ali endorsements,is hereby countersigned by 09/28/2004 Au�horized Signalure Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CIASS AUDIT OFFICE OFFICE CHECK GROUP Rider Risk Specialists MA 9015 2 704 Insurance Agency Inc WC 00 00 01 A(11-88) PO Box 115 Includes copyrighted material of Ne NaBonal Council on Compensation Insurence, Cataumet,MA 02534 used with its parmission. � SC��"..:.;��iY' �� i t THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #OS-OQ4 FEE: $50.00 This is to cerafy that Bayberry Condo Association 503 Route 28, West Ya.rmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS Tlus 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 Cabins so licensed as adopted by the Board of Health,and expires December 31,2005 unless sooner suspended or revoked. Januarv 26.2005 BOARD OF HEALTH: Best�Htis�.h. (��/H�. ' p��t�� v�e�� Number of Units: 18 cabins or 22 units and Rp�¢h�`� B�y� e�e�a Manager's apariment. ,�{�y �'(�(y, /r,/�/, fQstst�'?eeis�asurt, R./� ruce G. urphy, S.,CHO Director of Health 5��.�;'''�� _ r � -.� � �W-'^ � . � r, , : �� `� ��&,. � D o ,�--'-,Y�-AR.� TOWN OF YARMOUTH BOARD �'�i AI�TH' �� _-� APPLICATION FOR LICENSE/P�'II -200 ��S'' NOV 0 3 2003 o , t,�'' Y % .,y,;s * Please complete form and attach all necessary documents by December 31, ALTH DEF'T. Failure to do so will result in the return of your application packet. S I EN : S B - -E►�l�2 LOCATION ADDRESS:^�.� /�t.�.w S' - CU � L/a.v�/'!'l6G�, /C/J� MAII.i1V� ADDRESS: ��a /V1.Q rlCi,� G� �� • ��,o�n�, fV`l`� �'�L�3 % OWNER/CORPORATION NAME• iVLANAGER'S NAME• TEL. # MAILTNG ADDRESS• POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this forzn. 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' reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food 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• -------_— �_ - —--- _ -- -- - _ , ---- —-- ---- - - - v�: Each food establishment must have at least one Person In Charge (P1C) on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premi.ses at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED EEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . ._--____--._�30--- - , -- - _ t-CABIN S�U ��t'v�,.��v� —MOTEL _ S50 INN $50 CAMP $50 _SWIMMING POOL S75ea. LODGE $50 TiZAiLER i'�RK $SG _VvHIRLPUOL $75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQII[RED FEE PGRMIT# L[CENSE REQUIRED FEE PERMIT# 0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT S25 >(00 SEATS $I50 COMMON VICT. S50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FEE PERMIT# LICENSE RGQIJIRED FEE PBRMIT# <50 sq.ft. $45 _>25,000 sq.R. $200 _Vf NDING-FOOD $20 _<25,000 sq.ft. $75 _(�ROZ,f;N nL•SSI;RT $35 _TOBACCO S25 NAME CHANGE: $to AMOUNT DUE _ $ 5p . ��.s�--- **•**PLEASE TURN OVER AND COMPLETE OTHER SID��ARIt�''' " . � ADMINISTItATION ' � 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 W�RKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES t.� NO NOTICE:Permits nin annualty from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2UO3. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTM�NT 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. �DDITIONAL F ULATION� POOLS POOL OPEle1ING:All swimming,waciing and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standazd plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing. FOOD SERVICE �O_NSUNLR A�VISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POI,ICY• 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. __ F�Q�EAi-��'fifi�.�t'�3'�,. __ __ _ . _ _ 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 yo«r Frozen Dessert Permit until the above terms ha��e been met. OUTSIDE C FF�• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COO iN =• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: G d 3� �° SIGNATURE: PRINT NAME & TITLE: �TV�cA.;S�/�'io y— ' l 0/22/03 � ' � �R ~ � ` " The Commonwealth of Massuchusetts � � � Department ojlndustrial.-iccidents � ; Offlceo//a�stl�stliis � 600 Washington Slreet � � Bnston, Mass. 02111 / y\� . . ' � . � � . " �� W'orkers' Compens�tion insurance Affidavit �m�� ,�A� �S S��//N . a �on: c � � � 'o -3S"a � �Y � ( am a homecw�ner rtormin;all work mysel . \�' � ( am a sole proprieror �r.,�. ha�e no one ��orkin� in am•capacity �� I am an employer pro�idin�w�orkers' compensation for my empioy�ees w•orking on this job. comnan�• name• �ddress• city: ehone#1• _ insurance co. Aolicy# � I am a sole proprietor. general contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu�cin: ��orkzr �ompensation polices: �omQanv n�me• address city.• D110f1!�' insur�ncc co Qolic}� — ggmoany name• . . —addra�• - Sjiy: nhoee M• _ inenran�r�n_ Ap��* 1 Faiiure to secure coveraee as�eqwred under Secnoo 25A of MGL 152 ea�Ind to the iepaidoa oterivi�l peaaltles of a d�e ap to 51.500.00 a�d/or ooe yean'imprisonment a w•ell a�civil penaitia io the[orm of a STOP WORK ORDER aad a liscoPS180.00 a dar apiost ma [a■dersn.d mar a copy of thH statement may be fonwrded to the OlTice of inve�tigftiom of the DIA for eoven�e veri8qtfo�. I do hrreby cenifj� der rh�pains a d p�nalti� ojperjury that thr injorniation provrdtd obove is ut�e and eorrrd _ _ , . :' . . 3C/a� Si gnaturr`` � . . Print name � � ' / ^ one��A.3 `� �� `-�� .. o(Ticial use only do not M rite in this area to be completed by eih or towa oflleial , �':.