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Home My WebLink AboutApplicaitons, WC and Licenses � � ��J ` f Ya � - _�� (_+aw:_ � °��'��s TOWN OF YARMOUTH BOARD OF HEALTH � �� `�' �� °� Y=�� '�,s APPLICATION FOR LICE��lP ' ��Q4�" NOV O 5 00 �.�..��- 2 3 * Please complete form anci attach all necessary documents by Decem r 3�� DEPT. Failure to do so will result in the return of your application pac . NAME OF EST Ri i HM NT• �-� �� t1. �t� � T i # �oQ, ��s Z-33 Z �QCATION ADDRESS• R M,A-c�1 L`t LVIAILING ADD F�S• Ir�e� �t- '� Q�c�rn�u�t-�. nn�=s . D�-6� 3 WNE C RA ON A Me S h�,.�c� �.� , MANAGER'S NAME• �-e�� P TE # Sog -��-l -064 �r MAILING ADD FSS• 6 9 M�f�1 S1 C�r�k �ari,�.a�•J� �1�t,R a�-6�� POOL CERTIFICATION�� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P�oo7-(7perator�s�and aftacli a copy of the certification ro this form. �. �Rv ��-r t� p�--c� 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 6usiness. 1. �ev A�g Qo�-�� 2. S a v i-}-o� �� 3. ' 4. FOOD PROTECTION MANAGERS - C�RTIFI�ATIONS• 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. �SOIv IN C`1-IAi�Gr� __ _ 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. LZESTAU�ANT SEATiNG: TOTAL# LODGING: QFFI F U E ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $SO _�A3IP: ,rn50 I iviOTEL $50 �–�f° —�N $50 _CAMP $50 ( SWIMMING POOL$75ea.��$ _LODGE $50 _TRAILER PARK $50 1 WHIRLPOOL $75ea�� FOOD SERVICE� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $30 �� _NON-PROFIT S25 _>100 SEATS $150 _COMMON VICT. �50 _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED PBr PERMIT# LICGNSE REQt11RED FEE PGRMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $2pp VENDING-POOD $20 _<25,000 sq.R. $75 _PRO'l,F;N DGSSI:R't' $35 TO[3ACC0 — $25 NAME CN..AN F• gto AMOUNT DUE _ $ �30.OO "**'�*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 of Worker's Compensation 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 � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR iNSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE S�ASON. 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 OPEI�TING: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 Staie 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 CONSUMFR ADVj.SORY: 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 Yarrnouth 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 obta.ined at the Health Department. FROZ��1�F.,��FR'I'St - _ - __ _ _ _ __ 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: ��,a�1d� SIGNATURE: PRINT NAME& TITLE: ��""" ��` 10/22/03 � , . e� - � The Commoawealth of Massachusetts � � Department oJlndustrial.-1 ccidents � o Olflceol/erestJpsdiis 600 Washington Street ' =` Bnston.Mass. 02111 w,, ,�.� W'orkers' Compensation Insurance Atfidavit Anoiicant intormation• Plea�eYRiNTT�.'�.ia n�m� �-eS �W Cl` �Q � '�� e$�-' �-w� � �c�l�-�ti! location� �� N1`A-ln1 S`j �it� �!�.a'E-- '�CLti tinuc''� nn.�j-- J`,-tp'�-,� �hone� S�� `�� S 'Z 33 Z � I am a homecwner perturmmg all w�ork myself. � I am a sole proprieror��,', ha�e no one��orkin: in an�•capacity a .pcn�,�ino workers' compensauon for my employ�ees��rkine on this job. � . _ �omnanv name• {�I�P,��1 4�c� Ct3�rQ Q� g��} 1� Q�- `�-v�n � s �1� address• 6 "l �'Vly�}�i n� S."� cih•: w�`� �G��-1�,��c.._h�-� A�l i!�- C3Z-��3 nhone tl �'+�s S�^ �"�'y 3 3 2 �sur�nceco �Ya�le.��✓S '�,�-�w� CA 0�- 11� G9ZfY� �` b�Ll� ��`�"'T � A �a� � I am a sole proprietor. ;enerai contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follo��in� ��orker �ompensation polices: comoanv name: address• �n': hon #! insu�ancc co. p�� # comoanv nams• address• siri: �ee+� insurance co �� a Failure to secure coverage as requ�red unde�Seenoo 25A of MGL 1S2 n�lad to tbe iopo�idos of erisiat!peadtles o(a O�e op to Sl¢00.00 a�d/or one years'imprisonment as w�ell a�eivil penaitlee io the form of a STOP WORK ORDER aed a liae of SI00.00 a day q�inst ma I a�denta�d tbat a copy of thy statement may be fonvarded to the OtTice of Inveetig�tiom of tbe DIA for eoven`e veri8atfo�. 1 do hrreby cerrif}�unde�rh ains and prrta![ies ojperjury that 16e iRfornration pmvided abovt is trae and conect Signacure � t ��d 6 ��3 Print name ��`e'"'��^ Q� one At Sv��"'�S"i 33-z •- ofTicia! use only do not N rite in this area to be completed by eih or town oAleial ciry or town• YARMOIIT$ rmitAicen�e a ' P� nBuilding Departmeot ❑cheek if immediate response i�required ❑Lietasiog Board 261 �Stiectmen'�ORce contact person: �r QHeaItA Department phone M;_ �08� 398�2231 ext. nother .�...�C � .t .1��, � S1N(.f. 1903 � � .