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Home My WebLink AboutApplications, WC and Licenses ;�_, � :: r �L� �� 5 � ► TOWN OF YARMOUTH BOARD OF HEAL � � APPLICATION FOR LICENSE/PE 2 � � � NOV 1 0 2008 �� * 1 m 1 f rm and attach all neces �'' `" �� b 4'" ecemb �H D E PT. P ease co p ete o �` Failure to do so will result in the return� �,� ou��pplicahon pac et. NAME OF ESTABLISHMENT: L Lr� �EaL"6� ��'/G�/�' •�.��'��-T7DlX TEL. # �1��ll7�a LOCATION ADDRESS: �Ll�t'i /1D�: �b , MAILING ADDRESS: p B, �d �'G�vTiy MDY� /� ?�-LG� OWNER NAME: TA ID (FEIN or SSN}: CORFORATION 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 Poal Operator(s) and attach a copy of the certification to this form. 1. C1��'i/�-.�1SI b� �67125 2. Pool operators must list a minimum of two employees cun ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach capies of employee certificatians to this form. The Health Department �vill not use past years' records. You must provide new , copies and maintain a file at your place of business. 1. 1,��9�L'�?� ��' �.AlLP� t�f �fr'AL76/- 2. 3. 4. ' FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-tune 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 applicatian. The Health Department will not use past years' recards. You must provide new copies and maintain a file at your establishment. 1. 2. PERS4N IN_��R�"rE: . _ -_ __ -- .___ _ _ _ _ Each food establishment must have at least one Person In Chaxge (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 hained in tlie Heimlich ' Maneuver on the premises at a11 times. Please list your employees nained 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 �le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQL�iRED FEE PER.MIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B S55 CABIN $55 MOTEL S55 INN 555 _CAMP S55 I SW-1MMING POOL �80ea. � _LODGE S55 _TRAILERPARK �105 _WHIRLPOOL $80ea. ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S8� _CONTINENTAL �35 NON-PROFIT �30 >100 SEATS 5160 GOMMON VIC. �60 WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. ��0 _>25,000 sq.ft. 5225 VENDING-FOOD S25 _<25,000 sq.ft. 580 _FROZEN DESSERT �40 _TOBACCO �55 ?v,��cxA�GE: �io AMOUNT DUE = S 80 . 00 *****PLEASE TURiV OVER AND COMPLETE OTHER SIDE OF FORi�'I***** -----�—, �'i . ... . . .. ' � ; ; ADNIINISTRATION ' , I Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 COMPEN5ATION INSURANCE j 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 � ` F __ __ _ _ _ _ _ ___ ; M4TELS AND OTHER LODGING ESTABLISHIVV�NTS � TRANSIENT OCCUPANCY: For purposes of the limitations af Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customa.rily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 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 CNIR 64G, as amended, shall generally be considered Transient. , POOLS POOL OPENING:All swimmin wad' and whirl 1 hi h h g, uig poo s w c ave been closed for the season must be ins ected b the Health D artment rior to o enin . Contact the Health De artment to schedule the in ection fi y, ep p p g � sp ve(5�days pnor to opening. 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. �---- --------- _� ___� _ _ , _ . . �_ - - � k .- - __ . . _._-. ._ ,�-._�.�. - --'--�-,.__. . - POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of ' closing. FOOD SERVICE : CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of an�food�roduct by a retail or food service establishmerrt is�rohibited. ; NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED 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 TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. t �� € DATE: //-��' SIGNATURE: t PRINT NAME&TITLE:��CP/� �. CG�!/2,8 p ��5. �lU'� ��'/�/�' /�s�C", � i � � 10/21/08 � ,. _ , � - , �\ The Commonw i ealth of Massachusetts � Departntent oj'Industrial Accid'ents , �N�� 6D0 R'ashington Street, 7`"'Floor Boston,Mass. 021I1 + Workers'Compensation Iasarance AHiday{h BnildiHg/PlembiBg/EleMricat Co�tractors �ati�• P'ksse�RI1VT kglbt�v name: �L 1f�L 1 LG"�''1 /T�/�.��S ,t�'S��C//��/D�/ aaa�s: ��C�. �l�X ��/ /�ffr ��v� �p��t ��rJ�Bp citv �VTFT ��/fal�/� state• i !/d- zip. �✓�CI 7 phone# iS4�"�g'jt—�'7tta2- work site location(full addresslc ❑ I am a homeowner performmg all work myself. Project Type: ❑New C�sttuction QRemodel ❑ I am a sole-proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees working on this job. �1� _ com�ae�.ame: _ ad ess: ��` ci #: �O- /� # ; .: ._•.;; , t, : _. : , , ,;.� .d:� . s ,3,�.,.� :�.�:�=�k _�� .. .._.: � >.., „ ❑ I am a sole�xaprietor,ge�sl coatrsetor,or�omeo c!e o )and have hired the co�acta�s�listed below wh�have the following workers'compensarion polices: / ��- comwgv n�me: � �/'� 5 � d , (/� #: iesQa�ce eo. � # . .a., , .,; �:: . _. , � ,: „ ... ,.,. :: . , j,�;;��.� :: addteas• ci_�. oLode#. -- -- -- _ _ _ __ _ . _ _ __ __ _ ___ ies - # _. =� ,�,_:..- _. : _ .�; �. . _ � �;." : � ,.�; �r� � .:; �-0�� Fa�m lo aecm+e ovverage:s reqaired ae�er Salisn ZSA�f MGL 1S2 aa k�d b fYe�p�a�f'ai�ial pnaNies�f a 8ie�►b t1,3N�N atdl�r �Ya�'�PWonment ae wr8 as dvY pesaltks in the form e[a 3TOr WORK ORDER aed�8oe KS169 is a day agatuat me. 1�d t6at a cepy ot tWa stahmeat may 6e fonrarded�o tLe 016ce a[Im�tlona�f tlu DIA fer coverage veriAeafise. ' ' /do kaeby ctrty`y xrder�lns avid pe�rafties of ptrJury t6at tlYe Iwfo�anadoe provdded ebove is lrxe and onrnr� signature � ��'�, �f�o�D�" Date Print name ��P�•� ,y', �!�/y2i�'� Phone# ��'��Da2c�, effiicial nx oaly de not�vrite�t�is area ta be�ietdi bY citY�*pw�e�c�l aly or tewa: Pt*��# i—LRai.1��n� ❑check if imme�a6e re�ea�e ia req�red ��E Board ae �s O�ae P�� Dqar�t �..�a s�c m�aa� #' r . < s , November 6, 2008 Town of Yarmouth Board of Health Re: Safety Report Blue Rock Heights Swimming Pool To Whom It May Concern: This letter is to certify that during the year 2008, there were no accidents or other incidents concerning the safety of the users of the pool. Oceanside Pools was and continues to be the certified pool operator and inspected the pooi w�ekly. Pool monitors inspected the pool four times daily and a log was kept of the results. A daily lag of users was also kept. There was an adult attendant during all hours the pool was open which were 10-12, 2-4 a.nd 7-9. Rules of behavior are prominently posted and a tel�phone is available in case an emergency should arise. The pool is not open to the public. Its use is confined to members of the Association and their gues�s. All swimmers under the age of 18 must be accompanied by a parent or guardian. Sin�erely, JI ;��I� Ralph A. Conrad Treasurer Blue Rock Heights Association 1 � r � + c � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � ; BOARD OF HEALTH ; PERMIT NUMBER: #09-002 FEE: 580.00 � � This is to Certifi�that Blue Rock Heig�ts Assoeiation 148 Blue Rock Raa,�, South Yarmouth, MA IS HEREBY GRANTED A PERMIT Ta Operate a Pablic, Semi-Public Swimming or Wading Pool At Btue Rock Hei ts Associatian - INDOOR POOL 148 Blue Roc Raad South Yarmauth MA This pemiit is granted in confornuty«�ith Article VI of the Sanitary Code of The Conunomvealth of Massachusetts,and. expires Decznnber 31,2009 unless sooner suspended or revoked. No��ember t4,2008 BOARD OF HEALTH: .`��¢tt S�, �..lv.� (�tti�t C��vQlf�e0 2.�. 3Ce�l�eX��tC¢ �'�av�nuXft *Restriction:Safety report must be submitted annually aith application. .nJi._(_�-_�J.��Ql(l/L� Boazd of Health Hearing.06 21:99-Do not need CPR i�l'i_ltl� ��g�1L� �../v. First Aid and�6�ater Safety certifications. �alJ�Gl�lL J. J�� BI'UCe .�tlt'p �� ,� Director of Health � a ;•:. �i�v�RocK N�i6N7s �`�Y'�k�. TOWN OF YARMOUTH BOARD OF HEALTH :�;. � � ��°� ` � � APPLICATION FOR LICENSEIPERMIT-2� , �. �� .. � �, 1 � zoo� � - * Please com lete form and attach all neces � �' P sa��oeuments '� ember 31, 2007. Failure to do so will result in the return of�our a��li ;tion pac�et. ,� � , NAME OF ESTABLISHMENT: 1�iLU� �Q�(' /��G��4 �Sv4'C1,��TeN TEL. #v"��g�`�fi�� LOCATION ADDRESS: 3y�� c�__� � MAILING ADDRESS: i�.0, 1�OX79f�dv��i�rersr.�! �i� �GG�` OWN�R NAM�: Tt�X ID (FEIN or SSNI- 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 taw. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. _ -__ __ _ 1. D��r,o� �a��s 2. Pool operators must list a minimum of two employees cunrently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. T�te Health Departfnent will not use past yea�s' reeords. Yo� must provide nev� copies and maintain a file at your place of business. � t��l V�Lq (�7 /�b�J-2b Dk' l�g,�-c7-,� 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 Establislunents, 105 CMR 590.000. Flease attaeh copies of eertification to this applieation. The Health Departmec�t witl not nse past years'rec�rds. You must provide new copies and maintain a file at your establishment. 1. 2, PE��9N IN��G�: __ __ ___- ---_ _ _ _ _ _ _ . _ �. . __ _ _-- - --- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �. 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�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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE O1�LY LODGING: LICENSE REQUIRED FEE PER'b1IT# LICENSE REQLrIRED FEE PER'�III'# LICENSE REQL'IRED FEE PER'�fII'� ,B&B S50 _CABIN SSO _MOTEL S50 �nvrr sso - ------ ---- _c�:ur_ ____ ___s�o -.- , ----___-_.�_ ,� 5v�u�n��a�r:-s�r�a�—�o�+��.� - _LODGE $50 _TRAILERPARK 5100 _V4'HIRLPOOL S75ea. FOOD SERVICE: LICENS£REQUIRED FE£ PERMIT� LIC£NSE RbQLTIRED FEE P£RAZIT� LICEIvSE REQL'IR£D FEE PER'�IIT� 0-100 SEATS S75 _CONTINENTAL S30 lv'ON-PROFIT �25 _>100 SEATS S150 _CO�ION VIC S50 _V41-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'� LICENSE REQL�IRED FEE PERtiIIT= LICENSE REQL'IRED FEE PER�IIT= _<50 sq.ft. �45 >?5,000 sq.ft. 5200 _VENDING-FOOD S20 _<25,000 sq.ft. �a75 _FROZEN DESSERT S35 _TOBACCO S50 ' :vA11�CIi?�'vGE: sio AMOUNT DUE _ $ 7S. Oo *****PLEASE TGR\OVER�\D C0�IPLETE OTHER SIDE OF FOR�Z***** r ,. 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,QR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: /' YES 'V NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCITPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocrupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and htatel us�: Transient occupants must have and be able to demonstrate tha.t they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 �enerally 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)manth 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, shall generally be considered Transient. * NOTE: Enc�osed Motel Census must be completed and returned with t�is a�p�ication. POOLS PDOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days prior to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � hy a State certified lab, prior to opening, and c�uarterly thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOUD SERVICE � CATERING POLICY: I 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 caxered event. These forms can be obtaine.d 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: 4utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ; OUTDOOR COOKING: - flutdaa�coc3king,preparation,er-display of any food product by a retai�or food service establisttme�t is preh�bited. -- NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETLJRN � c THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. � � ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; � DATE: �^�v� SIGNATURE: �� ` 7 PRINT NAME&TITLE:�L� /�-.Cd�� /� Il,�� y 4 ' � The Commonwealth of Massachusetts Department of Industrial Accidents > N�rltfrw�l'M� 6Dl/ Washington Stree� f�'Floor Boston,Mass. 02111 Workers'Compeasatiou Isa�aaee Affidavit:Baildiog/Ptambiag/EkMrical Coetraetors '1ir� P�e PR�i�'1`1e�ibl► name: �bL� �DCk �'1�t'�7� �C�.�7ZftN aadress: P.Q .�d� �QI �'��' I�L,f✓� j2AGlC' �A1�� ci �O U%Id Y�/LMDU� state� ��' zio• O7 GG� phone# S'4`�'34�-�7�a, work sitc locatian�ruu address�: ❑ I am a hom�wner perfo;ming all wo�lc myself. Project Type: ❑New Co�struction�Remodel ❑ I am a sole pro�ietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees wotking�this jo � - - --- _-_-__.-_ _t.o__..�._,. _�. >;:x� — _ _ - . : __ __ _ -- - . ._ _ _ _ -- — ----- _. - com dme: �d�ress• d�l" � eae#: co. �'° f # ❑ I am a sole�� ,_ �� . ,... __ -. . � , �_�y .��_� . -'� proprietor,ge■erral co'►tractor, eowwe�(crrdc one) �ve lrired the contract�s listed below who have the following workers'compensation poli S: � n{{J l �� #: . �. # �, ,�..o�. �: �: �#. ------- -- ----- � - ---— ..: �. - : _ �. : . : - ; . ..,.: ;: Fa�m�e 6n aecarc w�vera�e u req��ed aader Satloa ZSA�f MGL 152 cu Ind b IYe isp�dtlH�f er4�ia1 peraNia sf a Sae np b=1,SM.N a�dkr o�yean'isprbeament as we8 as dv/peeaNks in tre form af a STO!WORK ORDER aed a Aee a[S1M.M a �wpy er tl�e�atemeee may ne rorwardea�o eee omce dr l.re�or tke nlw fa�r esvera$e verkeau.e. ��e. 1 a�aastua t�at a !do Nenby certi�xnder t t�s a�AptnsG�Fes of perjrrry tlYat rlie iwfor�wotton provJded abot�e ts trwe�nd cor�+e�cR �8� r S' Date G"�� Print name _� � � Cldl�� Phone# �0��"!�� efficial ase osly do nat�vrite ia t6is ara to 6e cemPleted 6Y e&Y er E�wa affichl eity or te�rn: pe�fl�ce�e# �� ❑ehecic if immedi��e re�ssx is ral�� s Offiee �HnR6 De�at'deat e�atad pera0n: Pke�e g; ❑pma' e,�vieea s�p-zaas) N 'I 1 November 12, 200? Town of Yarmouth Board of Health Re: Safety Report Blue Rock Heights Swimming Pool To-�om It May Co�cern: This letter is to certify that during the year 2007, there were no accidents or other incidents concerning the safety of the users of the pool. Oceanside Pools was and continues to be the certified pool operator and iinspected the pool weekly. Pool monitors inspected the pool four times daily and a log was kept of the results. A daily log of users was also kept. There was an adult attendant during all hours the pool was open which were 10-12, 2-4 and 7-9. Rul�s of behavior are prominently posted and a telephone is available in case an emergency should arise. The pool is not open to the public. Its use is confined to members of the Association and their guests. All swimmers under the age of 18 must be accompanied by a parent or guard�an. Sincerely, Ralph A. Conra Treasurer Blue Rock Heights ,Association � � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-003 FEE: $75.00 This is to Certify that Blue Rock Hei�hts Association 148 Bl� Rock Road*South Y outh, M� IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Hei�hts Associarion - INDOOR POOL 148 B ue Roc Road 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. _ November 16.2007 BOARD OF HEALTH: .�E¢�(�t S/j,�� „�/�(,i (�� C'�'_a��r-�_,e.L�s .�. 9ie��iR�c��tee C.'l�awrnuxn *Restricrion:Safety report must be submitted annually with application. .�,^/If�R�[� �.��¢�1�/L� Board of Health Heazvg,06/21:99-Do not need CPit, ��QQfj(�r,q,�(,/ny ,f�,�lv, Firsi Aid and Water Safety certifications. BI'UCC Director of Health ' ' 1 � � V� KwF ROCK E4E'tGt1�T5 , .F 2 f;�R.� TOWN OF YARMOUTH BOARD OF HE�,4LTH��/� � T. � � `O APPLICATION FOR LIC 2006�' � � - � ,��_ o =. .,,� `` � ' ` NOV 1 4 2005 � . * Please complete form and attach all n�r�essa�y documents by December 31, 2005. Failure to do so will result in the eturn of your applicaxion pacl�et; , NAME OF ESTABLISHMENT: �l(J� �D�K' �,�"/Gr�'TS ,A�'Sa��'rra� TEL. # SSO�39��7�2 LOCATION ADDRESS: 6C ut� �Bct� ,�� MAII.,ING ADDRESS: P.D� l�D�C ?ql � .5t1vT•4! Y.�,Qr�t�uTL/ �'i� e�`1` OWNER NAME: TAX ID(FEIN or SSNI• 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 form. _ _ _ _ _ _ 1. B��.oN��n� �O�D�S 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. i. t�.A�t�,�� g� g�,�Qp a� r��.��.�- 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 applica.tion. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. PERSONIl�_�HAR�'iE; __ - — - - - -- --_ __ _----- ---- - ----- -_ _ ___ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ', L 2. HEIlbg,I�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-chokmg procedures below and at�ae�i ecrpies 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. ' RESTAIJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50� �II�iN �50 CAMP _ ------�50__ . -- _ _ _ _�SVk�Ilvflv�Tfi I'00�.$75ea2� >�_ _ �� _LODGE $50 TRAII,ER PARK $50 WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# . 