{e�! { ciry or tow�n: Y�M�IIT$ _ per Building Department �Liunsio6 Board 0 cheek if immediate response i�required OSeleetmen'�01Tice �Health Departmeat contace person: phone M;_ �508} 398�2231 eat. nOther .. .�. ��,,. ` � ' -' �_,�_,__.� WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE � Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts �800� $76-2765 NCCI NO 26158 POLICY NO. AWC 7012685012003 PRIOR NO. NEW BUSINESS ITEM 1. The Insured Bayberry Viliage Condominium Association Mailing Address c/o Robert Lupien Keene NH 03431 32 Monadnock St (No. Street Town or Ciry County State Zip Code ❑ Individual ❑ Partnership ❑ Corporation � Other Association FEIN Other workplaces.not shown above: 2. The policy period is from 05/17l2003 to 05/17/2004 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; _ _ _ . _ _ _ MA _ B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 10 0,00 0 each accident BodilylnjurybyDisease $ 500,000 policylimit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: See Endorsement WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit Ciassifica�ons Premium Basis Rates �e Estlmated Per 3100 Estlmated No. Total Mnual � Mnual Remunere0on Remuneretion Premium INTRA 251208 SEE EXT NSION OF INFOR TION PAGE Minimum premium$ 269.00 Total Estimated Mnual Premium $ 270.00 As indicated,interim adjustrnents of premium shall be mad�: Deposit Premium $ 277.00 � Mnually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $147.00 x 4.5000°/a $7.00 This policy,including all endorsements,is hereby countersigned by 04/23/2003 Authodzed Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Rider Risk Specialasts MA 9015 701 Insurance Agency Inc PO Box 115 —V1IC 00 00 01 A(11-88) a�tamet�� Indudes copyrighted material of the Nalfonal Council on Compensalion Insurance, ��., . used with its pertnission. �� . . �---_.. �-- THE COMMONWEALTH OF MASSACHU5ETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-001 FEE: $50.00 This is to Certify that Bayberry Condo Association 503 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS This License is issued in conformity with the authority ganted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amende�,and is subject to the provisions ofthe Laws ofthe Commonwealf�ofMassachusetts relating thereto,and upon such terms and c�onditions,and to t�e rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31,2004 unless sooner suspended or revoked. November 4.2003 BOARD OF HEALTH: �e.�c�a�xloa�. ��oqdo�. ��., �a�iriva.� �a�ick�1�D�c.x�o�e. `l/fce (�aea Number of Units J 18 cabins or 22 uaits and �o�e'ct�• �aoa�c. � manager's apartment.---- _ _ 'st�efe.�.��-�-'f2.. .__-___ _ Bruce G.Murphy,MPH, .S HO Director of Health ��.� ; ��D :. < .. _ GfL�;��06 ��°�= gAyF��R-`I CoNDa. oF_Yae TOWN OF YARMOUTH BOA '�3'H��1LTH � .� �� ,� � . .- ,� ��-.. G;� C� res> ._., (1 ;7 � CG 3� - -'� APPLICATION FOR LICEl�� I`�2003 °; ,!i ,Y, .� <�;, � tj * Please complete form and attach all n ents by Dece ber�l,`200�. �� Failure to do so will result in the rn your application pa k��+�� -r-.._f r.,�-;,��- N F S T: fM- � T d -�� (v,�, L I M " - MAILING ADDRESS• 3� /v!o /F4c�/�� J .s',�-. (��c�vaP� /v'1-�- �3 _3/ OWNER/CORPORATION NA1��E• ly�iv�i^v�n'�i�r"uv�• TEL # MAILING ADD SS• - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opera.tor(s)and attach a copy of the certification to this form. 1. 2• Poal 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 m�intain a fde 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 em�loyee 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• PFRS9Ai IN CHAI�:F��- -- -- _ __—.: ,---—�_ _--- - _ _ _ _�_ Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2• HEI LICH 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 fde at your place of business. l. 2• 3. 4. RFSTAj�JRANT SEATING: TOTAL# OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 I CABIN $50 _MOTEL $50 INN $50 _CAMP $50 _SWI1vA�iING POOL$SOea. LODGE $50 _TRAILER PARK $50 _WHIIiLPOOL S25ea. FQOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $I50 COMMON VICT. $50 _WHOLESALE $75 RF.TAIL 5ERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# TOBACCO $20 _<25,000 sq.ft. $75 �TOBACCO $20 _<50 sq.ft. $45 >25,000 sq.ft. 5200 _FROZEN DESSERT$35 �iAME CfLANGE: �lo AMOUNT DUE _ $ 5 0.p0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF * *�; ��q,��!e ��.� `��t�s lL.F� _ ..�::-.�._ _. ._ _ ;____ �� - ` , . 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 ATTACHEL OR 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 i/ NO NOTICE:Permits run annualiy from January 1 to December 31. IT IS YQUR RESPONSIBILI�'Y TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002. SEASONAL ESTABLIS�-�VVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL 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. -- �'R4�T�F��'S• --- __ _ __ _ _ _ _ ___- - _ 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), ust have prior approval from the Board of Health. OUTDOOR COOHIN • Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �/ / 7j SIGNATURE: � PRINT NAME & TITLE: ,j'p� �� .