�i � PPLEBY�'I�NYti�AN f�,'7/2003 n[eshwa Corp. d/b/a E est Inn & Sui�::es 6� Main Street ��est Yarmoutl��, MA 02673 FE: Travelers ]:ndemnity Co. of Ill - #6KUB7743A,85603 Workers C'ompensat�on I�ear Kevin Pat:el, �nclosed is the above policy with Travelers Indem:nity Ca ��f I!1 for the renewal term of OF/O1/2003 to ��8/O1/200=�. The total annual premi�.zm is $2,b21.00, which wiil be billed d�rectly to you by the cornipany. �,,� 1 he palicy Iimits are as fc�llows: B�odily Injury by Accident $500,000 EEodily�njury by Disease(:Limit) $500,000 B�odity Injury by Disease{:Employe�) $500,004 7 he policy preinium has k;�een calculated using the�Pollowin€;information: (_a�ASSIFICA7:'IO1VS: PAYPIOLL EXPOSURE: �[ote1-a11 other employee;�. $70,g(�0 �[otel-Restaura.nt Employees If any basis 7 he above is a brief description of the coverages provided. k'lease read your policy to become familiar with its �xact coverages, limitatio�is and ex�lusions. �lease review the exposua-es and if there are any si�;nrificant �hanges, please contact our c ffice to avoid additional premiums at expiration. , I� the event of a claim, please contact the Assigneci Risk di��ectly. The d'zrect claims r.porting teleplione is l.-F�00-832-7839. ,,,`i ncerely, � 1�1a . Ca ;��o �. C omm rci i:�es Account Manager INSURANCEAGENCY pF ESS�EX�COC1N'd'Y INC. !Q5 I,ASTERN AVENUE, SUIU"E 207, p�DHAM, MA 02fl2b-4515 �TE1. '81-329-5420 FAX 781-329-�8b1 �EDHAM • CO�rCORU • BEVERLY 6-M,hlL:info�applebywyman.aom !Website:www,ap�labywyman.com . ��-� _ �� WORKERS COMPENSATION AND � EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-7743A85-6-03) NEW-03 INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1. INSURED: PRODUCER: MESHWA CORP DBA BEST INNS & SUITES 69 MAIN STREET WEST YARMOUTH MA 02673 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from Os-oi -03 to 08-01 -04 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers � Compensation Law of the state(s) listed here: MA . � m m B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in d, item 3.A. The limits of our liability under Part Two are: o_ Bodily Injury by Accident: � 500000 Each Accident a— Bodily Injury by Disease: $ 50000o Policy Limit o_ Bodily Injury by Disease: � 500000 Each Employee � C. OTHER STATES INSURANCE: Part Three of the policy appiies to the states, ff any, listed here: � � SEE ENDORSEMENT WC 20 03 06 d� � . �� D. This policy includes these endorsements and schedules: o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE . o �_ 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating u� Plans. All required information is subject to verification and change by audit to be made ANNUAL�v. � DATE OFISSUE: 07-23-03 LP ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: APPLEBY & WYMAN INS AGCY 72TLW 004885 �� 1Yavelers - `,� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY � TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KU6-7743A85-6-03) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 701 1 MA BUREAU F I LE NO: ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 1693 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 244 �, TERRORISM RISK INS ACT 2002 21 TOTAL ESTIMATED PREMIUM 1958 TAXES AND SURCHARGES 63 DEPOSIT AMOUNT DUE 2021MP A/R (WCIP) # Minimum Premium: $ 223 EMPLOYERS LIABILITY MINIMUM: $ 50 `� DATE OF ISSUE: 07-23-03 LP ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: APPLEBY & WYMAN INS AGCY 72TLW �^�\ � �� WORKERS COMPENSATI�N AND -- EMPLOYERS LIQBILlTY PO�1CY EXTENSIO�I OF INFIO PAGE—SCHEDULE WC 00 00 01 ( �) POLICY NUMBIgR: (6KU8-7743A85-6-03) I� SURER : ?F� TRAVE�.ERS INDffcMNITY COMPANY 11347-�MA IPSURED'S NAME : MESHWA COR� DBA BEST INNS & SUITES ' RATE EIJREAU ID: 000048617 PREMIUM EjASIS E57IMA1' D RATES ESTIMA7E1) TCTAL ANf� AL PER $100 OF ANNUAL Cl ASSIFICATION CODE REMUA�RA1';ION RENAJIVERATI01�4 PREM7:UM L( CATI C N 001 01 FE TN EN'fITY CD 001 ME SHWA CORP DBA Bt ST IPWS & SUITES, 6! MAIPI STREET --� W! ST Yl,RMOUTH, PAA 02673 � Hi �TEL: ALL OTI-ER E:NPLOYEES & ' '� S, .LESPE RSONS, DRII�ERS 9052 7(�80d 2.32 1643 � .�. —� H� iTEL : RESTAfJRANT EMPLOYEES 9058 IF ANY 2.32 �. �� T. �� , � �� r�• �� . �� ..�� — •---- •-----------•�--------•-------------------•------- ------------------------------- '"'� 1 .00% E'MPL . LIAB. INCREASED LIMITS�(9807) I$ 16 � ADD FOR INCREaSED LIMITS MINIMUM �(9848) 34 � 1ERIT RATING/EXPE:RIENCE MIOD: NONE MODIFIED Pf2EMIUM N01� � TOTAL ESTIMATED ANNUAL STANDARD P{dEMIUM ' 1693 �� --- EXPENSE CONSTANT�(0900) i 244 "'�' 'I'E RRORI SMI RI SK I NS ACT 20Q2 (9740) ' 21 3.70% MA WC SPECIAL PUND AND TRUS'f FUA� ' 63 TOTAL ESTIMATED Pi2EMIUM ! 2021 " DEPOSIT AMOUIdT DUE ' 202! ooaaae D �TE Of' iSSUE: 07-23-03 LP ST ASSIf�l: I�A SCHEDULE NO: 1 OF LAST THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-006 FEE: $SQ.00 Tt►is is to cenify that Meshwa Corp. d/b/a Best Inn& Suites " 69 Route 28 West Yarmouth MA ' HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS . This License is issued in confomuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusettsrelating thereto,artd upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,20Q4 unless sooner suspended or revoked. November 12_2003 BOARD OF HEALTH: Best�tuit�. �j�, /L�.