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Home My WebLink AboutApplications, WC and Licensesi " �� 'L� .��« , u � � TOWN OF YARMOUTH BOARD OF HEALTH �� r � � APPLICATION FOR LICENSE/PERMI�-�Q09 ' 6f�O V 2 Q 2008 � �-.� .� � �� , ' * Please complete form and attach all necessary::�c��s t5y Dece ' .��4�. Failure to do so will result in the retur�}c�yo�"r application pac et. I 1 NAME OF ESTABLISHMENT: r3UC..�e- l�N� Vt(,L.�� CprJDD�tNi�S TEL. # 'SF3�''��- G�t 3 LOCATION ADDRESS: g� '�V� 1 S�A1vr' p.D. W�q��u� � �-� . Z��,�-.3 � MAILING ADDRESS: �&i '$uc.�►c. CS�►� 'QD 1t�! . }�.A�.n�u,v�� N�-�t, eLb�.� OWNER NAME: ��c.k. IS�r�v �/iu...�� CbhiDo i ��rK^'rRCJt�TAX ID �FEIN or S Nl: 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 Pool Operator(s) and attach a copy of the certification to this form. L 2. ' Pool operators must list a minimum of two employees cunently certified in basic water safery,standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department �vill not use past years' records. You must provide new capies and maintain a fle at your place of business. 1. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is certified as a Food 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' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: , _ _ _ _ _ _ _ - -_ __ __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained 'ui 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER.�fIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT� _B&B �55 CABIN $55 MOTEL �55 O -0(3 _Rviv SS> _GHIvir ��5 2-SS7VIN1IV1TNCi POOL �80ea. � �y-n[c� _LODGE S55 _TRAILERPARK �105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMI7# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S8� _CONTINENTAL $35 NON-PROFTI �30 _>100 SEATS �160 �COMMON VIC. �60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQLTIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. �50 _>25,000 sq.ft. 5225 VENDING-FOOD �25 _<25,000 sq.f�. S80 _FROZEN DESSERT �40 TOBACCO $55 ��«E cx��cE: sio AMOITNT DUE = S ��p.�o "****PLEASE TUR'v OVER AIVD CO'VIPLETE OTHER SIDE OF FOR'VI***""* � � ( � r . 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, 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 D� NO _ ._ __,__ _ MUTEI.S AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short terrn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy 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 CMR 64G, as amended, sha11 generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the�armouth Health Department by filing the re�uired Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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 retail or food service establishmerrt is prohi6ited. NOT'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: C �Z D� SIGNATURE: �' PRINT NAME&TITLE: �-t--�� -� � ��1�-��-t�'L /�,b�, ' , io�ziios � � �� om:S., Hale FaxID:781-444-0090 Rodman Date: ii/12/2008 10: 00 AM Page: 2 of 2 � . ACORD_ CERTIFICATE OF LIABILITY INSURANCE OPID SH DATE(MMIDDMlW) PRODUCER $UCKI—2 11�12�O 8 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE . Rodman Insurance Aqency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR � 145 Rosemary St. , Bldq. A ALTER THE COVERAGE AFFORDED BY THE POLICIES BE�O . � Needham I�, 02494-3238 ' Phone: 781-247-7800 Fax:781-444-0090 INSURERSAFFORDINGCOVERAGE NAIC# INSURED i INSURERA: A.I.M. Mutual Insurance Co. � B ck Island Villaqe Gondo INSURERB: C O Office INSURERC: 4 1 Buck Island Rd INSURERD: W Yarmouth MA Q2673 � INSURER E: COVERAGES ; 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 111E POLICY PERIOD INDICATED.NOTWITHSTANDING ; ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEGT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR � MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' LTR SR TYPE OF!NSl/RANCE PQLICY IJUI�ER pATE'(MWUDD/YY) DATE(MM/pDlYY) LIMRS GENERAL LIABILriY i EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY EfQ1ED— — PREMISES(Ea occurence) 3 CLAIMS MADE ❑OCCUR MED EXP(My one person) S PERSONAL 8 ADV INJURY $ GENER.4L AGGRE�ATE $ GEN'L AGGREGAiE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PEa LpC AUTOMOBH.E LIABILITY ANY AUTO COMBINED SIN6LE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AtIfOS BODILY INJURY $ (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AtIfOS (Per accident) PROPERTY DAMAGE $ (Per acciderd) GARAGE LIABILfTY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LUIBILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ REtENTION a $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABIIITY X TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE �G6002685012008 ].1��$�Q$ y,1�08��9 E.L.EACHACCIDENT s 500000 OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE a 500000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT $ rjOOOOO DESCR�TION OF OPERATIONS/LOCATIONS/VEHICLE3/EXCLUSIONS/iDDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION YA�� SHOVLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRRTEN NOTiCE TO THE CERTiFICATE HOLDER NAMED TO 7HE LEFT,BUT FAILURE TO DO SO SHALL TOW11 of Yarmouth IMPOSE NO OBLIGATION OR LIABILfiY OF ANY KM1D UPON THE INSURER,RS AGENTS OR ' Health Dept RePReserrrnrnes. �� •IT n� n��f ��. ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH i BOA1�D OF HEALTH � PERMIT NUMBER: #09-014 FEE: 580.00 i ; � This is ro cerrify thar Buck Island Villa�e Condominium Trust d/b/a Buck Island Village Condominiums a 481 Buck Island Road West Yarmouth, MA � ; �' IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa e Condo. - OUTDOOR POOL 481 Buck Island oad est armout This permit is granted in conformiry with Article VI of the Sanitarv Code of The Conunonwealth of Massachusetts, and expires December 31.2009 miless sooner suspended or revoked.r _ December 4.2008 BOARD OF HEALTH: `.�Ee�¢IL S�� .JV., ��l�ttilltt *Restriction:Safety report must be subinitted annually�vith appticarion. �a�AX�b `.� ��,C�t�� [C� ��lWYfiLtY�L Board of Health Hearing,�5107�O i-Do not need CPR, �!!�P�JY� `3,✓��4Ufn� (?� First Aid aud VG ater Safety certiiications. �y��n� ,��/�(. 1;Ift�tE.�. ��.I�4 Dir ctor of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER_ #09-013 FEE: �80.00 rhis is to cerrif,�rhat Buck Island Villa�e Condominium Trust d/b/a Buck Island Villa�e Candominiums _ 481 Buck I land Road, West Y�rmouth, MA IS HEREBY GRANTED A PERMIT Ta Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa e Condo. - OUTDOOR POOL 481 Buc Island oad est armout This permit is granted in confornliry��ith Article VI of the Sanitarv Code of The Coirnnoin�ealth of Massachusetts,and expires Decetnber 31.?009 unless sooner suspended or re��oked.� _ December 4.2008 BOARD OF HEALTH: ,�1�EQett S�C/�� ,J�(.� (?�(xttt(LtL *Restriction:Safety report must be submitted annual(y�t�ith application. �q� �_ �� v� �?(��t Board of Heaith Hearing,0�;07,01-Do not need CPR �l�p�� , ��n Ce� � First Aid and t�b'ater Safety certitications. ary�y (��iQum� ��(. t:l,.`'`'a�'".�• ��I�QO Bruce .Murp y, . , — Director of Health . • i3vuc-Is�.Vieu�� .J�=Y�'k� TOWN OF YARMOUTH BOARD OF HEALTH �,��p s � ' APPLICATION FOR LICENSE/�EF�1V�� r'�`�► ? �' ..0� �. � CU�7 . .� ��„;'� - *Please complete form and attach all necessary.,�oc�ier�s by December 3l, 2007. Failure to do so will result in the retur��f your application packet. NAME OF ESTABLISHMENT: /,�l��I.