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 `>100 SEATS $150 `COMMON VIC. $50 WHOLESALE $7S RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICINSE REQUII2ED FEE PERMIT# L,ICENSE REQUIl2ED FEE PERMIT'# _<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOQ sq.ft. $75 _FROZEN.DESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 7 S .00 "'"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•'•*" ' � � , � Anivmvis��oN � 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 � i Compensation Insurance. THE ATTACHED STATE WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � � � � ; ; CERT. OF INSURANCE ATTACHED i 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 RESPONSIBILITY TO RETIJRN � THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHMENTS 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 COMN�NCEMENT. RENOVATIONS MAY REQUIItE 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 operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. I POOL CLOSING: Every outdaor 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 E 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: —JFrozen desserts must be tested on a monthly basis by a State certifi�ttfiai�� t��a�ts mnst-b�s�rn�the-��alth ! 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��OS SIGNATURE: Yl/l� I PRINTNAME&TIT`LE: 1?dLP� � Di/a�p 'S(z�,�S . �LU� ��C��'lG�� 'vL . , � 09/28lOS , � i '��.�sE ��rva.r� -�-n � G3 C� C5 I� Il M L� DD �lar�,n�o�-�+ I-��-r��D�w,—. The Commomveakh of ss h setxs ��y�, 2-� z$ Departmentofindu ' Ac��t� 9'20�6 so.�1�Mo�t� I"t� oZ.b`�{ N�M TH �EPT. 60o wosh��wn� Bosto�,Mas� 02111 - -- -- � Worke.rs'C� tioe Iasm�aee AtSdavit:B�it ' bio�lEleedrical Coitnctors �: �C U� �6�t� h��r�.��' ��o�t,4�� e�: ��b . �o'�' ��'1 /�8" ��v� �a� �a�-b saiy ��'��l `��d U� �e• �'l/� Zip• Oo2 6 G`f n�o�# a+ark site locati�(fnll address): ❑ I am a homeowner petfoaning ali wadc myself. Ptoject Type: ❑New Ca�tructio��Remodel I am a sole anci have na one w in an ❑ Addition ❑ I am an e.mployer provid"mg wo�s'compensati�fa�my employ�s working ar►this job. _ : _ —_ � /d^' _ �� • ❑ I am a sok p�oprietor,geserat cs�tmtor,or kom czrcle o�have lri�d the ca�ctots listed below who have the following w�s'compensation Polices: � ��j,�jJ , r--k , �� , �, #� s��mre:'_ �...�,.�,.�.�. �: dt9: ��- Faihre r seem a�nera�e as req�hrd uder 3ee�a 2SA�t MGL 132 ea�lead b IYe hrp�itM��f crdd�al psailia�f a�e tip a=1,3M.N adhr s�e yean'�pt�t as we�n dv�pwdtles�tie f�r=eta 37f�t WORIC ORBSR a�d a�se dS100.N a�r��e.1 odeis�ud p��_ _-------e�py a�tib�t�fie forwatdedio t0e O�ke7f lav�o�atUlE"111�iP�csvt�age ver�aHi�:_:�___ . _- �t_ �_. --_ --~�-- -- . ___ 1�o beneby c der dYe d of pe�rrry tkat tbe iwfor�t�to�provided abov�e�fa trxe awd oo� signature r� `��-S , nate /v2/�''�4� Print natne �R�L P� /7 - �(/l��-P Phone# ��3`T�'=/u o?-� .ffici.�.se•n�y a.a�t wrke i�t�s ana r�ee e�P�br�7r•r�•� �'�� per�/�ease/ (�1Beidin�D�a�eat Qiioe��Bsard ❑ehect if�te re��se b re4afr'ed �Sdeet�'s O�oe �� ' P�#s � ' ; ; � `� �--=-_� The Comnwnwealth of Massach�usetts N 0 V 2 �_ ___ -_- Departn�ent of Iadushial AcciJenls � Z 005 _- — N�'r/lirws�fMMi -- __ - _-- 600 R'ashiRgton Stree� 7"�`Floor _ _ - - _�,,, Boston,Mass. 02111 wurkers'com�sahoe Leon.ce A�avit:B�ilai�rn�.mb�/Ekcdrxal custraenors ,.._.... , u � .,_ , � _ _ }M�}�� ,� . � �,� � � �,;, ,,.. , . .. .: �aa� .3� �:� : °�,��. t�� .. name: 1��.U�' 1��' �icFlG�7� �550��i-v7�,e� aaa�s: �'�� Lv�Z f�D`u2 I�� 1�� 0��C 74I �.� ��v� �-.�� n• �''l.�- an• �� #�D�"—�g�—�7�.Z , r work site locaria�rfall addnssl: oI�8�,,,��W�m,,�: Project Type: ❑New C,a�rucuo�o�� I am a sole 'c�or and have no one w � in any ca ' Buil ' Additian , , _. � � � �� ,��,�.�._ � �� D I am an e.mpbyer providing workers'compensation for my employees wo�cing oa this job. ao�o�v�u- �i: �k: ❑ I am a sole . _ proprietor,ge,erat cvtlraetor,� Lom circle ow�)and have lrired tbe contractors listed below who have the following workets'compensation poli�:r`�� - � �k�;��:;��f _�.�.r ,�n-,�� r. r, . , , . �- �,. r ;��: � . , A n. �• ? ;� � • . , � r:..�. .��. : .�.:. �Y�ame: �: sity: olaie#• , ,, ,. . # ... .. .� �:�:;�.5„ -'�',- , .�v:: . `' :.. � �S;.r�.:m, �.K+.,�,�%;,:� .``�;�s�_:�`.�-�s��' � . sxt�,.t�'r,?'��,.. r'e�.:,yY�'".�.. ��%� ._, Fa11�te b�ecm+e oe►erase as reqdnd�r 3a8o12SA�f MGL 1S2 cu Ind b fYe h�p�itlN�f er�i�al peaal�a�f a��p b SI,SM.M ud/�r oae yetn'6.pri�ueat as weY n dvi paulf�h t6e fers sf a 3TOt WORK ORDER aad��e af S1As.M a day a�aimt�e. 1 aede�d tlnt a c�py�f tiia�h�m�ent map be fonvardcd ro tse Omce etlave�afleffi of tlrc DIA ter tovrrage veWAatly. I ro be►+eby ce ' rnder tbe pni d pen ' of perjrrry tlYat tlYe infor�naeton prowded abor�e ts d�rre awd oemrt ; SiBnature Date �/""�7•�.S Print name ��/d �_ ��J1�� 7��.� Phone# �Q�.��%�'ZZ- efficial aae only de nat�vrife i�t6is arra to 6e eompleted by c�y or Mwn o�cial city ar tewa• ��y�� n� ❑check if immedia6e n�peme ia reqained ❑Sekc�es s O�ee motad petaon: phone#; a��t 1�� OIhQ : � � November 10, 2005 Town of Yarmouth : Board of Health i,��y � 4 2005 � Re: Safety Report _..._� _ :_..:. Blue Rock Heights Swimming Pool To Whom It May Concern: This letter is to certify that during the year 2005, there were no accidents or other incidents conceming the safety of the users of the pool. Oceanside Pools was and continu�es t4 be the certified pool operator and inspected the pool weekly. Pool monitors inspected the pool f4ur times daily and �. log was kept of#he results. A daily log of users was also kept. There was an adult attendant during all hours the pool was open which were 10-12, 2-4 an�. 7-�. Rules of behavior are prominently posted and a telephone is ' available in ca.se an emergency should arise. The pool is not open to the public. Its use is confined to members of the Association and their gu�ests. All s�vimm+ers un+der the age of 18 must be accompanied by a parent or guardian. ; Sincerely, Ralph A. Conra Treasurer Blue Rock Heights Association . ; -- � 1 � + , j THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD UF HEALTH � PERMIT NUMBER: #06-OQ1 FEE: $75.Q0 � This is to Certify that Blue Rock Hei�hts Association 148 Blue Rock Road South Yarmouth, MA IS HEREBY GRANT ED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool ,At Blue Rock Hei�hts Association -INDOOR POOL 148 Blue Rock Road South Yarmouth, MA This per�iit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31.2006 unless sooner suspended or revoked. November 15_2005 Bo�oF��.�: B��`h. �o�P,�,�,hl.$. • •Reskidi�►:Safety repoat must be submitted affivally with a�rlication. ��Gl�e�� Board of Health Hearing,06/21{99-Do not need CPR, • �g�y��y� R,^/, First Aid and Water Safety certifications. fY/lfl� r K� Director ofMH lth� ,R ., .. , �6 ,— � - - 2?�� Bc.�E Rouc lta� �°`�R�so TOWN OF YARMOUTH BOARD OF HEALT�. � -�� APPLICATION FOR LICENSE/PERM�T-�5 °:: /s �., , Q [� CG '_ = D �. * Please complete form and attach all necessary docum�en�.s�t � ece er►$�,1/Z�O�. 2004 Failure to do so will result in the return of your�pp�ication p ket. NAME OF ESTABLISHMENT: L!/ '' d'CY ��rS SDC��T��TEL. #�D�d"�a95`- 7� LOCATION ADDRESS: 1 D MAILING ADDRESS: I°.d� �dX �"r/ . .SDII�:� y.�•el�sdvTh� r�li�-� D�GG�f � ,�---� OWNER/CORPORATION NAME: MANAGER'S NAME: TE.L. # 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 form. l. 0��.��s�a� 9a�Zs 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopuimonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. U1,�J Uh� !�r �D�RO �X fi�'.�vTlf 2. 3. 4. FOOD PROTECTION MANACjERS - 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. 1. 2. _ _PE�SOP�Il�£HARF�E: ------ ---_ __ _ _ _ _ ___. . _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlVILICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. T6e 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# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMI"t# I;ICENSE REQUIItED FEE PERMIT# BBcB $50 CABIN $50 MOTEL $50 _INN $50 CAMP $50 I SWIlvIlvIING POOL$75ea. ��Q6� LODGE $50 'TRAII,ER PARK $50 WHII2LPOOL $75ea. FOOD SERVICE: ' LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQtJIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 �VENDING-FOOD $20 J<ZS,d00 sq.ft. $75 FROZEN DESSERT $35 _TOBACCO $2S NAME CHANGE: $10 AMOUNT DUE = S 7��4 '••""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 permit to operate a business if a person or company does not have a Certificate af Worker's � Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE E AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth 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 1tESPONSIBILITY TO RETIJRN ' 'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2004. SEASONAL ESTABLIS�-IMENTS ARE TO CONTACT THE HEALTH DEPART'MENT FOR INSPECTION 7-10 � DAYS PRIOR TO OPENING FOR THE SEAS4N. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPR�VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. � � E � ADDITIONAL REGULATIONS ` POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. ` ! � FOOD SERVICE CONSUMER ADVIS�RY: Each food establishme�t 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 H�a1th 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. �'RO�EN BESS��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),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a reta.�l or food service establishment is prnhibited. DATE: J��/�4 � SIGNATURE: PR1NT NAME& TITLE:IP,��A�� f1_ LO�va.�� `r]?�,�s ►�Lv� �a�t /�i�i6�YYs .�SS4�. ' 10/22/04 __—�ti The Commonweahh of Massachusetts ===�- � DepaR�neRt of Induslrial Accidentr _ — M�M - "_ � 606 A'ashington Stree� �"'Floor =�, Boston,Mas� OZlll " worlcera'com aatioe Lsma.ee affia�.�ir:s.it l�dric9l cu'haenors �: � �lG/ �S: �� Iv4X . �tr 6��i1�'�1�rt�u+sa� san: /'�1�, ar: (�?�L�f ,�# wo site 1 -o� ruu�dr� : I am a homeow�perfarming all wark myself. Projed Type: ❑New Ga�ian�Re.�►odel �-�,(,��!�o'�,t�j I am a sole 'etor and have no one w in an Buii ' Addition "'�- ❑ I am an employer providing wa�s'cflmpensatio�f�my e�nployees wo�cing�this job. ao�o�v�• ad��s: , +e�*: �� ❑ I am a sole proprietor,geaeral co�lractor,or homeow�er(crr+cle owi)and have hu+rd the contra�cWrs listed below wlw have the followmg workeis'c�emsation polices: e�m�: �_ c�v ai�a��Ee ��rre: �� _ t�: aiia�e�: _ —_ - � . Faihre�s secee a�►era�e as reqi�ed uder 3ee1�2SA�f MGL 1�aa Ind a tYe L�p�tl�rf crl�id peallb rf a�se�p b SI,SM.N aadl�r �e years'imptbuac�t as wd as eM pwiltla ia tYe fira�ota 3T0!WORK ORDER aed a�re a[t1M.M a d�y api�t�e. I�edeis�d that a cqry ef tYis�tlm�my 6e firwardcd/o He 018ce�lav�af tlu DIA tar esverage vq'IAntl�a. I ro bereby c e 1 of pe�xry tAiat tbe u�fonx�toe provided obov�e ia dare and�omct s�� `t� /2 s �� //�2�•di� , Print name '`-�°`�/� �D'��dib�p Phone# �DP��P�-�D�2 •�drl ax oHly aa�oc.vrkc�ttib area te ne a�pietsd Dr dlr�lswn e�ial dty or te�vu: perm�/iioe�se# �BaYdi�D�Oment �Bsard ❑ckeek if immediah r+eapsne b reqotr+�d �'s O�ee �� ce�act P�'san. �e#; �O�a (��-�� . � � . � I November 21, 2004 ; Town of Yarmouth Board of Health Re: Safety Report ' Blue Rock Heights . Swimming Pool � To Whom It May Concern: This letter is to certify that during the year 2004, there were no ' accidents or other incidents concerning the safety of the users of the pool. Oceanside Pools was and continues to be the certified pool operator and inspected the pool weekly. Pool monitors inspected the pool four times daily and a log was kept of the results. A daily log of users was also kept. There was an adult attendant during all hours the pool was open which were 10-12, 2-4 and 7-9. Rules of behavior are prominently posted and a telephone is available in case an emergency should arise. The pool is not open to the public. Its use is confined to members , of the Association and their guests. All swimmers under the age of ' 18 must be accompanied by a parent or gua.rdian. I � Sincerely, Ralph A. Conrad � Treasurer Blue Rock Heights Association ' , % {- � S . # � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-009 FEE: $75.00 This is to cenify that Blue Rock Hei�hts Association ' 148 Blue Rock Road, South�armouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Hei,ghts Association -INDOOR POOL 148 Blue Rock Road South Yarmouth,MA This petuut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and . expires Deceinber 31 2005 unless sooner suspended or revoked. December 28 2004 BOARD QF HEALTH: Beir fr�ci�st�S. �'o�rt,/��. ' P��, v�� ffixe�iction:safecy reporr musc t�e s�,�itt�a�nuatty wirn�pucaaon R�o/d�� p�B�?/o[�/�t,A�c�ss� Board of Health Hearing,06/21/99-Do not nced CPR, dYP.�6IL e�il�� KJI.n� First Aid and Water Safety ceitification4. n Director of H�ealth '' 1 i � ' 04'•Z''.q� �� .. ,�Q TOWN OF YARMOUTH 0 � _ '� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACMEES � � ��4PORA�tD�6�� Telephone (508) 398-223i,Ext. 241 — Fa.x (508) 760-3472 B O A R D O F H E A L T H ! To: Yarmouth Board of Health Permit Hoiders � �; �2 rG ;� �; �- ;..�, ;�,, ' j � From: DavidD. FlaherEyJr., RS. ;�� .'.' " l�,"J� nspec � � TownofYarmouth h��-�� PT. ; � Re: Federal Tax ID Number Date: March 22,2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed infornlation to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer lderrtification Number(FEIN}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. So� businesses use the ow�r's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record Please fill out the fields below and return this letter to Yarmouth Health Department 1 I46 Route 2$ South Yarmouth,MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to call. The office hours are Monda.y to Frida.y, 8:30 a.m to 4:30 p.m The telephone number is(508)398-2231,e�ct.241. Establishment: 1U� /�� /.f.E",�bJ3' ��'.��FEIN or SSN: Location Address: �� vL��' �DGI� �Dr�1� �D., �x �� 'O UT,�} y'/�`/2�avT.� �i.�-'�Ja�G�f Signattue: � Print: i��o/� .�4.� C'Ort/,�'�a Title: YiC/i/�-S_ �� Printed on ( Recycled � S Paper ` i �i . � y ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or perrnit to operate a business if a person or company does not have a Certificate of Worker's Compensatian Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' 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 f NO NOTICE:Permits run annualty from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2UO3. � SEASONAL ESTABLISHMENTS 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 i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � ADDITIONAL REGULATIONS � � POOLS i POOL OPENIl�iG: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 CONSUMEI�ADVISORY: I 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 farms can be obtained at the Health Department. ' Fl7(l7.FN ilTi CCTi,�3------ -___ . -----_ _____ - --_- _ - --- � - A��.:t��,��. - _- - - , 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 CA�'�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Boazd of Health. ; OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. '� DATE: //-/-d3 SIGNATUR�: ' PRINT NAME&TITLE: �� ,g_ Cer�,�'�s, �Lv��p� ,l��ic.�rs ,�Ssoc 10/22/03 _,-� - � : �. � The Conrnronwealth of Massachusetts � � Department ojlndustrial.-lccidents ; OfIIC0o1/�reSt/OftJiit I 600 Washington S�reet ' ` Bosron. Mass. 02111 �'~ ��y' W'orkers' Compensation I�surance Affidavit ARc�licant information: P'IessepRll�TTrd.'kTir n�mr� �1.U� �dC�' }i',1%G.6fTS .��'Bi¢�St lucation: �LUJ� �Cf�( �tf1�/J �'_U77��.�4�� I'lt� l'If\ �Oflt k (/l�0��7�'_'I/�7� � I am a homecwner pertorming all work myself. � I am a sole proprietor�-� ha�e no one��orkine in am•capaciri� �/�y�,. 1/pL�/,+,t7�,CKS � I am an_empio�er�o�i�in�workers' compensation for my empioy�ees w•orking on this job. comnanv nams• address: ' s�t�" nhone N• i�surance ca oolicv# � I am a sole proprietor. general contractor, or homeow�ner(circle onel and ha�•e hired the contractors listed below «ho ha�e the follu��in_ ��orker�� ompensation polices: s4mt�anv name• address• �i�v: phone M• insurancc co. Rolic=•!! comoanv name• add res3: �': nboee i!• insurance co�_ �x� a Failu�e to secure coveraee as required uader Seceoo 2SA of MGL 1S2 a�Idd to tbe i�paidos ot erisi�al pe�dtles of a O�e op to 51.500.00 a�d/or ' one years'imprisonment a�well a�eivil penaltia io t6e form of a STOP WORK ORDER aed a fiae of 5100.00 t day qaiost ma t a�dersla�d tfat a topy of thh statement msy be fonvarded to the ORce of Invntig�qoo�of tbe D[A[or eovera=e veritkatfo�. /do hrreby cerrif�under�h ains und prnolties of p�rjury that tht iajornration provedtd abovt is true and eorrect Signaturc /`./-0.� Print name�/aL�� /�- Cp�Ij,Q,g6 7�'�,�S- �1 U.0 6PD� /��'/C:6�75 •�SSd�. phone If .. oRcial use only do not..rite in this area to be completed by eiry or town oflieial ciry or tow�n: Y�M�IIT$ _ perrnitAicense N nBuildiog Department . �Lieensiog Board �cheek if immediate response i�required 261 �Seiectmen'e ORee pHealth Depanmeat contact person: phone M:_ �508} 398�2231 eat. nOther .. .