$, ' n��, v� �� R�t�. a�, �� s�, Q.n! ruce G.Murphy,MP ,R S., H Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #04-014 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 ofthe General Laws,a permit is hereby granted to: Meshwa Corp., 69 Route 28, West Yarmouth, MA Whose place of business is: Best Inn& Suites Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD OF HEALTH: �te�afa�nri�c D, C�and�,r, �1L.D.. ��rra+c �a�iick�?fcD�xott, 2/�ce ��ua�c �'odent�. �7au•,a, L� �� s�. �� November 12.2003 , ruce G.Murphy,MP .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiIMBER: #04-004 FEE: $75.00 This is to Certify that Meshwa Corp. dJb/a Best Inn& Suites _ 69 Route 28 West Yarmout MA HAS BEEN GR.ANTED A LICENSE TO ' ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2004 unless sooner revoked. November 12,2003 BOARD OF HEAL7'H: bne�c��l�c j�, Ejyt�O,�, �,j� ��,� �a�uck�D�, ?/�ec C''ka.ur.rta.� ,�o8�t�. �aoca�c, eP�r,� � Skar�. �1Z. Bruce G.Murphy,MPH HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-008 FEE: $75.00 This is to Certify that Meshwa Coro dlb/a Best Inn&Suites 69 Route 28 West Yarmout MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Best Inn& Suites - INDOOR POOL 69 Route 28 West Yannout _ 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 12.2003 BOARD OF HEALTH: $e�c��, l��. 'j�.D., �� at�riek�c?�ez.�wt�, ?/r.'ce L'�ua� ,�o�art� b''aoacac, C� �ele� Skak, ,�12. ru G.MiuP Y�M�' � •, O Director of Health , �.� , r---��l+�N- __.. �F�R,s TOWN OF YARMOUTH BOARD OF d�Et�LT�-I �� ' t::: � �� __ �i�; a o��c APPLICATION FOR LICENSE/P��Y�..2003,� y �: s� � k ,� �� ,� �� ti a�`�; � � �� •'' . * Please complete form and attach all necessa y Dece er��:,r�LO�� U��..�, Failure to do so will result in the return ur a plica 'on pac ----�-...- 8 � '� NAME OF ESTA3LISHMENT• �� ^+^ � �� - TEL. # s�€�-��-�- G�� LOCATION ADDRESS: 6 �t ►��N�� S"T ,^w � `la'��w'h^ . �� a ��- � . MAILING ADD FSS• - OWNER/CORPORATION NAME• M�S��c� Lc� , MANAGER'S NAME• ��v a ar.� �c--�-�.»Q TEL. # s a�-��-i-0��t� MAILING ADDRES S• ��i eu R-c� s--� , �,•,� �f a�v��6w, �. u�c A- �2 6� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P�el Oper�t�r;s? and a�±a�h a copy of the c�:-}:ftc:.t�on zo th�s fc�rm. � � ��'�l l. ��V� 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. ��a�� P�=� 2, k -r � � �� pG-k-�� 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' reeords. You must provide new copies and maintain a Sle at your estabiishment. 1. 2. Fri�Sf3i��I'3 �clr�C�: _ _ _ _ _ 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-chokmg procedures below and attach copies of employee certifications to this form. The Health De�artment 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# LICF,NSF.REQUIRGD PGP; PERMIT#� LICENSG REQUIRED FEE PERMIT# B&R $50 CABIN $50 �MOTEL $50 ��3�OI) INN $50 CAMP $50 �' � �SWIMMING POOL' � �� — — ' � o LODGE $50 _TRAILER PARK $50 / WH(RLPOOL FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LiCENSG REQi11RED FEG PERMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS $75 I CONTINENTAL $30 �03��3� _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# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROTFN DFSSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $_��f1�' ZL� *****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 of Worker's Compensation Insurance. TNE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. O Il�( RANC '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 3 l. 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 SEASON. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to 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 ADVI54RY• Each food establishment which serves or selis ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. --- FROZEN DESSERTS: rozen esserts must�e testea on a mon�fifiy�iasis�y a atate certi#i�#c iat�.--7'est resu-3ts inust be �e►~�t tu t,tz I�ealt . 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. (�UTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibitecl. DATE: �.� �} �Z SIGNATURE: �� 4�� Cn�-�� PRINT NAME & TI'I'LF: ��-��C �c� �a�o�.{ � 10/18/02 � ' � � The Commonwealth ojMassuchusetts � � Department oJlndustrtal.-lccidents o Ofllceoll�estl�s�liis 600 Washington Street ' ` Bnston, Mass. OZlll Q7N Sv,�'� . � . Vb'orkers' Compensation Insurance Affidavit Annlicant informallon• p►e�sepRiPTTe��r n a m r �C-S �1 W G C . +-'Q � 1�-�$�- �'v� � S C�,i."�`t,� . Lucation: �g� M 4'E l 1� S� �it� �n l� ��- �1 0.�-'�'�c c'� . Ad fl- �2 6�' 3 SD$ nhone� � ��'� 3�-- � I am a homecwner pertormmg all work myself. � ( am a sole proprieror �-,a, ha�e no one ��orkin, in am�capacin� � I am an emplo�er pro�_�dins w�orkers'compensation for my employ�ees w•orking on this job. s4 m o a n�• n a m e: �Q-S'�' `�U� � S Gl,.