�, ��p�u�/'��--- 10/18/02 . • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE . N��o.No L E G I O N P�� NwC�-oo26525 10901 • l. INSURED: BAYBERRY VILLAGE CONDOMINIUM Renewal of Polic No. SEE GU207B WC60026525 The]nsured/Mailing address: 32 MONADNOCK STREET �individual �Partnership KEENE,NH 03431 �Corporation or � ASSOCIA7"ON Other workplaces not shown above: Insured's l.D.No(s).(if applicable) See WC 00 00 Ol F.E.1.N.# Risk ID# - 2. POLICY PERIOD: The policy period is from OS/17/2002 to OS/17/2003 12:01 A.M. Standard Time, at the Insured's mailin address 3. COVERAGE: A. Workers Compensation Insurance:Part One ofthe policy applies to the Workers Compensation Law ofthe states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.The limits of our liability under Part Two are: Bodily]njury by Accident$100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 •each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,]isted here: SEE GU207E D:This policy includes these endorsements and schedules:SEE Guzo�A 4. PREMIUM: The premium:for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.`All3nformation requiredbelow is sub}ect to verification and change b audit. ' Code Premium Basis` Rate Per Estimated Annual Classifications No. Total Estimated $100 of Premium Annual Remuneration Remuneration SIC Code : 8641 See WC 00 00 Ol If indicated below,interm adjustments of premium remium for Increased Limits part Two,If applicable shall be made-- � otal Premium Subject to the Experience Modification remium 1�9odified to Reflect Experience Mod.of �Semiannually; � Quarterly; �Monthly otal Estimated Standard Premium remium Discount,if applicable $ MA—DIA Assessment $7 xpense Constant Charge otal Estimated Annual Premium Minimum Premium $269 De osit Premium $269 Total Estimated Annual Premium $269 Name ofProducer: RIDER RISK SPECIALISTS INSURANCE AGENCY 1NC. ��7i.��J Servicing Office: Small Business Underwriters Countersigned By 03/19/2002 TWO PARAGON WAY,FREEHOLD,N.J.07728 .4uthorized Representative Date TH1S 1NFORMATION PAGE VV1TH THE VVORKERS COIV}PENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,C0111PLETES THE ABOVE NUMBERED POLICY. ' GOPYRIGHT 1987.NATIONAL COUNCIL ON COMPENSATION 1NSURANCE �YCOOOOOIA R 10001(ED.7•93)()) � . ' � �/��1�.,ti'�`��i�� (MA-DEC}I O/98 �, . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #03-002 FEE: $50.00 This is to Certify that BayberrXCondominium 503 Route 28. West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS 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 Commonweatdi ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked. November 20 ,2002 BOARD OF HEALTH: (��. �efli��,__ e/ra,Guvu�c _ _ _--- ____ D. Gt"�ndo�c. 7K D., �1/tc� � Number of Units: 18 cabins or 22 units and ��a�� , �� manager's aparkment. �4�iick�or�xot� �tl�c��c. �� ruce G.Murphy MP .S.,CHO Director of Heal S�.r��.`��iw�� .- , - �'�u 3��t B��c C��Da. . ; � � TOWN OF Y' RD OF HEALTH --- —��` ' � APPLICATIOI�FOR�I • �� E/PERMIT -2002 � �N rG' �� '�? '`: � �-�� '�• �iv � `�� t ; * Please complete form and attach all necessary documents by December 31, 2001. Failur to o w 1 esu t i the return of your application packet. HEALTN DEPT. AME OF ESTABLISHMENT: ° TEL. # '63 3 .�-6 L TION S• 5d� - �� MAILING ADDRESS• 3a .�Icrna�l�,o�� -- Keen� ; N'�l o`��f-3/ OWNER/CORPORATION NAME• MANA ER'S Nt�ME• TEL. # _ MAILING ADDRFSS• POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ,---- Yodr6pera�or�j aric�-a�ach a capy afthe�ertificatron t�this-fonn. - - 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. 1, 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. pERS�NIN�HARGE: _ _ _ _ - _ _ _ --- ---- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 1 CABIN $50 Oe�"Od�}' _IbfATE $50 INN $50 CAMP $50 �SWIMM POOL$SOea _LODGE $50 TRAILER PAItK $50 _WHIRLPOO $25ea. �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 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 CHANGE: $io AMOUNT DUE _ $ h6�-6� *****PLEASE TURN OVER AND COMPLETE OTH�S��O�'F�M'�� ''�� , � t , 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�/ 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 ESTABLISI-�IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS �,_. _ __ �_,-- ., _ POOLS _ POOL 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 swinuning 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. ('ATERING 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 DES�ER�S• _ __ _ _ _ _ _ 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 waiterlwaitress service),mus 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: >/ j Q �0 I SIGNATURE: � �rv PR1NT NAME& TITLE: ��3� �U O� G � "' � i'� �.aS (/i�'�% 1'� - 09/11/Ol � � � . • Th e Common wealth of Massach usetts � � Department ojlndustrial.-�ccidents ; � ; OJ1Iceo/I�es�lostJiis 600 Washington Street ' •� Boston, Mass. 02111 �~ '��y W'orkers' Compensation Insurance Affidavit Annlicant information: PleesePRi�7"Ti�.'iJic n�mc ,f-X.l I/�`Y'!.� �Y1 �O lucation� Jr03 /r(Q,1/1�1 �f' • �it� �• uGl�l/'/YYS (� T�i }N 1;� ohone� 1.�� ".