�. ��,,: i � November 1, 2003 Town of Yarmouth Board of Health Re: Safety Report Blue Rock Heights Swimming Pool To Whom It May Concern: This letter is to certify that during the year 2003, there we�e no accidents or other incidents co�cerning the safety of the users of the pool. Oceanside Pools was and continues to be the certified pool operator and inspected the pool weekly. Pool monitors inspected the pool four times daily and a log was kept of the results. A daily log of users was also kept. There was an adult attendant during all hours the pool was open which were 10-12, 2-4 and 7-9. Rules of behavior are prominently posted and a telephone is available in case an emergency should arise. The pool is not open to the public. Its use is confined to members of the Association and their guests. All swimmers under the age of 18 must be accompanied by a parent or guardian. Sincerely, ��- , Ralph A. Conrad Treasurer Blue Rock Heights Association � I , "", i THE COMMONWEALTH OF MA5SACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-002 FEE: $75.00 ; 'rhis is w cert;fy that Blue Rock Heights Associa.tion 148 Blue Rock Road. South Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Heights Association - INDOOR POOL 148 Blue Rock Road South Yazmouth. MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31,2004 unless sooner suspended or revoked. November 4.2003 BOARD OF HEALTH: �ewc�`�. �jfaaalaMc. ��., (�ua�a �i�tic+�'��rixatt, �Ilee ��c •Restriction:Safiety teport must be submitted annually wid►application. i��. �OAEdI. � — �oard ot��allth Hearing,06/l l/99-Do not�ed CPR, __.�O�PK�'�t, i��- _ First Aid and Water Sa�ty certifications. ruce .MutP Y,MP R ., Director of Hea1th � (3�u t PocK 1fE'1G NTS w TOWN OF YARMOUTH BOARD OF•HEALTH APP I F �NSE/PERMIT -2002 � �t�� :n * Please complete form and attach ece d .:by December 31, 2001. Fai e� ��vi�ult�in the return of your application packet. �a 7�. �,� � a� E ESTABLIS MENT: /`�� rrL� s �s c�L��.- '^�-� TEL. # ��?7 4 L LOCATION ADDRESS: (��__ � �2,�4,.� �C ��t� MAILING ADDRESS• P c� � �� l ; 5 e�.y c.�� rh,��z-� �ti t9- OWNER/CORPORATION NAME: MANAGER'S NAME: TEL # 1VIAILING 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 form. 1. ��e�.z�s�� iac}o� S 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._UJ��'L�� `C � �{'�'f4,�J �� {"C:f�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 Sta.te 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. __ FERSQN II�Ci��RGE: __--- __ _ _ ___ _ _ _ _._ ____ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l. 2. �EIMLICH CERTIFICATIONS: All food service establishxnents 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 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# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $SQ Cz� _INN $50 _CAMP $50 / SWIMMING POOL$SOea. Oa— $ _LODGE $50 _TRAILER PARK $50 WHIRLPOOL $25ea. FOOD 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 RFTAL�.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: $10 AMOUNT DUE _ $ 5�•OQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �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 per�nit 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2041. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRTOR 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 � 4 POOI�S 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'ONSUMER ADVISORY: Each food esta.blishment 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. T'hses 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),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: � �" f �I"� f SIGNATURE: �/ � PR1NT NAME& TITLE: ��1`' 09/11/O1 . . � The Conrmonwealth ojMassachusetts � � Department ojlndustrial.-�ccidents - � o OIJIce o/Ieres�lostliis + 600 Waslrington Streel ' ` Bosron, Mass. 02111 �"' ��y, V4'orkers' Compensation Insurance Affidavit n m•� L'C. � r(.�r� �j',�(,� � location: /�/` G/,cP /( D tf�C � � /L'� � d �� /Z'� r"c � Cf�L`� , � �` �hone� � I am a homeowner pert�rmir�'atl work myself. � ( am a sole proprieror �� ha�z no one��orkin_ in am•capacit}• .. �.�� (/'�y C�,e v��-�.Q. �f- � I am an employer pro��ins w�orkers' compensation for my employees w•orking on this job. comnan�• name• �ddress• cit�•: phone�t• iesurance co. poiicy# � I am a soie proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu«in� ��orker .ompensation polices: s4m�an,v name• address cit�•• �hone q• insur�ncc co. policv# s�m�2nv name• tddresr. —_ _ _— - ��': phone M• insuranss ca Reliev 1t s Failure to secure covera�e as required under Secaoo 25A of MGL 1S2 es�ind to tbe iopo�idoa oterioi�d pe�altles of a ti�e ap toI1,500.00 a�d/or one yean'imprisonment i�w•ell a civil penaltla io the form of a STOP WORK ORDER aed a liee of 5100.00 a d�y K�in�t ma [a�denta�d that a , copy of thy statemrnt may be fonv�rded to the Oliiee of Invatig�dom of t6e DU for eoven�e veriBeatio�. l do hrreby cert' � nder the pains and pertal�its ojperjury that 16t injornratinn providtd ebove it trut and corrtct Signaturc J f�- l �✓U., Print name �l�Cl�� '(,, �iYL f/L��'�)(� Phone Il .. otTicial use onl. do not w�ite in this area to be completed by ciry or torva oflleial ciry or town: Y�M��T$ _ permit/lieeeu 11 nBuildiog Dcpartment �Lieeasiog Board �cheek if immediste response i�required 261 �Seleetmen'�OtTiee �Healt6 Department contact person: phone N;_ (508) 398�2231 eat. nOther i � BLUE RfJCK HEIGH'TS ASSOCIATIUN, INC. P.O. Box 791 South �armouth, MA 02664 Date: November 15, 2001 To: Board of Health From: Blue Rock Heights Association, Inc. Subject: Safety Report- Swimming Pool 1. This is to certify that during the year 2001 there were no accidents or other incidents concerning the safety of the users of the Association swimming pool. 2. Oceanside Pools was, and is,the Certified Pool Operator and inspected the pool weekly. 3. The pool hours were lO:OQ A.M. to 12:Q0 P.M., 2:00 P.M. to 4:00 P.M.,and 7:OQ P.M. to 9:00 P.M. and the pool had an adult attendant at all times. 4. The water was tested four times da.ily and a log was kept of the results. A daily log of users is also maintained. 5. Rules of behavior are promiflently pasted and a telephone is availab�e if an ' emergency should arise. ' 6. 'Tlie pool is not open to the public. Its use is confined to Association members and their guests. All swimmers under the age of 1$ must be accompanied by a parent or � guardian. ; Thank you, I r ,,.,} � n � `� �� John Mullen ; Baard of Directors � i Pool Committee Chairman ' i I � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLJMBER: #02-018 FEE: $50.00 This is to Certify that Blue Rock Heights Association. Inc. 148 Blue Rock Road, South Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Heights Association - INDOOR POOL 148 Blue Rock Road South Yazmouth.MA This permit is granted in confornvty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March 15 ,2002 BOARD OF HEALTH: �s�. �e�'rez, �� . . D C%ozdou. 7 D.. 2/lce *Restriction:Safety report must be submitted annually with application. ��t� �, �� Boazd of Health Hearing,06/21/99-Do not need CPR, ��t�iC��0'�O� Fitst Aid and Water Safety certifications. .5' .� e . , . ., Director of He h t � �: . 6�uE Koc�r f�� 2�f;AR.�c TOWN OF YARMOUTH BOARD OF H c' �" � �w�� Q � � � O � � � N APPLICATION FOR LiCENSE/PE Jf,�,, �'� �,'�' R'�`- N�V 2 5 2002 � ��•• * Please complete form and attach all necessary n y Decem er 31 2002. Failure to do so will result in the return of application pac etH�ALT6-i DF_P�1". i � ZI�VI_�OF ESTABLISHMENT: P�t�e. !�e� I�d��ah�s A�ss c�i a+�on TEL. #i'o$ �4 4-�75tZ � �Q�ATION ADDRESS: �I u.� ��e., �oad �VIAI��T�ADDRESS: � � �tix 7�Lt. Sr�. �ct.r►r►. vv� � IK F} I � R'S ,�i' � # ",3'� ' Z ' MAILING ADDRESS: POOL CERTIFICATIONS: Tl�e�oo�_suge�visQr must be certified as a Pool Operatarz as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this 1`orm. ; L D G ea►nS�de. t�b B�S 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. 4�la.i�Gd. b� 43 b a�.d s�- �.t�►� 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 atta.ch 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 If�T CH�R�E: _ ____ _ _ . ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. �STAURANT SEATING: TOTAL# OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# L}CF,NSF.,RI:QUIRBD FGG PERMIT# LICENSG REQUIRFD FEG PERMIT# _B&B $50 'CABIN a50 _MOTEL $SO _1T1N �50 _CAMP $50 LSWIMMING POOL��O� _LODGE $50 _TRA[LER PARK $SO _WH[RLPOOL $75ea. FOOD �RVI �•: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _0-100 SEATS $75 _CONTINENTAL $30 �NON-PROFIT $25 ' >100 SEATS $150 _COMMON VICT. $50 �WHULESALE $75 RETAIL SERVI f LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $45 _>25,000 sq.ft. 5200 _VENDING-FOOD $20 ° _<25,000 sq.ft. $75 • _FRO�FN DF,SSERT S35 _TOBACCO $25 NAMEC ANCE• $�o AMOUNT DUE = S 7S,Dd *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � f � f ,r^ -' i � E ADMINISTRATION ` Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 COMPL'ET�D AND SIGNED;OR f , . � . � CE�T. OF INSURANCE ATTACHED 2 , / ' P. AFFIDAVIT SIGNED AND ATTACHED " WORKER S COM � Town of Yazmouth taxes and liens must be paid prior 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, 2002: � - � SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 ; DAYS PRIOR TO OPENING FOR THE SEA50N. � P 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 F TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ADDITIONAL REGULATIONS � C POOLS ' POOL OPEIVING:All swimming,wading and whirlpools which ha�e been closed for the season must be inspected by the Health Department prior to opemng. � 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. ' CAT�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 DF��F.RTS: ' --�rozen c�esser�s mus be tes e on a mon iy basis��a��aate i;e�°tified ia�—T�sr r�its must�i��nt-t�-th�-H�;� 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),L�have prior approval from the Board of Health. OUTDOOR COOI�I 1�Gs Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ( l- 1.S'd�- SIGNATURE: �, pR1NT NAME &TITLE: �"'dlti.,,. Q rkcc,��4 S d�- e�-�l o�-�r�'rs _ 10/18/02 i � '� . ' r �y �\ The Coin►nonwealth of MossQchusetts � � Department ojlndustrial,-�ccidents � o olllceoll�es�lostliis 600 Washington Slreet ' ` Bnston.Mass. 02111 . � y v'� W'orkers' Compensation (nsurance Affidavit Anolicant intormation• p� n«pRi1�7�L9-s•�, n�m� � �lI�C. �. G�L C�fil��s�1.`�'S �T$� O L 4 0..��Bti► Lt�cation• ►�1�U�. �A�� IC. � . 5 6. �Q..X`tiK9�1`E'bl,, �� t� nhone� Y'O'g"��"C7'T�k2. � I am a homecw�ner perturming all work my�self. � I am a sole proprietor �r.,', h��e no one ��orkin_ in am•capacit}• — A��t vo�u�,{ee►-s ___ . :�.-eFl:-efg' e�pensatterr for m}€Yrtpley�ees�orl�ing on c#is job. comoan�• name: �ddress: citv• phone p insurance co. A�Y� � I am a soie proprietor. ;eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu��in: �sorker� .ompensation polices: comoanv name• �ddresr cin.: phons!! insurancc co. ooli .•# comoanv name• -- — _ ______ — _ ___ __ address: _ - --- — ---- _ _ __ -- --- - � � sitv: phone+� , insurance co. �x� t : Failu�e to secure coveraee as requ�red uoder Secnoo 25A of MGL l52 ea�Ind to the iopo�idoa p(erjsl�a!ptadtles of a O�e op to 51�00.00 a�d/o� i one years'imprisonment a�w•d1 aa eivil penalde�io the form of a STOP WORK ORDER aad a fiae of SI00.00 a day Kainst me. t a�dersta�d t6st a � eopy of thh statement may be fonva�ded to the Olree of Inve�tigauoo�of the DU for eovenge veri8ptfo�, � 1 do hrreby cenif}�under rhr poins and penal�ies ojperjyry thm 1he rnjorniation provrded obovt it trtre and correct Signature 1�� "Q � Print name �. one At •- otTicial use onh do not+.rite in this�rea ro bt completed by eih or towa o81eia1 , ciry or town: YARMOUT$ - pennitAieeau p nBuiidiog Departmeot ' Q eheek i!immediate response i�required ❑Litensiog Board 261 OSeiectmen'�OfTice contact person: 50 ❑Healt6 Depairtment phone M;_ �_ 8� 398�?231 ext. nOther .. ._� :< ..�.� f � :��r � z P.�Lt? � ?rJ 'a'� ?IG''S`iJ :�S�OCIA'�'IO',r �'. 0. .'_'d`r 791 �OU�?i y,q?�10t?TH, ,�iA oz66� 1O' �e°a1�t�ifDepar�mer�t , ��'rom: Blue ''oc�k Heights Association ; �ate : 2 r �';ovember� 2002 � aub ject : :�afet�r '�eport-�'��-I� �tivimming Pool � 1 . This is to certifv that durin�; the �rear 2002, there were no accidents or � . .. � other incidents concernin� the safety of the users of the pool. 2. Ocear.side Pools �faas and is the certified uool operator , and inspected the �ool v�reekl�=.Pool monitors insnected the nool four times dails.r, and a lo�; �r�as kept of the results. A dail�;� log of users was also ke�t. There was an adult attendant durin�; all hours the pool �hras oAen� wh�ch ;�rere 10-�2 , 2-�, and 7-�. 3. ''ules of behavior are nrominentl�r nosted and a telephone is available in case an emer�enc`r should arise. 4�. The x�ool is not open to the nublic . Its use is confined to members of the As; Association and their g;uests . All s�nrimmers under the age of 18 must be accomnanied by a Aarent or �uardian. � Submitted b� John I'�rul en � B08.!^d Of D1reCtorS Pool Committee Chairman i � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-028 FEE: $75.00 Tt,is is to cercit'y that Blue Rock Heights Association _ 148 Blue Rock Ro South Yarmouth. MA IS HEREBY GRANTED A PERMIT j To Operate a Pub6c, Semi-Public Swimming or Wading Pool At Blue Rock Heishts Association INDOOR POOL d. 148 Blue Rock Road South Yarmou MA . , : , T`his permit is,granted id conformit}+with Article VI ofthe'$anitary�ode of The�ommonwealth of Massachus�tts,and '� e�pires I7�cember 31.2003 unless sooner suspende+d ar`revoked. ,...{ , � �-� ��eceinb�r 1�$' � ;2002� � BOARD�F�t�L'IT-I: .�-��t,��f,��e�z. �;`�'rs�r��c�� - ` �c�ri�c D. (�'ozdawc. '�C.D.. 'l/tcc *Restriction 5afety report must be submitted annually wifh a�lication. :: j��. ��, �� Board ofHealth Hearing,06/21/99-Do not need CPR, 1�Q�1lC��Fltsiftatt` � First Aid and Water Safiety certifications. �L�S'�, i�� , ��G.M� y, H, ., . ..� � � �,.. Director of Health ,.. . .. � �� _ . �` I�(u� I�c�c� +-1��, ' f1s��c_ r� _ , � TOWN OF YARMOUTH�i,��l,�13 pF HEALTH � � � � � � � !, APPLICATION FO��.��SF�'ERMIT-2000 D E C 0 6 1999 ' ' � �(��`� `�� * Please complete form and attach all necessary docume�afs by De�ber 31, 1999. FailureHtaF�v� PT. , the return of your application packet. �iAME OF ESTABLISHMENT��,�/L�D CI{ /7�l Gfl�"S I7S5r�c'�A7�D�/�,�,V�TEL # 3 9�- O 7�� LQCATION ADDRES5x ,/ � 2� �0,9 c� �AILING ADDRES$: C�, �o k Z 9� UWNER/CORPORATIOl�NAMER �m = . MANAG�R'.$_NAME: — , TEL # , 1V�.�,I�IG ADDRESS: — POOL CER'TIFICATTt�NS: The pool supervisor must be ccrtified as a Pool Operator, as rec�uired by new State lavr. Please list the ' designated Pool Operator(s) and attach a copy of the certifi�ation to tlus form. , 1. F�C��q:r� ��- ��!r�f t 2. Pool operators must l�st a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopuimonary 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 ptace of business. 1. 2. 3. 4. ��IGH�ERTIEICATIONS: ; All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich i Maneuver on the premises at a11 times. Pleatse list your employees trained in anti-chokmg procedures below and ' attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I 1. 2. i 3. 4. F - - --- ' RESTAU�tANT 5EATING: TOTAL#��- �4�V-SMOKd1�TG-SEATS: TOTAIr#_� _ I ------------------------------------------------------------------------------�----------------------._--_----------------------------------- OFFICE U.�E QNLY LODGING• LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 _INN $50 _CAMP $50 LODGE $50 �TRAILER PARK $50 MOTEL $50 �SVV:aVIlVIING POOL�_�$soea. 2K-22 WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS �150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 ' — � — ; RETAII. SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $2q ' _<25,000 sq.ft. $75 FRQZEN DESSERT $35 � >25,000 sq.ft. $200 , N�,ME CHANGE: $10 AMO�TNT DUE _ $ C�' � '•'"'pLEASE TURN UVER AND COMPLETE OTHER SIDE OF FORM"'•" U�`� . � . ..... i . . , .. � � . � . �. ( �� l ADMINISTRATION y ; UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED ! TO HO�.D.I,SSUANC� OR RENEWAL OF ANY LICENSE 4R PERMIT TO OPERATE A BUSINESS IF A � PERSOl�•Oi� '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 j ,/� / ��,��c CERT. OF INSURAN�ATTACHED E � r�� f �p ��U�� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � �u ` TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE pF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: j YES � NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER_��. IT IS YOUR RESPONSIBII.ITY TO RETURN 'TI� COMPLETED APPLICATION(S) AND REQUIRED FF�(S) BY '; DECEMBER 31, 1998. � SEASONAL ESTABLISHIVV EIENTS ARE TO CONTACT THE HEALTH DEFARTMENT FOR INSPECTION 7-10 � H1 DAYS PRIOR T4 OPENING FOR TI� SEASON. � i c ALL RENOVATIONS TO ANY FOOD ESTABLISHIViENT, MOTEL OR POOL (i.e., PAINTINCi, NEW � EQUIl'MENT,ETC.),MUST BE�tEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRI4R TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. j ; �DDITIONAL REUULATIONS i i POOLS � POOL OPENING: ALL SVVIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR � THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTI�NT, AND►T�iE WATER TESTED FOR ,__ PSEUD4MONAS, TOTt�I,�L��RM AND STANDARD PLATE COUNT BY A S'£ATE CERTIFIED LAB, � PRIOR TO OPEl�1ING, AND QUARTERLY THEREAFTER. ' i � i POOL CLOSING:EVERY OUTDOOR IN GROUND SVVINIl��IING POOL MUST BE DRAINED C?R COVERED WITHIN SEVEN(�)DAYS OF CLOSING. i FOOD SERVICE '��ATERING POLICY: , �� ANYONE WHO CATERS WITHIN TF�TOWN OF YARMOUT�-I MUST NOTIFY THE YARMOUTH HEALTH i 4Y` , DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM ?2 i HOURS PRIOR TO 'TI� CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT THE HEALTH i DEPARTMENT. � � FROZEI��ESSERTS: � FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII..L RESULT IN THE SUSPENSION ORREVOCATION OF YUURFROZEN DESSERT PERNIIT UNTII,TI�ABOVE TERMS HAVE i � BEEN MET. -- - __ __ i i OUTSIDE CAFES: � i OIJTSIDE CAFES(i.e., OUTDOOR SEATING WITH V�AITER/WAITRESS SERVICB), MLJST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. : I ; OUTDOOR COO��tG: � ; OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD ! SERVICE ESTABLIS�-IMENT IS PROHTBITED. � � DATE: r' �-6�- y`�' SIGNATURE: ° ' � � � � � � � `. PR1NT NAME& TITLE:_.1u��2 %C�. ��c.�.��f�( 11/12/99 ��ehG� o�� 6:Ec��r✓'. � .� - ; : � t _ The Commoaweolth ojMossachusetts � � Departmenl ojlndustrial.-lccidents � a OfJlceoJ/�s�lostliis I � 600 Washington Street ' •� Bnston.Mass. 02111 �'~ ��y W'orkers' Compensation insurance Atfidavit ARnlicant information• p7essepR '�• n�m�: ��ILI.� r��G G� h`�,/��1�/ �7/✓LiL CCt ��vu locatian: %5�� !�7�1,�.� ��/l� �C�l' ttt� �.� �cY" Y'�,�/C t.�I' � fr L ��/ ehone M �`��G T�2� � I am a home wner pert�rming all work my�self. � f am a sole proprieror�r.� h��e no one ��orkin_ in am•capaciry � I am an employer pro��din�w�orkers' compensation for my e�tpioyees��orkirre on this jvb. comoan�• name: address: �itv: ehone q• i�sur�nce co. p��,p � I am a soie proprietor. generai contractor, or homeowner(ctrcle oneJ and ha�•e hired the contractors listed below «ho ha�e the follu��in_ ��orker :ompensation polices: s4moanv name: �ddress• ��n" ehone t!• iosurancc co. ,Folicy# zompanv name• — ad d ress: s►fi'� nhoee i!• insurance co� �{� • Failure to secure coverage as requ�red uoder Secdon 1SA of MGL 1S2 n�ind to t6e ioporitioa oteriai�d peadtla of a d�e op to 51,500.00 a�d/or one yean'imprisonment a�w•ell»civil penaltia io the form of a STOP WORK ORDER aed�Ifae o�S100.00 a day a=ain�t ma I a�dersta�d t5st a copy of th'n statement mav be forwarded to the Oflice of Investig�uom of the D[A ta eovera;t verifiado�. /do hrreby cenifk under th�pains and prna!lies ojperjury that�ht injornmtion providtd obovt is true and eorreet E �,j` Signature `f-'u�� ,/l�z=t�(��f�"� Date l Z 'G'� ` /�/� Print name ;,'�-l� �� ,�G �'��l,C-�1C'lY1 � Phone N .�� ` 7,�l� � .. oRcial use only do not..rite in this are�to be completed by cih or town oAftial ciry or town: Y�M�� _ permitAiceese p nBuildiog Departmeet �Liceasiog Boa�d �check if immediate response i�requi�ed 261 �Selectmen's ORiee �Healtb Departmeat contact person: phone M;_ �508� 398--?231 est. nOther .. .,,, � I � 1 i � BLUE ROCK HEIGHTS ASSOCIATION PO BOX 791 SOt�TH YARMOU?'H, MA 02664 December 6, 1999 Mr. Bruce Murphy Board of Health Yarmouth Town Hall ` Yarmouth, MA o2664 Dea.r Mr. Murphy, At the request of the Blue Roek Heights Association Officers and Board of Directors, the Yarmouth Board of Health granted the Blue Rock Heights Association a waiver of the requirements for pool attendants to have certifieation in Water Safety, First Aid and CPR for the 1999 �wimming pool season. We were very grateful for the waiver and were able to enlist more volunteer attendants. Based upon the success of th� 1999 season, we respectfully request a continuation of the waiver. There were no incidents or 911 emergency calls during the eight weeks of operation. In accordance with state law, Oceanside Pools inspected the pool weekly, and the water was tested daily by pool monitors . During the upcoming season, we will operate with the same safety and security measures we have alway� used as stat�d in our 1� June 1999 letter. The only changes that might be made are, if we experience a summer as hot as last summer, the hours of operation could be extended or, if a member wished to have a private party during usual non-operating time, this would be allowed. In any case, should such eventualities occur, the pool would be monitored in the usual fashion. We, therefore, ask for favorable consideration of this req�aest for a continuation of the waiver with, or preferable without, a time limitation. S��cerely, John R. Mull n Board of Directors , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-22 FEE: $50.00 This is to certify that Blue Rock Heights Association Inc. 148 Blue Rock Road South Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Heights Association -INDOOR POOL 148 Blue Rock Road South Yannouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. December 16 , 1999 BOARD OF HEALTH: ,T�id� ��. (�rcuac _ l�oa� �. S�, ,�?2.. '`l/�ce eltavr�a�c - 'Restriction:Safety report must be submitted annually with application. !�� 74G(� Board of Health Hearing,06/21/99-Do not need CPR, 's�a4�iCd First Aid and Water Safety certifications. 4.� ruce . urp y, , ., Director of Health � � II b�� .- . � -� TOWN OF YARMOUTH BOARD OF HEALTH 3�+� . - - � APPLICATION FOR LICENSE/PERMIT- 1999 � � �� M � � �x - �-� : ��. J U N 1 1 1�99 * Please complete form and attach all necessary documents by `4 m,. � , $ 'Fail re to dv so wil result in the return of your application packet. � � HEALTH DEPT. --------------------------------- -------- ;- ----- --------------------------------------------------- E TABLI O ATI N D M LI D � RAT N ER' N # IN � -------------- �----------------------------------------------------------- POOL CERTIFICATIONS� he pool supervisor must be certifed as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. �� f��PQY��I�� 2. � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus form. The Health Department will not use p�st yeurs' r�cords. You muat provide new copies and maintain a file at your place of business. 1. 2 ' 3. • 4. ' HEIMLICH CERTiFT('ATinNC• ' 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 wil!not use past years' records. You must provide new copies and maintain rt file at your place of business. 1. 2. 3. 4 RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# QFFICE U�E ONL.V --------------------------------------------- - ---- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _� $50 _CAMP � $50 � _LODGE $50 _TRAII,ER PARK $50 _MOTEL $50 I SVVII�Il�IING POOL $SOea. '' I FOOD SERVI .F- .�"P�OL $25ea, LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 _>100 SEATS $1 SO NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 BETALi-SFRVI F• LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAM� C' AN[_F� $10 AMOUNT DUE = S� ^ """""pLEASE TURN OVER AND CpMpLETE OTHER SIDE OF FORM •��w � - -. . �� .� � .� ; ADMINISTRATION � , UNDER�HAPTER 152, SECTIl�N 25C, SUBSECTION 6,THE TOWN OF YARMOLTTH IS NOW REQUIRED TO HOL� ISSUAlVCE OR RE�IEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON� O� CQI�!I��!�13��.q�ES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURAl'�C�.--'�'IfiE A�'T'A ED 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 CHE PROPRIATELY IF PAID: YES NO ' NOTICE: PERNIITS RUN ANNUAL Y FROM JANIJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY I' DECEMBER 31, 1998. SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIENT, 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. � � ADDITIONAi.RFGL1i ATION� j i i POOLS � POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR � THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTNIENT,AND'1'HE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, � PRIOR TO OPENING, AND QUARTERLY TI�REAFTER. f E POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIVIlVIING POOL MUST BE DRAINED OR COVERED � WITHIN SEVEN (7) DAYS OF CLOSING. ' FOOD SERVICE �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. 