�`t`e-7 . �dress: � � nh�Q 1� S".� citv: iN ' �j��"Yv� O C+vYY� /+.l�} c31-'6�3 nhone H• .�� `��, - ��S .2-`33 2_ insurance co. �`��'�i 1W ;...� �.1 ulo�l �-ih( � A.4�Y# i��.2 C� � b �Ql�}1._ -� � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed belo� ��ho ha�e the follu��in_ ��orkzr� �ompensation polices: s9moanv name• address• citv�: ohone k• insur�ncc co. R�y# s2m�anv namr. address: _ _ __ _ _ __ _ _ _ _ __ _ --- -- _ cih�: nhQn�+�. insurance co. ��r,� � Failure to secure coverage as required under Seenoo 25A of MGL 1S2 ea�Iqd to tht iopo�idos oterisiafl ptadtlef of a Ooe op to Sl¢00.00 a�d/or one yean'imprisonment a�w�ell a�eivil penaldt�io the form of a STOP WORK ORDER asd a Aae of 5100.00 a day at�inst ma I a�dena�d t6at a copy of thy statement may be fonvarded to the OlTice of inve�tigatiom ott6e DIA for eovenge veriAutio�. /do hrreby cenif}�under th�Parns and penalties of perjury thw!ht injorniation providtd abovt is ttue and eorred Signaturc � �vG�-%� �r 1-.�� D� Ill��-� �Z Print namc � .��"�A f�-I� Q l'�' `T�Z�. Phone�l �� --��' 2��.� .. o(Ticia! use only do not Mrite in this area to be compieted by eiry or town otlitial ciry or town: Y�M�IITH _ permit/liceaae p nBuilding Department QLicrosiog Board �cheek if immediate respoese i�required 261 �Stleetmen'�OtTitt �Healt6 Depanmeat cone�cc person; _v � phone N;_ �508} 398�2231 eat. nOther .. < .,,, , - , ' THE COMMONWEALTI3 OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #03-019 FEE: $75.00 This is to Certify that Meshwa Corp. d/b/a Best Inn& Suites 69 Route 28 West Yarmout MA I5 HEREBY GRANTED A PERMIT To Operate s Public, Semi-Public Swimming or Wading Pool At Best Inn& Suites -INDOOR POOL 69 Route 28 West Yarmouth MA ; This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2003 unless sooner suspended or revoked. December 6 ,2002 BOARD.OF HEALTH: , (��ra�rle�'� �elfu��c. ��xct�. S'e.cyct.ni�c D. �ji°'cdoor. �D.. `l/ice . �o�t�. ��ou�, L'f�k ��D� S �?�l. ruce G.MiuP Y, R.S., H : Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-008 FEE: $75.00 This is to certify that_ Meshwa Corn. d/b/a Best Inn& Suites 69 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE 1N THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS T'his License is issued in conformity with the authorily granted to the Board of Health,by Chapter 1,40,Sections 51,of the General Laws,and amendmems thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the carrying on of the occupation so licensed as adopted by the Board ofHealth,and expires December 31,2041 unless sooner revoked. December 6 ,2002 BOARD OF HEALTH: �ra�ed`�. �e�, (�uaoc �ee.a�D. C%on� �D.. ?/�ee ,Z'Z'o(,�t�. ��c, C� ��D�tt � s� .�t ruce G.M y, . .,CHO Director of Health � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiIMBER: #03-011 FEE: $50.00 This is to Certify that_ Meshwa Corp. d/b/a Best Inn& Suites 69 Route 28 West Yarmout MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issu�in conformity with the authority granted to the Boazd of Health;by Chapter 140,;$ections 32A,32B, 32C,32D and 32E as amended,and is subjeat to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upan such terms and conditions,and to ifie rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2403 unless sooner suspended or revoked. December 6 ,2002 BOARD OF HEALTH: (�� i�e�,; ��i�, �e� D. G�'a7do�, �11.D.. 2/ice ,�a�� f��uac, L� �a.r3ite��'1fcDauAcot� �ePe.c .Skalc, ,�.?72. ruce G.Murphy R.S.,CHO Director of Healt TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-039 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section S ofthe General Laws,a permit is hereby granted to: _ Meshwa Corp., 69 Route 28, West Yarmouth, MA Whose place of business is: Best Inn& Suites Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2003 BOARD oF HEAI,Ti-I: C�anP,ed�f, xe��. ��r�c �e�cla.ni,i D. G��azaloAc. �111.D.. �1/�ce �o�rt 3. ��. �?� �a�iiu��e�x�t s ��t December 6 ,2002 � ruce G.Murphy,MP .S.,CHO Director of Health . • aEs-r ►NN � � ' ' TOWN OF YARMOUTH.B ARD OF AEALTH !'�°�'�`�'0�°��°�" �. APPLICATION F�,,� �SE/PERMIT -2002 _ _�.f�au�'� �'aos� �rc� * Please complete form and attach all necessary documents by December 31, 2001. Failure to do so will result in the return of your application packet. �TAME OF ESTABLISHMENT• �� t,h � 5 C�:�{{-ee S TEL # �� 233 2 LOCATION ADDRESS• � � �+s� +�a�nl �t- , ad�s t taa lv�do�..�,r, +�v� A ��(��' � MAILING ADDRESS: —' GI o ^ QWNER/CORPORATION NAM : me s h v�a- cA-��p • MANAGER'S NAME• D.2v ah� �. TEL # � � � ��S �3�Z MAILING ADDRESS: Co� ��- �ncuv� �-C t�.,e�� 4 az�oc.�.h., �. m � D �G�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)_a�dattach-a�ep3�_nf il�e r�tiff�caticu��c�-tk�is for�n. 1. ��'a�'1 s� �o•�-�� 2. �c��i�� t Pool operators must list a minimutn 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. a-��S'� G�-e� 2 �o�V*l{-a� e�!