�SL•��1� i��}G'� ` ��ik� TEL. #��bs/3 LOCATIUN ADDRESS: y�� urX L.s'cs�n �- w • ,�t�a�?H, . y o�.6�,3 MAILING ADDRESS: p�!3o x SS�6 ,N1,g.S13P�, M/`� 6 a�� OWN�R NAM�: Bu�K1s%s�� I(i l(�F� C�,�t�o ( n✓s7' TAX ID (FEIN or SSN)-� CORPOR.ATION NAME (IF,�'PLICABLE): MANAGER'S NAME: ,�i9��'S7'A�7� � �1'G��'/�/7 � rC TEL. # S� �3 ��o� MAILING ADDRESS: 1�4 o X SS�, /�f,45/{�'�f, A- b�.6� ,__ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifieations to this form. The Health Dep�rtment will not use past years' reeords. 1'ou must provide nev�= copies and maintain a file at your place of business. l. 2, 3. 4, FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of eertification to this application. The Health Department witl nat nse past ye�rs'records. You must provide new copies and maintain a file at your establishment. I. 2. ._PER�QN IN CHARGE: _ _ ____ - -- _ — _ _ _ ---- 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 ar more must have at least one employee trained in the Heitnlich Maneuver on the premises at all times. Please list your employees trained in anti-choking proc'edures 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 PER'ViIT* LICENSE REQLiIRED FEE PER'1�III'* LICENSE REQL`IRED FEE PER'�IIT= TBBcB S50 _CABIN S50 MOTEL S50 �INN �50 _CAIVIP S50 2 S�'IVLVIING POOL 575ea. �� _LODGE �SQ _TRE4ILERPARK 5100 _w'HIRLPOOL S75ea. FOOD SERVICE: ' LICEI�TS£REQUIRED FEE PERMtT� LICENSE REQUII�ED FE£ P£R�1IT� LICENSE REQt;IItED FEE PER'bi1T= _0.100 SEATS S75 _CONTINENTAL S30 lv'ON-PROFIT S2� >100 SEATS SI50 CO.'�L'1�ION VIC. S50 R'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERti1IT� LICENSE REQL�IRED FEE PERi�fIT= _<50 sq.tt. �45 _>25,000 sq.t�. 5200 VENDING-FOOD S20 _Q5,000 sq.ft. �75 _FROZEN DESSERT S35 TOBACCO SSO �r�c�►�vc�: sto _ AMOUnT DUE _ $_/SO .Ob *"***PLEASE TL'R\OVER?l�\D C0�IPLETE OTHER SIDE OF FOR�1**'�** ! l 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 1NSURANCE ATTACHED ' OR / WORKER'S COMP. AFFIDAVIT SIGNED ANU ATTACHED �� Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: / YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be ', limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient accupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. ' Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ' * NOTE: Enclosed Motel Census must be completed and returned with t�is apptication. ; POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected ' by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count - by a State certified lab, prior to opening, and quarterly thereaftsr. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town af Yarmouth must notify the Yarmouth Health Deparfinent 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 urrtil the above terms have been met. OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitres�serv�ce),must have prior approval from the Board ofHealth. OUTDOOR COOKING: _- flutdva�r eoaking�preparatian;�r display o€any foo��od�ct by a retail or€�d service es��blis�ttiet��p�ahi6ited: NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ' THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEME:�TT. RE�iOVATIONS MAY RE E A SITE N. DATE: l/ 6 �7 SIGNATURE: PRINT NAME&TITLE:/�'��7��'`�, ��'NG G�NT : io:��n� � , , �'\ ?'he Cammonwealth of Massachusetts Departnrent of Indaslrial Accidents �� 600 Washington Street, 7`a Floor Bosto�e,Mas� 02111 Workers'Compeesndoa Issaranee Affidavih Baildi�glPlambi�glElecttical Contractors , � name: '� �� (�.�� /� �� /V��'v�'L1 acklress: Y�� V��S�/Up /� i �. r''"'�`��?� s te: / E�' zi :O��o 73 � 7�7'g'�5�3 work site location(full addressl_ 7�� d f/C_L.5 C H-NO �� W, �ll�c�u7(-�.