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 TI�HEALTH DEP�RTMENT. FAILURE TO DO SO WILL RESULT IN THE 5USPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERMIT UNTIL TI-�ABpVE TERMS HAVE BEEN MET. ; OUTSLI�E CAFES: OiJTSIDE CAFES (i.e., OLJTDOOR 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 i SERVICE ESTABLIS�IMENT IS PROHIBITED. DATE: CQ SIGNATURE: ' PRINT NAME & TITLE: `� S �D� � � �1� �� . � , r � . , 'f � . �"' + The Comnionweulth ojMassachusetts M � Department ojlndustrial.-lccidents � ; Of/Iceol/�s�lostlyis ; 600 Washington Street , ,,•= Bnston,Mass. 02111 " " W'orkers' Compensation lnsurance Affidavit n ( ' � � k � I am a h eow�ner pertorming all w�ork myself. �I am a sole propriztor�� ha�e no one ��orkin_ in anv capacitv--�a�,` V S , � I am an empio�er pro�idino w•orkers' compensation for my employees w•orkine on this job. comoan�• name• add ress• eitv• nhone�#• insur�nce co. Aoiicy# � I am a sole proprietor. :enerai contractor. or homeowner(ci�cle onel and ha��e hired the contractors listed below ��ho ha�e the follu�cin_ ��orker� ,ompensation polices: companv name: address• city: nhane M• insurancc co. Folic}# com a�ny name• address• �y: nhoee 1f• insurance co. eoiiev N s Failure to secure coveraYe as required uoder Secrioo 25A of MGL IS2 ea�iad to t6e iepaitioa olerioi�al pesaltles ota Ooe op to S1.S00.00 a�d/o� one rears'imp�isoament a�w•ell a�civil penalda io the form of a STOP WOItK ORDER and a fiae otS100.00 a day Kaiost sa t a�dersa.d cha�a copy of thy statement mav be fonvsrded to the 011ice of Inveatigftions otthe DU tor eovenge verifitstM�. I do here • nde rh pai s an al�ies of perjury that the injornratioa provrdtd abovt is true ond corrtet Signaturc �� Print name one M �' LC�C.L�� - o(Ticial use ooly do not..�iee in this arc�ro be completed by ciry or town otfleisl city or town: Y�M��T� _ permitAieense M nBuildiog Departmeet �Liceasiog Board �cheek if immediate response is required 261 �Sdectmen'�ORu pHealt6 Departmeat contact person: phone p;_ �508� 398-•2231 eat. nOther � : . THE COMMONWEALTH OF MASSACHUSETTS o�` TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NLTMBER: 99-101 FEE: $50.00 This is to Certify that Blue Rock Heights Association 148 Blue Rock Road, South Yannouthn 1VLA IS HEREBY GRANTED A PERMIT To Operate a Pu61ic, Semi-Public Swimming or Wading Pool At Blue Rock Heights Association -INDOOR POOL 148 Blue Rock Road South Yarmouth. MA This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires De�ember 31. 1999 unless sooner suspended or revoked. June 16 , 1999 BOARD OF HEALTH: �d�1L. �et�ed, ��rast �oa�c S, SuElluu.a. �?72.. ?/ice �avunao� *Resh�icrion:Safety report must be submitted azmually with applicarion. j�o�C�1t� �7,ouNL ' Board of Heaith Hearing,06/21/99-Do not need CPR, ,5' —�Od�d First Aid and Water Safety certificarians. d� C6 Director of Health , ��p� , � Q � . r'- V�`tl' \ o S ^n.: i';......_'... ,._, ..��. � TOWN OF YARMOUTH BOARD OF HEALTH (� �� ,,, ;4: ; �:l;`. ;;,,`� APPLICATION FOR LICENSE /PER.MIT - 199 �U� 0 7 1998 * Please Complete form and attach all necessary documents by December 31, 1997. Failiiie to do ' so will result in the return of your application packet. N---------��E----------------------------- --------------------------��------------ ------#-------—�-----y.� s: s= ING D S • • ' O N U � � EL. � � C / SO /,� --------'------------ -= 1-- - --- - ------ ti - ---- -'--- �=---- - -__...----- POOL CERTIFICATIONS: 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 fortn. The Health Department will not use past years records. Yoa must provide new copies and maintain a file at your place of business. 1.� .�,�.�'s%.,��l,� 2. ,�r.fL D �,��1��/�"LL 3. 4. HELM�,ICH CE TIR FICATIONS; .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 maintaia a file at your place of business. 1. 2• 3. 4. RESAURANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL# ---------------------------------- • OFFICE USE 4NLY � DO GING: LIC. REQLTIRED FEE PERNIIT# LIC. REQUIRED FEE PERMIT# B&B $50 CABIN $50 : INN $50 CAMP $50 LODGE $SO TRAILER PAR.K $50 __ MOTEL $50 _ � SWIM POOL $�Oea. � � WHIRLPOOL $25ea. �'OOD SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# 0-100 SEATS $75 _ CONTINENTAL $30 >100 SEATS $150 _ NON-PROFIT $25 _________ COM. VICT. $50 � WHOLESALE $75 ' ' , �]ftVI .' . LIG REQUIRED FEE PERNIIT# LIC. REQUIRED FEE PERMIT # <50 sq. ft. $45 ________ TOBACCO $20 <25,000 sq. ft. $75 FROZ. DE5SERT $35 >25,000 sq. ft. $200 � — ��7 AMOUNT DUE � { i _ ` ADMINISTRATION . - �' UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE 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 INSURA.NCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TU RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES�._ NO NOTICE: PERMITS RUN ANNU.ALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO IZETURN THE COMPLETED AP'PLICATION(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 OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED T�AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS NLAY REQUIRE A SITE PLAN. ' . II � i)DITIONAL REGULATIONS � POOLS ' POOL OPENING: ALL SWIIvIlVIING, 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 � OPEI�TING. ` � POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE � DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE � �,TERNG POLICY: " ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING 7'HE REQUIkED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. , �� .�N D�SSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RE5ULTS M(JST BE SENT TO T'HE HEALTH DEPARTMENT. � FAILURE TO DO SO WILL RESULT 1N THE SUSPENSION OR REVOCATION OF YOUR ' FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. O 1T ID ,��: OUTSIDE CA.FES (i.e. , 4UTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �,�HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. ; QI�TD04R COO ,j�1G: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY F�OD PRODUCT BY A �RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. �^ ;'J�� ; DATE:..�.� � ��a SIGNATU : ��/ i I PRINT NAME &TITLE:�1►��/,�/l��,�i��m�� i �/`�i�h7�j��/C� € 10/97 page 2 of 2 I ' ' a � � The Co»�monwealth of Massachusetts � W Department of Industrial.-�ccidents � ; OIJICdoIl�ast/ostJiis � 600 Washington Street ' ,•� Bostoa. Mass. OZI11 �~ � W'orkers' Compensation Insurance Atfidavit Aonlicant information• Pleasc n�mr� <G(L' y �v/) l/G�(D!T✓ /�IJ��QG��/b`� ,�N ��LYs�" ,�lv� ,c°o�� s'd��`.� �/.�,C�or��1,�,� �� nhone� �/�Q�� (� I am a homeow�rter pertormin�all w�ork myself. �� jfi�j,25 � ( am a sole proprietor �r„a. ha�e no one ��ori�ing in anv capaciri� � I am an empioyer pro�idins w�orkers' compensation for my employees w•oricing on this job. comnan�• name• eddre55' citv: phone tl• insurance co. ooiicv# � I am a sole proprietor. generai contractor, or homeow�ner(circle oneJ and ha��e hired the contractors listed below ��ho ha�e the follu��in� ��orker� ;ompensation polices: companv name• address: citti•• �hone 1i• — insurance co. policy 1! com�v name• ad d ress• �y: eboee i�• insvrance co. noliev 1f t Failure to secure coverage as required unde�Secnoo 25A of MGL 1S2 ne Itad to t6t iopositioo o(erimivl pesaltles of a Oae op to 51�00.00 a�d/or one yean'imprisonment��w•eil a�civil penaities io the form o[a STOP WORK ORDER and a tise of SI00.00 a dar apinst ma [s�dersta�d t6at a copy of thH statement mav be forrvarded to the OtTice of Inveetig�tiom of the DIA for eovenge veritiado�. 1 do hrreby cenij}•under rh�poins and penalties of pe 'ury thct t6e injorn�ation provided above is tnie and correct Signa re ate d'C/l/�1'�J!O Print name ��/dJG� � /7�� Phone�l/��J"��3!! ��` y .. oRcial use onl� do not write in this area to be completed by ciN or town olllcial city or town: YA��IIT� _ permit/licease� nBuilding Department �Licensiog Board �check if immcdiate respoese ie required 261 �Selectmen'�ORee �Health Departmeat cont�ct person: phone q;_ �508} 398�T231 ext. nOther ,,.. ..n �.�<vi�� . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: � 98-101 FEE: $50.00 This is to Certify that Blue Rock Heights Association 148 Blue Rock Road, South Yarmoutl�MA __ IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At Blue Rock Hei�hts A�sociation - INDOOR POOL 148 Blue Rock Road South Yarmouth,MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expu�es December 31. 1998 unless sooner suspended or revoked. ��,y 14 , 19�8 BOARD OF HEALTH: �� etf��, C��n �oan G. �a[livan�lC.�/•, Vice C.hairmun � �o�art� /,rown a�ria�[��a�ot��i�ooPed • �8�0' �� . Director of Health � �