-p� 3. �`�-�ci.tic..�os Q 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. PERSON IN C�iARGE: - - Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. L 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 _CABIN $50 1MOTEL $50�Z, �o�-D/ _INN $50 _CAMP $50 �SWIMMING POOL$50��;�c�—o�S _LODGE $50 _TRAILER PARK $50 I WHIRLPOOL $25ea. �Gb��QD 7 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $30 �]� _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RFTAIL 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: $i o _ AMOUNT DUE _ $ `LO S•O O _ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� 1 i I � �� 1 ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certifica�e of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �, � V�JORKER'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 RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS�IlV�NTS 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 Departrrient prior�o 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. _ _ __— __ -_ - FRn7FN 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. t, 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: �� 1 � � SIGNATURE: � PRINT NAME &TITLE: �«�� P� � M�`^�-�e^� � 09/11/O1 , , N� , � The Commonwealth of MassQchusetts - � � Department ojlndustrial.-lccidents � a Ofllce ol/ev�sUpstl�is 600 Washington Slreet � : Bnston. Mass. 02111 �'" "�y W'orkers' Compensation lnsurance Affidavit A.nnlicant information• PleasePRiNTTe�'� n�m4 {��L�LSk �--h1.t ,� S c.1,if-�� lucation• �� fLt D��h S � �� Gv��- —Q cz.n.rn��--uy1 /Ul 6� ' o a 6 � 3 ohone� SoC� - �`a-�';��,3 3�. � I am a homeoµner pert�rming all w�ork myself. � I am a solz proprieror =�,'. ha�e no one ��orking in anv capacih� �j I am an emplo�er pro��iing w�orkers' co_mpensation fo_r m�employees w�orking on this job. __ _ S�_Pan�• name. �4-'-S�ln�G� C C� ;�ddress• � — cih�• t! �O � ' � "'I � r �1 � Q I hone fi• insur�nce co �� - ��r'Y1 CCl-S�`�-�� Y# N�-d ( � a � O�� - - � I am a sole proprietor. :enerai contractor, or homeowner tcircle onel and ha�•e hired the contractors listed belo� ��ho ha�e the follu��in� �+orker ,ompensation polices: m nv n ddress• �� phone#• - insur�ncc co Roltc}'# m anv n e• . __ _ �ddrcss• sity ohone M• — insurance co R0�.1'* t Failurc to sccure covenge as�equired under Secnoo 35A of MGL IS2 cs�Ind to tbt iopaition oterivi�l pesdtla of a O�e op to 51,500.00 a�d/or one yean'imprisonment aa well a�civit pen�ltie�io the form ot�STOP WORK ORDER aad a list of 5100.00 a d�r Ktiost ma I a�dersts�d tfiat a copy of thH statemen[mav be forwarded to the OtTice of(nve�tig�tioa�ottAe DU for eovera;e veritieado�. I do hrreby cenij}�under rh oins and enalties of perjury thal tht injormation providtd abovt is trut aad corrtct Signaturc � , t 2� ��' Print name ��=V 1�1 ��`z�-- Phone N �'�`� � f'�6�'� , .. otTicia! use onl� do not M rite in this area to be completed by eity or town oAleial citv or town• YA��II� _ permitAicense M nBuildiag Department ' OLiceasiog Board � check i(immediate response is required 261 QSelectmenb OlTiee �Hea1tA Dcpartmeot contact person: phone�:_ �508� 398�2231 ezt. nOther � � — �� — � Ead�ern Cadcuz��y 325 Donald J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY INFORMATION PAGE Policy Number: WC01 620070 ° Federal ID#: 1. Named insured/Mailing Address: Meshwa Corp. Legal Entity: Corporation DBA Best Inn &Suites • 69 Main Street West Yarmouth, MA 02673 Insured Location Add�esses: 1. 69 Main Street West Yarmouth, MA 02673 2. Policy Period: The policy period is from 08/01/2001 to 08/01/2002 12:01 A.M. Standard Time, at the insured's mailing address. 3. Coverages: A. Workers' Compensation Insurance: Part One of the policy appiies to the Workers' Compensation �aw of the states listed here: Massachusetts B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states excepT those listed above in item 3A and ND, OH, WA, VW, &WY. � D. This policy includes these endorsements and schedules: Refer to Attached Schedule T'otal Estimated Annual Premium: $1,455.00 � Countersigned: Appleby &Wyman Insurance Agency of Essex County, 105 Eastem Avenue, Suite 207 =' Dedham, MA 020266088 By �' • � Date: 07/11/2001 orized representative) KB �. , � , — �� Ead�-er�Ca�ua��~y W� 174 (Ed.4-84) 325 Donald J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY � EXTENSION OF INFORMATION PAGE Poticy Number: WC01 620070 (Best lnn &Suites) 4: Premium:44:4 The premium for this policy will be determined by our Manuals of Rules, Classification, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classification ' Premiu:m Basis Rate Per Estimated Descri tion Class Total Estimated $100 of Annuai P Code Annuaf Remuneration Premiums Remuneration Massachusetts Rating Hotel-A/O Empioyees,Salespersons&Dr 9052 $ 50,000 $ �.27 $ 1,135 Coverage B-500/500/500 `9807 $ $ 50' Standard Premium � 1;185 Expense Constant � $ 214 Division of Industrial Accidents Assessment $ 56 Totai EstimatedAnnual Premium $ 1,455 ; The minimum premium applicable to this policy is $206.00 . .� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-011 FEE: $50.00 �'his is to Certify that Meshwa Cor� dlb/a Best Inn& Suites - 69 East Main Street,West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or revoked. ��n s ,Zoo2 Bo�.Rn oF�ai.�: �;�a��Dxy�. .�ree ,�o�t� �iou�vc, � �a�iic�Z��xo� '�fe� .Slrali. ,�.�l. ruce G.Murphy,MP .5.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIVIENT PERMIT NLTMBER: #02-075 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and . Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Meshwa c oru n9 rast Main Stre�, We�t YarmoLth, MA Whose place of business is: Best Inn& Suites Type of business: Continental Breakfast — To operate a food establishment in: Town of Yarmouth Permit expires: DecPm��r 2' �nn� gpp�OF HEALTH: Lla�ed� �e�°1�-�-�-�"�- �eAc�D. �'and°'t 'I1t D., ?/1ce . __ ,�a�iait� �zo�wc, �-_ . �a�rick'nlcDez.xatt � s�, �� March 8 ,2002 Mp �R. .,CHO Bruce G.Murphy, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #02-015 FEE: $50.00 'rhis is to certify that Me hwa Co . d/b/a Best Inn& Suites 69 E t Main S eet West Yartnouth MA IS HEREgY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Bes Inn& Suit s -INDOOR POOL 69 East Main Street West Yarmo MA This pennit is granted in confornuty with Anc�le VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March S ,Zoo2 BoaxD oF��.�: ��D�y� .D.. �jue ,�'a�t� b�no�. Llar� �a�itck�cD�u►rot� �� s�, �� ruce . urp y, , • •, Director of Health THE CONIlVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-016 FEE: $50.00 This is to Certify that Me hw Co . d/b/a Best Inn& Suites 69 E t M in treet West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Pub6c,Semi-PubGc Swimming or Wading Pool At Best Inn& Suites - OUTDOOR POOL 6 E Main S eet West Y u MA T'his permit is granted in confomtitY with Art�cle VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31 2002 unless sooner suspended or revoked. March 8 ,2002 BOARD OF HEALTH: ��D��ionda.a, .�iee �o��rt� �'�ratwa. (� �a�rick�lc?�eu� �� s �� ruce . urp y, , •, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-007 FEE: $25.00 'rhis is to Certify that Meshwa Corp d/b/a Best Inn& Suites 69 East Main Street West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PR.ACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity witli the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws, and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2001 unless sooner revoked. March 8 ,2002 BOARD OF HEALTH: �� , e r��. ��, �� e��a.,�r,�2�. �i°'rd°'a, 2�.. �/�ce ,�o�it� �r�, e� �a�riek 7Kc�D� �feP� .Ska�. ,�72. ruce G.Murphy,MP .5., O Director of Health �;..< TOWN OF YARMOUTH BOARD OF HEAL'� � � o [�,� [� 'J � � Q ' APPLICATION FOR LICENSE/PERMI 0 � ',�C�2� 1< �,, ��r� b��'.�aiy" O a '� Please complete form and attach all necessary documents by Dece � " 1, '` ailure o��l�pi�-jn � the return of your appl�cation acket. � � ------------------------------- -- p --------- ------ �� N�LVIE OF E�TARI iSNMFNT.-- ��5� "�-v��n � ��••}-�----- --------TET #--- ------ ------- �., , , r �+�s� at-'�►�, � S'b ' 3 '�-3'� L ��IL.IIVG ADD F�� MANAG�R'S NAM k ev i v� �W �' t�� ; �,,.�., � s`�`�� . ---, TFT # ,�ZjF �s y�'3 i M.A.I L I N G A D D F.S�� G,S r mccl.�. C�- � +r�. �pc,,v�,•,ucti,. - ----------------------- ----�_---_________________---------_____------------------------------ POOL CERTIFI .,4T1c�NS• The poot 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. 1. ��- P�� a�°u:,,�,. k�o a-�C' t�'.:�2.1. 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 Heaith Department will not use past yeara' records. Yon must provide new copies and maintain a file at your place of bueinesa. 1. �� <=-��i� �n ��_�,,, �--t cn� 2. 3. �;'c�.�..�-,.,.� 4.— HEIMI,ICH CERTIFI ATION • 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' record�. You must provide new copies and maintain a file at your place of busiwess. l. 2 3. 4. RESTAURANT SEATING: TOTAL# NON•SMOKING SEATS: TOTAL# LODGING. OF��E ONL.Y �� ' �'�_______�___ . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $SO (o �or- 0 3 / MOTEL $50 �d!_OS� 2 SWIMMING POOL $SOea = � /-0 y t WHIRLPOOL $25ea. �0/_a3�6 FOOD�RVICE. �"' NOTE: Per the new 105 CMR 590.000 State San�tary Code for Food Eatablis6ments,the effective date for food protect�on manager certiftcation is October 1,Z001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 / CONTINENTAI, $30 �b/-/� _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 TOBACCO $24 _<25,000 sq.ft. $75 FROZEN DESSERT �35 >25,000 .ft. $200 � 1YAMF.