�J�a `L�/6�� I am a homeowne pert�rmin,all work myself. � I am a sole propri�ror =-� ha�eno one ��orkin� in,am�capacin• . N� --_ 0 l�man_em�La�e�pra��ne µ�ork�s'compensatinn for my emp yees w�orkine on this job. comnanv name• 1ddres5• citv: phone M• insurance co. policy# � I am a sole proprietor. generai contractor, or homeowner(clrcle oneJ and ha��e hired the contractors listed below �t ho ha�e 1/'/�,the follu��in� ��orker_ �ompensation polices: �v I•C com a�nv name• address• csy: phone ti• insur�nce co. Qolic�•# com�nv name• address• �: ehone If• insurance co. eoliev if ' Fsilure to secure coverage as requ�red uoder Secnoo 25A of MGL 152 ess Ind to t6e iopoeidon of erisi�d peedtles of a O�e op to 51�00.00 a�d/or one yean'imprisonment a�w•ell aa civil penalde�io the form o[a STOP WORK ORDER aed a tine of 5100.00 a day q�inst ma [a�denta�d that a copy of thu statement may be fonva�ded to tht ORice of inve�tig�uoo�of tbe DIA for eovera;t veritiado�. I do hrreby certif}•under the poins and penal�ies ojpery'ury that tht injo►mation p�ovided abovt is ttut and eor►ed Signature �� Date /1 j/ � /a � Print name .�lJ �. � J �P one�c ��'" 3 5�- --D/�2..---. .. olTici�l use onl� do not Mrite in this�rea to be completed by ciry or fown olileial ciry or town: YARMOIITQ _ permitAiceaae q �^�'._j°��t��artment — p� � �!E'E oard �check if immediate respoese ie required �Sdectmen'�OtTiee ea t 6epirtment contact person: _��q;_ (508) .398--?231 eat. nOther - ' SMALL BUSINESS UNDERWRITERS PO Box 6519 Freehold,NJ 07728 ENDORSEMENT INVOICE Workers Compensation April 26,2001 AGENT: RIDER RISK SPECIALISTS INSURANCE Total Premium Received: $258 AGENCY INC. � � P.O.BOX 115 Amount Due: $0 CATAUMET,MA 0253401 15 Policy Period: OS/l7/2001 to OS/l7/2002 Phone: (508)564-7200 Fax: (508)564-7272 Policy Number: WCb-0026525 Re: BAYBERRY VILLAGE CONDOMINIUM C\O ROBERT LUPIEN On a Policy Endorsement we require the Full Estimated Annua] Premium be paid. CALCULAT]ON OF THE COST OF THE SUBIECT POLICY ENDORSEMENT AND ANY ADDITIONAL OR RETURN PREMIUM: Premium Basis Rate per Code Total Estimated $100 of Estimated Classifications No. Annual Remuneration Remuneration Annual Premium BUILDINGS NOGOPERATION BY OWNER 9015 $1,687 3.58 $60 ESTIMATED ANNUAL PREMIUM $60 UNMODIFIED PREMIUM $60 MODIFIED PREMIUM $60 LOSS CONS7'ANT 0032 $20 PREMIUM TO BALANCE TO MINIMUM PREMIUM 0990 $65 TOTAL ESTIMATED STANDARD PREMIUM $]45 EXPENSE CONSTANT 0900 $107 TOTAL ESTIMATED PREMIUM $252 DEPT.OF INDUS7�R]AL ACCIDENTS ASSESSMENT 4.0% $6 TOTAL ESTIMATED PREMIUM COST $258 MINIMUM PREMIUM $252 TOTAL POLICY COST: 5258 AMOUNT PAID TO DATE: $258 PT�EVIOUSLY RETIJRNED AMOUNT: ($0) PREMIUM REFUND: SO PLEASE CONTACT YOUR AGENT WITH ANY QUESTIONS. .................._._......._._.._................................___.._..._....._.._._...._........._...._._._...____._._.___.__....r.__..__._...._._._....._._._..___._..___.._ . __.___..__....__._._.._....._____....._._.. .._.._. . (CUT ON DOTTED LINE) Return this portion with your check payable to: Legion Insurance Company. Please write policy number on your check. Send To: P.O. BOX 6519,FREEHOLD,NJ 07728 Policy Number: WC6-0026525 Policy Period: OS/l7/2001 to OS/l7/2002 Amount Due: $0 BAYBERRY VILLAGE CONDOMINIUM Due Date: N/A C\O ROBERT LUPIEN Amount Enclosed: $ 32 MONADNOCK STREET Check Number: KEENE,NH 03431 Check Source: _Agent _Insured (Please Check One) �G� .. � �..,, .: � �� '� (MA-ENDIN�10/98 7 4 � , , �egion Insurance Company FORM: GU 207 ' PO Box 6519 EDITION: 6-78 Freehold,NJ 07728 Page l of 1 4/26/O 1 POLICY INFORMATION PAGE ENDORSEMENT This endorsement,effective on OS/l7/2001 at 12:01 A.M. standard time,forms a part of Policy No. WC6-0026525,effective from OS/17/2001 to OS/17/2002,of Legion Insurance Company,NCCI No. ]0901 Issued to BAYBERRY VILLAGE CONDOMINIUM C\O ROBERT LUPIEN STATE: Massachusetts This endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following coverage part(s): ' Part 1. Change in Workplace of Insured(WC 89 06 08). Workplace Added: 503 MAIN STREET WEST YARMOUTH,MA 02673 Nothing herein contained shall be held to vary,alter,waive,or extend any other terms,conditions,provisions,agreements,or limitations of the above mentioned Policy,other than as stated above. *Producer Name In Witness Whereof,the Company has caused this RIDER RISK SPECIALISTS INSURANCE AGENCY INC. endorsement to be signed by a duly authorized *Servicing Office representative of the Company. Small Business Underwriters PO Box 6519 � Freehold,NJ 07728 AUTHORIZED REPRESENTATIVE SC��ED (MA-ENDORSE)3/99 � � , , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #01-005 FEE: $50.00 This is to Certify that Bayberrv Condominium SQ3 Main Street/Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO � OPERATE CABINS 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 regazd to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended ar revoked. March 1 ,2002 BOARD OF HEALTH: ��f, i�e�'Cei, �c%�avr�u� �D. C��, 7 ?�.. `l/iee Number of Units: 18 cabins or 22 units and �a�ezt� �aotwc, �� manager's apartment. '�u�tic��er�rrat� � � Bruce G.Murphy, , .5.,CHO Director of Heal ��r`V f��,'�� BayaEiz.2y Co�vUo. Asst�l. � � � Q � � � � d � � '� TOWN OF YARMOUTH '' E�'' � APPLICATION FOR LICE��` �I � =2001 �� 4 2�Q� * Please complete form and attach all necessary documents by December 31, 2000. Fai L��lb�bl��5ult in the return of your application packet. -------------------------------------------- ------------------�----- f' �///t�r�-�-r�ss-------_----1----------------------35"�-4 6�- N o ;-, �' av �� o c�d.,o�/c . o QWNER/CORPORATION NAME� �_ M�.I�IAGER'S NAME: TEL. # MAILING ADDRESS: ----------------------------•---------------------------------------------------------------------------------------------------------------- POOL. . .R FICATIONS: The poal supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two emplayees 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 maiwtain a file at your place of business. L 2. 