�Hd►IYSE�. �10 /Q.C;� AMOUNT DUE = S � ***•*PLEASE TURN OVER APiD COINPL�TE OTHER 31DE OF FORM••""* r_ _ ,�.... _._ _ ; ADMINISTRATION , • ' • � , [lncter Chapter I 52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of ahy license or permit to operate a business if a person or company does not have a Certificate of Worker's Comperisation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFlDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � 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 V NO 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. SEASUNAL ESTABLISHMENTS ARE TO CONTACT THE HEAL,'TH DEpARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENITIG 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. ADDITION I.RF,[�i1t ATION� POOLS POOL OPE�IING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depaitment,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening,and quarterly thereafter. .�. �'�OL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE LIEW STAT . NITARY OD FOR FOOD T IS1;A��:�. The effective date for food protection manager certification is October l, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection m�nager. T�is provision is effective one year 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 imp lemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATFRjNG Pcli �rv 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. �ROZF.N DF��FUTc• 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. OL1T�inF [''eT�c. Outside cafes(i.e.,outdoor seating with waiter/waitress seiyice),��ve prior approval from the OUTDOOR 00 iN(:- ��of Health, ��O°r��nS�P�P�'ation,or display of any food product by a retail or food service establishm ent is pro6�bited. DATE:_ c� S�� 2�.� -� � SIGNATURE: PRINT NAME&TITLE: ��i� � �,�� 11/1(�/00 , + ► . � The Commonwealth ojMassQchusetts _ M W Department ojlndustrial.-lccfdents ; Olflce ol/erestlpst/iis � 600 Washington Street � �,` Boston, Mass. OZlll �'"' '�� W'orkers' Compensation Insurance Affidavit ��pticant informatiom P`�eas�PltilQ'I'Te�'bh� • s filfTll" ��"ciJ , � a-'�--�� J�JI� �� . . location• c�� MC�i`�l S � �� '`J.e_�n `RGI��n��YY\ � M v� D�-�.�'3 phone# S��S- -`�'�--S''Z-332 � I am a homeowner pert�rmin�all work myself. � I am a sole proprieror�:i� ha�e no one�tiorkin� in anv capaciry � I am an employer pro�iding w�orkers' compensation for my employees working on this job. comnan}� name• �ddress � �� '��..... ��. phone�• insur�nce co policy# � I am a sole proprietor. oeneral contractor, or homeowner(circle one/ and ha�•e hired the contractors listed below "ho ha�e the follo��in��orkzr �ompensation polices: m anv aam : a dress• � nhone#• insur�ncc co oolic�•# m an namr. � ohooe#• � oor�a � Failure to sccure coverage as rcquired under Sectioo 25A of MGL 152 eae lad to the impa�i000 o(erimi�al peedtia o[a tfoe ap to 51,500.09 a�d/or one yesrs'imprisonment a�well aa civil penalties io the torm of�STOP WORK ORDER�od a tine otS100.00 a day a`�inst ma [a■dersa.d chae a copy of thy statement may bc forwarded to the ORee o(Investigations of the DIA tor eovenge verifieatio�. /do hrreby certij)'under�he pains nnd penalties ojpery'ury that lhe injormation provided abovt is ttae and eorreex Signature__T�`-'-" \ Dau f�S\2'-�'1 d� Print name �� Phone� ��= L 3 3 Z ., ofticial use onl� do not Mrite in this area to be completed by city or town oftitial y�j�p� permitJlicense# nBuildiog Department city or town: — - �Licensiog Board 261 OSelectmen'�OfTiee �check iC immediate response is required �Health Departmeet phone q;_ �508� 398t2231 ezt. nOtner contact person: — (recised i;9t pJAI ,I _� ri �i t!d �.i y.�_ , HART � y . � �M�' " �� 'E=- INSURANCE .:� .. .. . � .�� , ,, . '"'T'. .}''T.s.=-��'-'� ':'�'�^-*-.�-.�_�� AGENCY, INC. 240 Main Strset, P.O. Box 700, 5uua�ds Bay, Massaehusetts 02532 (508)759-7325 --`-------- � � � � a �n � 8)759-7366 \'/ FAX , COVER S• HEET �QY242Q�� /� HEAITH DEPT. 20: eyc;�-�Lct�l; � FROM: �R� INSURAi.vC � , • , N_AME: . . . , . . . . . . NAME: DEB.RA AATI�I MA.RTTN , FAX: l�d � ,�nj - �;'�� . . FAX: 1-508-759-7366 � �- PAGES : ..�-� t DATE/TIME: �..� /r,��/�✓� � � � R�: • , � ~ .�� MESSaGE: � � � � ,�- i�� ,. ?,�; . D.� �' `7 . � ��j�. ��,.�,,. (� �L r.�.�-- (� c; � -�`' , . � �� . . .. . �� . j •d 99EL 6SL SOS J��N39d 3�Nd21nSN I l�IdH e9S �0 Z i 0 �bZ �eW - 5 24 Ol RRODUCER� tHIS CEFiT1FICATE IS ISSUED AS A MAT'CER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, tHIS CERTIFICATE HART INSURANCE AGENCY, INC. DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFOADED BY THE 240. MATN �T�tEET p0 Bt3X 700. POUCIES BELOW. �� HUZZARDS BAY, MASs. 02532 COMPANIES AFFORDING COVERAGE COMPANV LETTER A COMPANY B p �INSUflED LETTER BEST INN & SLIt.2'ES COMPANY L. 69 MAIN STREET RT 28 IETTER WES'.