3. 4. HEIMLICH CERTIFI�ATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SM4KINCr SEATS: TOTAL# __ ____ _ �__ __________ _ �.._ �_� �.�w � OFFICE USE ONLY LODGING: LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $so � c�snv �so �C��-o0 5 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL � $50 SWIMMING POOL $SOea. WHiRLPOOL $25ea. �O�D S�;RVICE: � NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAI., $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL S�',RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 T>25,000 sq.ft. $200 �ME CHANGE: $10 AMOUNT DUE _ $ 5 O .O O *****PLEASE TURN OVER AND COMPLETE OTHER 9IDE OF FORM�**** �� .� _ �� .� , ADMINISTRATION �` �, Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of;any lic�nsefc�rt�er�iit_�o opera.te a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE W4RKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �✓ Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY TF PAID: �� C'�'`a�O ' YES t/ NO v NaUe �� '��evri�ir� ,�i�/ �' ��uusss �v�'� �� o� NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHIvIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 DAYS PRIOR TO OPENIN'G 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 OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS• The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection ma.nager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATERING POI,.ICY• Anyone who caters within the Town of Yazmouth must notify the Yarrnouth 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 De�artment. FROZF,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 revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE G�FF:S: 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: /��y�� SIGNATURE:i��'�L �v"`��'`-e'�". i PR1NT NAME&TITLE: �D 6 Lu /�� e,� J✓'�45�'re✓ 11/16/00 � y � � ` _ The Common wealth of Mossach usetts � W Department ojlndustrial.-lccidents ^ a O/I/C001/OYQSI/�lUllt � A 600 Washington Street .� Boston, Mass. 02111 �'"' S"�y Workers' Compensation Insurance Atfidavit A.Rolicant information: PfeasePRIIQTTl�tc � m m c� ��M17�/'� ��Vl,cl� Ff-SSO�la./�!/'Y1 I��cation� 5�3 �Q_.vw �- • cit� � S 1� � i'�vl/1 Q U� �1�- D�U 73 phone# ��'.�s-2 `�l 6 Y � I am a homeown r pertorming all work myself. �ss��/� G'�S�`'«-t'.�5 �U�, � f am a sole proprietor�r,� ha�e no one��orkine in am•capaciry � I am an employer pro�iding w�orkers' compensation for my employees working on this job. compan�• name• address• �ity• nhone q• insur�nce co policy# — � I am a sole proprietor. general contractor, or homeowner(circle one) and ha�•e hired the contractors listed below ��ho ha�e the follo��in��orker�� ompensation polices: comoanv name• ^�dress• - ��• phone k• insur�ncc co ��53'� - com�anv name• - . _ _ . __ _ _ _ __ addr ss• - Sjly• phone t�• insuran�co M+��# Failure to secure coveragc as required under Sectioo 25A of MGL 1S2 as lad to the impositioo of erioi�al pesaltla of a O�e op to Sl¢00.00 a�d/or one yean'imprisonment as w•ell as civil penaldes io the farm of a STOP WORK ORDER and a fioe of S100.00 a day apinst ma I a�denta�d that a copy of thy statement may be forvvarded to the OtTice of Investigations otthe DU tor eovengt veri6titio�. /do hrreby certij}•under�he pains and penalties ojperjury that tht injormation provrded abovt is tntt and eorstet Signature �C.eM- ate l�'�i��d C� Print name ✓�6� L.f� [�<�✓l i1 ✓ �'�"S��'�r Phone�l ��.�- 3�a "�16�- ., o(Ticial use only do not..rite in this area to be completed by city or town oRicial ciry or towe: y�M��T$ _ permiNleense k nBuildiag Department �Licensiog Board p check if immediate response is required 261 QSelectmen's OtTiee �H-�Ith Departmeot cootact person: phone q;_ �508} 398--2231 egt. nOther Irevised 3;95 P1A1 { R'ORKERS COMPENSATION��D EMPLOYERS LIABILITY INSURAI�iCE POLICY - , INFORMATION PAGE NCC10901� L E G I O N P°'" "°. • WCS-0026525 1. INSURED: BAYBERRY VILLAGE CONDOMINIUM Renewal of Polic No. SEE GU207B __ _ WC40026525D Thelnsured/Mailing address: 32 MONADNOCK STREET �Individual �Partnership KEENE,NH 03431 �Corporation or ASSOCIATON Other workplaces not shown above: Insured's I.D.No(s). (if applicable) ' See WC 00 00 O1 F.E.I.N.# Risk ID# - Z. POLICY PERIOD: The policy period is from OS/17/2000 to OS/17/2001 12:01 A.M. Standard Time, at the Insured's mailing address 3. COVERAGE: A. Workers Compensation Insurance:Part One of the policy appiies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability lnsurance:Part Two of the policy applies to work in each state listed in item 3.A.The limits of our liability under Part Two are: Bodily Injury by Accident$100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: SEE GU207E D:This policy includes these endorsements and schedules:SEE GU2o�A � 4. PREMIUM:-The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All Information re"uired betow is sub'ect to verification and chan e bv audit. Code Premium Basis Rate Per Estimated Annual Classifications No. Total Estimated $100 of Premium Annual Remuneration Remuneration See WC 00 00 O1 If indicated below,interm adjustments of premium remium for Increased Limits part Two, If applicable shall be made-- ota]Premium Subject to the Experience Modification remium Modified to Reflect Experience Mod.of �Semiannually; � Quarterly; �I�fonthly otal Estimated Standard Premium remium Discount,if applicable MA—DIA Assessment $6 xpense Constant Charge otal Estimated Annual Premium $ Ivfinimum Premium $252 De osit Premium $252 Total Estimated Annual Premium �252 Name of Producer: RIDER RISK SPECIALISTS INSURANCE AGENCY INC. Servicing Office: Small Business rJnderwriters Countersigned By �� n4mannnn TWO PARAGON WAY,FREEHOLD,NJ.07728 Authorized Representative Date THiS INFQRMATinN PA(:F.WITH THF,��'nRKF.RS('nMPF.NSATInN AND F.MPLnYF.RS I.IARII.ITV iNSURANCF.Pni,iC'Y A�ID ENDORSE�IENTS.IF ANY,ISSUED TO FORhi a PART THEREOF.COMPLETES THE ABOVE NUM1IBERED POLICY. COPYRICHT 1987.\ATIONAL COUNCIL ON COMPENSATION INSUR.�INCE 810001(ED.7-93)(I1 W C 00 00 Ol A, � (b1A-D EC)10/98 , y � :: ; ¢ob o c� c � b � x .� � � �. �J � � o � N 0 � v, •� � .� a � o � � � o ,e�. w � ~ � N � � � � ti W � ; � F k" v � � � `� '�� E� .� 3 � '° o ,�'�O(J �,.�� W r,� •a � N �� o r . � hil � O � � � M � v O V � �W/1 ° �, o � �n' � , �,°��' r�/1 Ex-� `�"i `� W � o b c°'i � �c �A L1 U v� p°q :� � A � , Q; ,.'7. E'" � �-1 � a� c y � _ - � ' , � O '"'7 � � a � � ' O � W � �., � � � � '? a, a d' �"+ •� � A U b � �o aXi � }+ p � ^O � � � � � � w . �, aw � � zW � � � ° . d0 � � c� � � �.n �, � � . C7 W o � � ]C Q � � p •� zp � .� � o � � � � '� � pWq � � � o �° � c� . � � � � � � o � � � O � U � � � � � � � � � � x � � 'ti U O .'" � �" � ..fl N � a, W �k � � � rn 0 y O � w c� y � y v, �'x"'i � � � � M � � '� � , , W ao ti � , � � � � �a 'b o � � N � N ,� � � � � � '� � � .� � VN v�i ^� w H � tj � o 0 � y a M � � � � Q � N � •� o � a � � � � U w w Z �q . r �r..�..�. .� ._�.r.. � ..,.. .. � ..� ". " _ .... - ... . .. � , • ...� • • • . �' C � � , ' . . . . ., . . . . . . , '�+ � , � , . . . . i � �, ��eY'rt.� Ui �IGI�L CCri��.' f�� , TOWN OF YARMOUTH BOARD OF HEALTH G�3 f� C� � D M r-� �� " APPLICATION FOR LICENSE/PERMIT-�O.OQ-�� N 0 V 2 4 1999 ;r--,� ��.,� �� * Please complete form and attach all necessary documents by D�cei� `�1�1��_� ' 're.t�� 1��1�' the return of your application packet. `fW..�J � �� c� Gk,s��`��. ------------F ES-----------------N------�-----�-~�''�----�--_--- -----�---_--------- - -----`�---L-#--�.�� ----`. �P –' d,7. LOCATION ADDRESS� �,3/y1�,, .S�- �Lt/, Gfar.�v �!� e MAILING ADDRESS� 3� 6�� S . fr�,��C� B 3r�3[ OWNER/CORPORATION NAME: MANAGER'S NAME: TEL # 1V�A�,1�TG ADDRESS: - - - -----------------------------------------_------_-----� POOi CERTIFICATI�N�;, ; T6e pool sapervisor mast be certified as a Pool Operator, as rec�uired by new State law, Please list the ! designated Pool Operator{s) and attacn a-copy of the certification to ttus forrrr: 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Comrnunity Cardiopulmonary Resuscitation (CPR). Please list these employee§ below and attach cnpies of employee certifications to this form. 'Ifie 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 CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. I�STAkUR�N'� SF�'�TG: TO�'A�,# ------ ----�I9I�T-�M�Ki�VG SEA'F�:TOTAI,-�------ --------– -- ------------------------------------------------------------------------------�------------------------------------------------------- ----- OFFICE U5E ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $so 1 caBnv $so 2K- nvlv $so cnNrn �so LODGE $50 TRAII,ER PARK $50 MOTEL $50 SVVIlVIlVIING POOL $SOea. WI�tLPOOL $25ea. FOOD SERVICE: — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# 0-100 SEATS $75 CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 � WHOLESALE $75 I3ETAII.. SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 N�,ME CHANGE: $10 AMOUNT DUE = $ �(�) " """"PLEASE TfJRN OVER AND COMPLETE OTI�R SIDE OF FORM""••• __ -, « , ADMINISTRATION � UNDER CHAPT�R 15�, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE (.lR PERMIT TO OPERATE A BUSINESS TF A PERS(l�fi`-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 QF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE t)F YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII.IT'Y TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONIAL ESTABLISFIaVIEEN'TS ARE TO CONTACT THE HEALTH DEPART'MENT FOR INSPECTION 7-1Q DAYS PRIOR TU OPEI�]ING F�R TI� 5EASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONIlVIENCEM�NT. RENOVATIONS MAY REQUIRE A SITE PLATT. ADDITIONAL REGULATIONS POOLS POOL OPENIlVG: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR T�-�SEASON MUST BE INSFECTED BY TF�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TOTAIr COLIFORM AND STANDARD PLATE C4UNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SVVIl��IlvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI-�TOWN OF YARMOUTH MUST NOTI�'Y TI-�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO T'HE CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT TI-� HEALTH DEPAR.TMENT. FROZEN�ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.,L RESULT IN TI-� SUSPENSION OR REVOCAT'ION OF YOURFROZEN DESSERT PERMIT UNTII.THE ABOVE S HAVE BEEN MET. - — _ _ _ _ — __ OITTSIDE CAFES: OUTSIDE CAFES(i,e., OLTTDOOR 5EATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. QUTDOOR COOKING: OUTDOOR CUOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLISHIVIENT IS PROHIBITED. DATE: `Ir �.