[' YA��T77'H� �, Q2673 COMPANY D ' LETTFR LIBERTY MUTUAL SNSURANCE COMP.ANY COMPANV E LETTER COVERAGES�� r� �� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDINa ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU6JECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS Of SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEb BY PA1D CLAIMS. CO TVPE OF INSUpANCE POLICY NUMBER POLICV EFFECTIVE POLICV EXPIRAT�ON LIMITS LTR DATE(MM/DDlYI� DATE(MM/DDIV`n GENERAL LIABILITV��~^�� T�µi��Y~�� GENERAL AGGREGATE $ COMMEFCIAL GENERAL L1A81LITY PRODl1CTS-COMPlOP AGC,. $ CLAIMS MADE OCCUR. PERSONAL&ADV,INJURY $ OWNER'S 8 CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAf,F(Any one fire) $ �„_�_�„M,�,�q��.��^.,� a� �W��^ _MED.IXPENSE(Any on��person)$ AUTOMOB�LE LIA6ILITV � � COMBINED SINGLE $ ANY AU70 LIMff ALL OWNED AUTOS BODILY INJURY $ �� SCHEDULED AUTOS (Per person) HIREO AUTOS BODILY INJURY NON-OWNED AUTOS (Per eccidenl) � GARnGE LI�BILITY PROPERTV DAMAGE $ EXCESS LIABILITY ��-��~~��r"'�•, EACH OCCURRENCE $ UMBRBLLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKEH'S COMPENSATION e�»�r�0��.��- X StATUTORY I.IMITS D WG3�323338 7/4/00 7/4/Ol EACH ACCIDENT �100,000 AND DISEASE-POLICY LIMIT SSOO�OOO EMPLOYERS'LIA81Li7Y ��W�e��- �MT� _ �ISEASE-EACH EMPIOYEE S.LOO OOO OTHER . r..e.._....»..... �.,._......e..r.»,.�.._.,�..,__._ DESCRIPTION OF OPERATIONS/IOCATION3/VEHICLE5/SPECIAL ITEMS ��'"i� OPERATI�IVS PERFORMED BY N,�.ME. INSURED AS PROVIDED FbR BY THE TERMS & CONDITIQNS IN THE POLICY. FAX T0509-39B-�2365 ' CENTIFICATE HOLDER �� CANCELLATIOId � SHOULD ANY OF THE ABOVE DESCRIBED PQLICIES BE CANCELLED BEFORE THE r• EXPIRATION DATE THERE�F, TNE ISSUING COMPANY WILL ENDEAVOR TO 'I'OWN OF� YARMOUTH MAIL�.g_DAYS WRITTFN NO710E TO 7HE CERTIFICATE HOLDER NAMED TO THE FAX 508-398-2365 LEFf, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO 08LIGATION OR LIABILITY F ANY KINO UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORI2ED EPAESENTATIVE � ��L�'L�^-� ` .ACORD 25-5 7/90 . ` ;.... ....�. . • _ .:...:....:...:..�,t �".'�ORC��isORP.dFtAY11�(��.fi..�b< Z •d 99EL 6SL BOS h�W39d 3�Nd21f1SNI l�IdH �LS =Oi TO bZ �eW TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-175 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Me�hwa('�ro , 69 Main Stre�t,�,� Y rm� � h,MA Whose place of business is: Best Inn& Suites Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2001 BOARD OF HEALTH: �d 711. �e�ted. ��iavr�r.a� �ia�ed`�f. �e��. `l/ice L�ia��c �o�t� ��, C'?� �e.a�o�io� �, y�ard°�• .�. Ma,�25 ,2001 ` ' Bruce G.Murphy,MP R.S. O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #01-056 FEE: $50.00 This is to Certify that Meshwa Com dlb/a Best Inn& Suites 69 Main Street West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS 1'his 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 31,2001 unless sooner suspended or revoked. Ma,�S ,2001 BOARD OF HEALTH: ��L. �C�ed. (��vras,c� �lia�rlea�f. �a�. �/ice ��a,vusra� �o�,v�t�. ��, C?� �'exyaHci� ?�. G�anda"a ��. � „� Bruce G.Murphy, H, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #O1-094 FEE: $50.00 This is to Certify that Meshwa Cor� d/b/a Best Inn& Suites 69 Main Street West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Best Inn& Suites -INDOOR POOL 69 Main Street West Yarmouth, MA - This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. May 25 ,2001 BOARD OF HEALTH: �d� n�/etted. e,(/i-�_ A/xa� ��"`" �iW1�� T!'. J�B�IG�t�. V[C6 (i�ucvu4�Qat �O(f�W �. ��, (ii'r��"`� �eor" `�. Ll�d°`t, `�. ruce . urp y, . ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #01-093 FEE: $50.00 This is to Certify that Meshwa Co . d/b/a Best Inn& Suites 69 Main Street West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a PubGc,Semi-Public Swimming or Wading Pool At Best Inn& Suites -OUTDOOR POOL 69 Main Street West Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and expires December 31,2001 unless sooner suspended or revoked. Ma 2�5 ,2001 BOARD OF HEALTH: ��. �e�, C�� ,ca�ceed�if. �e1�i. �/ice �iavc�ra� ,�a�iit�. �'nou�, L� �eocJa�rsi� I�. �ionda�• .�, ruce . urp y, , Director of Health 0 0 ,.� m � a� �r o � � � c O � � �o A x o � � ;; N � v � �' .� � � � � � M ,� �g � tj o a'"i � � W �' � � � � W �a o �n � (.�.� � f� U � .o A `�( � ,.�� W � �.a � .� � .� �x a � O C,Wj � ,� .� aXi ��. ,�"o � � b H � o �, � � � o � rWV � 4x.. � '� p� . � � ti Ex-+ ►�Li � W p., E-' � �� v a`�i CN ��A �Q � � ,.,�a �� + a G� � t�° a. �c �'" (Tr W o� r�. � � O ,� � 0 � E-+ o � x � � QWa � o � � � E� �"' �' ~ E" � � �' � � � � � p � c� � z � �' ��'� .a � z � � � y � � � °� � �' c� ��-� � � � 30 � 3zx � � � � b o ooaa . � wH � � o � � w � o � � � � � � � � � ° � .� � W ' � � �., � UG o � � x � ,�,�,� ,ti�.� � � W � uV z � .� o � w � � � � W o � � •° U Cd (-� ..,, .� T1 pq � � � � � � o � � � � � � � �l�'" '^ � � '� N � .� ,.,a .n c«. � ^ z � „ � � � � � o � � � o > � • U •�• p,� � CUd ,C"'" � Qy y � ai �i y Cd C � a"�+ � U v�i