�� 9�j SIGNATURE: U � PR1NT NAME& TITLE: r Q.,S'V (^�%/ � �l/p�S/� 1 U12/99 r ` � � The Commonwealth ojMassachwsetts '" � � Department ojlndustrial,-�ccidents _ a Of1IC00/%YCS��fdl/t � 600 Washington Streel ' ,>•` Bnston. Mass. 02111 ~ '�� W'orkers' Compensation Insurance Affidavit A�nlicant information• p►�t�pg��,� �m�� Gt,�l�-P ru �+ /tir��F f/rv� ,�SS�� location: S�3 /�Q.t�vl� .�T • ' . -� �iv�o v�, �) /� � 03-.�S`� �-a�� --- � I am a homeowner zrt�rmin,all w�ork myself. � ( am a sole proprieror �-,', ha�e no one ��orking in am�capaciry (� I am an emplo�er pro��dino w�orkers' compensation for my empioyees workine on this job. comnan�• name• .�ddress: sitv: nhone� �surance co. ��y# � I am a sole proprietor. :enerai contractor, or homeowner(circle onel and ha��e hired the contracton listed below «ho ha�e the follu��in� ��orker�� ompensation polices: sQmoanv name: address• ��t�• nhons M• insurancc co. Folis�'# �mnanv name• address: �' ohoee+� insurance co. ��eY* t Faiiure to secure coverage as required uode�Sectioo 25A of MGL 152 n�lad to t6e iopo�idoa of eriof�d ptadtles of a 6�e ap to Sl¢00.00 a�d/or one yean'imprisonment as w•ell as civil penalda io the torm of a SCOP WORK ORDER aad a fiae of 5100.00 a day ataio�t ma i a�denta�d tbat a copy of thh statement may be fonvarded to the OlTice of Invc�tig�uom of tbe DIA f�eovenge veriAqtio�. I do hrreby cerrif}�under rhe poins and prna!lies ojperjury that the injorn�ation provided abovt is tntt and eontet Signature ' D� f�„e��.s Q y' < < Print namc _ /� �/�D/ f�'1 Phoneli �0,3' �o�� Q/ �a d�— .. o(Ticial use only do not..rite in this area to be completed by city or towa oQlei�l city or town: YA��IITFI _ permitAlceese a n8uildiog Department �Lieeosiog Board Q cheek if immediate response is required �Selectmen's Oliice - _ 261 __ __ _ __ __ _ __ pHealtA Depanmept contacc person: phoneN;_ (508) 398t2231 egt. nOther .. . < .,,, I � �---- . WCIRKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY , INFORMATION PAGE NCCI Co.No POIICV NO. �090�� L E G I O 1`I WC4-0026525 . 1. INSURED: BAYBERRY VILLAGE CONDOMINIUM ASSOC. Renewal of Policy No. C\O ROBERT LUPIEN RENEWAL The Insured/Mailing address: 32 MONADNOCK STREET �Individual �Partnership KEENE,NH 03431 , �Corporation or ASSOCIATON Other workplaces not shown above: Insured's I.D.No(s).(if applicable) See WC 00 00 Ol F.E.I.N.# Risk ID# - 2. POLICY PERIOD: The policy period is from 05/17/1999 to 05/17/2000 12:01 A.M. Standard Time, at the Insured's mailing address 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.The limits of our liability under Part Two are: Bodily Injury by Accident$100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: D:This policy includes these endorsements and schedules:wC000000a,Weoo0o01,wC811s,wc000al�,wc2oo3o1,wCzoo3o2,wC2oo3o3.a, WC200601,GU207E,890046 � 4. PREMIUM: The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All Information required below is subject to verification and change by audit. Code Premium Basis Rate Per Estimated Annual Classifications No. Total Estimated $100 of Premium Annual Remuneration Remuneration See WC 00 00 Ol If indicated below,interm adjustments of premium remium for Increased Limits part Two,If applicable shall be made-- otal Premium Subject to the Experience Modification remium Modified to Reflect Experience Mod.of �Semiannually; � Quarterly; �Monthly otal Estimated Standard Premium remium Discount,if applicable MA—DIA Assessment $9 xpense Constant Charge otal Estimated Annual Premium $ $ Minimum Premium $268 Deposit Premium $277 Total Estimated Annual Premium $268 Name of Producer: RIDER RISK SPECIALISTS INSURANCE AGENCY INC. Servicing Office: Small Business Underwriters Countersigned By TWO PARAGON WAY,FREEHOLD,N.J.07728 Authorized Representative Date THIS INFORi�1ATION PAGE WITH THE WORKERS COMPE�ISATION AND EMPLOYERS LIABILITY INStiRANCE POLICY AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE�tUNiBERED POLICY. COPYRIGHT 1987,NATIONAL COUYCIL ON COMPENSATION INSURAYCE si000i(ED.�-s3x�� wC o0 00 oi q � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-4 FEE: $50.00 This is to Certify that Bayberrv Condominium Association 503 Main Street. West Yannouth.MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS This License is issued in conformity with the authority granted W the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked. November 30 , 1999 BOARD OF HEALTH: �c`� ..teEfe�, ��cairman �oan G. �u[6ivan, �//., Vice (_.�irman Number of Units: 18 cabins or 22 units and l�oda,�t� �iown, C�er� manager's apartment. a�.ie[te Sa�o��y-.�ooPea ��lO�o�y��,� Bruce G.Murphy,MPH, ., Director of Health ' �, a ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOUTH IS NOW REQUIRED � � TO HOLD IS�UANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION + INSURANCE. THE ATTACHED STA'�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� � WORI�ER'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 NQTICE: PERMITS RUN ANN[IALLY FRaM 7ANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN T'HE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTA.BLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGLTLATIONS POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPAR'I'MENT,AND THE WATER TESTED FOR PSE�HE�MONUS,TOTAL COLIFORM AND STANDARD PL1�TE COUNT BY A STATE CERTIFiED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVINIlVIING 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 TI-� YARM�UTH HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT T'HE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAII.,URE TO DO SO WII,L RESULT IN TI-�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS - _ —__ -_--- _ _ __ _ ___ - _ -- _----- ------ _ _ _ _------ HAVE BEEN MET. OUTSIDE CAFES: OLJTSIDE CAFES(i.e.,OLJTDOOR SEATING WITH WAITER/WAITRESS SERVICE),MUST HAVE PRIOR APPROVAL FROM TI-�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISFIlVIEENT IS PRUHIBITED. . DATE: �%`3v�9� SIGNATURE:�i4��c�,�-Ge,�•� PR1NT NAME& TITLE: �� - ' a � C� � � M (� � , D�C 0 4 1998 HEALTH DEPT. December 1, 1998 Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 Reference is made to a check you would have received for $50.00 from Bayberry Condo Associates. The check number is 764 and was written on November 30, 1998. Tnadvertantly, I forgot to enclose the proof of workers comp insurance we carry for the association. Enclosed with this letter is the required proof of insurance that shquld be attached to the rest of the paperwork I sent with the check. Should you have any questions regarding this letter, please call Barbara Berry at 603-357-5093 and I will answer any questions you may have. Szncerely, `_��Q.��'�� '�,� Barbara L. Berry v Bookkeeper Bayberry Condo Associates 32 Monadnock Street Keene, NH 03431 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Nccl co.No Policy No. 10901 L E G I O 1`I WC3 -0026525 1. IIYSURED: gpygERRY VILLAGE CONDOMINIUM ASSO � ' Renewal of Policy No. � C\O ROBERT LUPIEN _I _ RENEWAL The Insured/Niailing address: �,pC;�.T to" � .. 32 MONADNOCK STREET ,�'a3 N��i i.� S'� ' M � �Individual �Partnership KEENE,NH 03431 W` �(°'r�'►��' i �Corporation or ASSOCIATION Other workplaces not shown above: Insured's I.D.No(s). (if applicable) See WC 00 00 O1 F.E.I.N.# Risk ID# 2. POLICY PERIOD: The policy period is from OS/17/1998 to OS/17/1999 12:01 A.M.StandardTime, at the Insured's mailin�address. 3. COVERAGE: A. Workers Compensati�n Insurance: Part One of the pe?icy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Twi of'the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident S 100000 each accident Bodily Injury by Disease� 500000 policy limit Bodily Injury by Disease� 100000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: D. This policy includes these endorsements and schedules: wC000000A,WC000001,WC000414,WC000311A,WC200301,WC200302, WC200303,WC200306,WC200601, 4, pREMIUM: The premium for this policy will be determinedby our Manuals of Rules,Classifications,Rates and Ratin� Plans. All information required below is subject to verification and chage by audit. Code �'emium Basis Rate Per Estimated Annual Classifications No Total Estimated $100 of �i� Annual Remuneration Remuneration See WC 00 00 O1 Ifindicatedbelow,interimadjustmentsofpremium PremiumforIncreasedLimitsPartTwo,ifapplicable $ shall be made-- Total Premium Subject to the Experience Modification $ Premium Modified to Reflect experience Mod.of $ ❑ Semiannually; ❑Quarterly; � Monthly $ Total Estimated Standard Prem ium $ MA- DIA Assessment $7 PremiumDiscount,ifapplicable $ Expense Constant Charge $ Total EstimatedAnnual Premium $ _ _ $ Minimum Premium$ 268.00 De osit Premium$ 275.00 Total im tedAnnual Premium $ 268.00 NameofProducer: RIDER RISK SPECIALISTS INSURANCE AGENCY INC. ServicingOffice: MASBU Program Countersigned B 04/10/1998 TWO PARAGON WAY,FREEHOLD,N.J.07728 Au[horized Represen[ative �a« THIS INFORM�TION PAGE WITH THE WORKERS COb1PE\SATION D PLOYERS LIABILITY [NSURANCE POL[C\' AND ENDORSE�tENTS, IF ANY, ISSUED TO FOR�1 A PART THEREOF, COMPLETES THE ABOVE NUy1BERED POLICY, 810001(Ed.�-93)(1) COPYRIGHT 1987, N.aTIOYAL COUNCIL OY CO�IPEYSATtON INSURANCE �VC 00 00 O( A THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT NUMBER: 99-4 FEE: $50.00 � This is to certify that BaYberry Villa�e Condo Association 503 Main Street.. West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE CABINS This License is issued in conformity with the authority granted to We 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 rclating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted by the Boatd of Health,and expires December 31, 1999 unless sooner suspended or revoked. December 15 , 1998 BOARD OF HEALTH: C�� .}ett6�, ��t��u.� �oaa� �ul[ivan, ��, Vice l,h,airmaa Number of Units: 18 cabins or 22 units and Ko�e�E� O�rowr�, �ler�r maIIsger's apaTtmeIIt. a�rieLGe�a�oGlhc�-J�fooPe� ic�eL O� ou��Lin Bruce G. Murphy,MPH,R .,C Director of Health ...a� �