� /+ O a 6 73 ❑ I am a hom�wner performing all work myseif. Project Type: ❑New Constructi��Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Builcling Addition �I am an employer providing workers'compensatian for my employees woiking on this job. comrnnvi�ime: - _ . --------__ -- �—.-- _ - -- - _ _ sddress. cftv: ol�eae#- co. X,�1 f�lV]Z1�- =�](��C.� �t� pE �(I�t7 G.�.00�l�o��C) �e�- O� , ;:. , � . ; , �,.z. : s �. .�:., ,:,� � .�-s�.«r��r.� '< ❑ I am a sole proprietor,ge�eral coatractor,or bomeowwer(cirde onc)and have hired tbe corn�actots listed below who have We following workers'compensation polices: ��m�v mm�• ad�tress• citY• u�a�e#: # 4omnuv dme• �u: si�Y: o�aec#- �_ .. # , Fa�m�e a sccQe avera�e as reydrea.�der sedioi 2f�A ef MGL ls2 can Ina a the�p.�iu.�.f ed.i�al pe�altla.t a S.e ap a t1,sN.M uat�_ o�e y�eus'Imprho�at as wd ae dv�pe�aNies in t6e fir�of a 3T0!WORK QRDEA a.d a Me d f1M.Os a day apinst re. I aedeisrind that a apy of tYis theemeot may be farwarded�e tAe Omce otl�ffi of t6e DIA tar average veriAcatls'. I do be�+eby cerlr;/'y xeder NYe palns end pentlties of perjwry tJYet tlYe l�fonwetlon prou�ded abaNe Is trrte ped c»rnrt Signature Date P�� Phone# offi�eiai ex anly do not wr#e ia this area to 6e c�pktcd by dly er�osrn a�cial cily ar te�rn: permnit/�iee�e# ❑BaildioE Depariment Board ❑cbeck if immt�ish rdpeax is rr9a�d QSdectmee's OISoe �Hakk Ikpat�mt ce�ct persoa: pho'e#; QOWer (*kvired Sc�-2003) Buck Island Village Condo�ninium 481 Buck Island Road West Yarmouth, MA 02673 June 2, 2008 Mr. Philip Renaud Board of Health Town Hall South Yarnioutti, MA 02664 Dear li�r. �tenaud: The BQard of Trustees of Buck Island Viliage Condoininium states the following. Our pools are maintained for the use of the residents af Buck Island Village and their guests only. Trustee James Farre�l and the Property M:in��er Florence Incerto monitor the pools �or safety violations. A�proximately te�► �ec�pl� utilize the pools on a daily basis and appr�xirnately �S per driy on week�nds. An emergency telephone (push button "911" capabilit3�) is tocated inside of tlhe i�ool area, all mechan�cal equipment is enclased in a fenced, locked af-en and chemicals are stored in a lacked storabe unit. We comply with appropriaiQ sig�xing on daily sign-in sheets for reside�its and theii•suests and every resident has received a copy of the pool rules. We shall continue to comply �vith all the requirements of t'he Z'armoi►th B�ard af Health for the safety of everyone ir► aur iammunity. Thank you for y our �i�ticipated appraval af oezr reques�t which will help us during the summe�- season witli��j#jeoparc�izing our safety anci that �f our guests. ' Sinc� ely, ,�, �'��'L�r�'�-�� ,< �•ti-�C�, %. r�'ames Fa�' �elr,Trustee I3uard af'I rustees I3uck Island Village �C�ndo�reinium Enctosed/Capy of BI��Puc�l Re�les . Buck Island Village Condominium 481 Buck Island Road West Yarmouth, MA 02673 SWIMMING POOL RULES 1. THE POOL IS FOR THE EXCLUSIVE USE OF RESIDENTS (UNIT OWNERS AND TENANTS) AND THEIR GUESTS. 2. OWNERS AND TENANTS ARE ONLY ALLOWED FOUR(4) GUESTS AT ANY TIME IN THE POOL. 3. UPON ENTRANCE TO THE POOL AREA WE ARE OBLIGED TO SIGN IN ON THE DAILY SIGN-IN SHEET WHICH IS LOCATED THEREIN. 4. THE POOL GATE IS OPENED BY THE ONE KEY DISTRIBUTED TO EVERY HOUSEHOLD. A GUEST COMING TO THE POOL : WITHOUT THIS KEY WILL BE OBLIGATED TO IDENTIFY WHICH RESIDENT THEY ARE VISITING. 5. NO ONE MAY ADMIT ANYONE TO THE POOL WHO DOES NOT HAVE A KEY FOR THE POOL AREA GATE. 6. CIGARETTES AND CIGAR BUTTS SHOULD BE DISPOSED OF IN ASH TRAYS OR IN THE `BUTT BUCKETS" WHICH ARE LOCATED IN THE POOL AREA. ALL OTHER TRASH MUST BE DEPOSITED INTO THE TRASH CONTAINERS. 7. FOR SAFETY REASONS ABSOLUTELY NO GLASS CONTAINERS ARE PERMITTED IN THE POOL AREA. S. NO FOOD IS ALLOWED IN THE POOL AREA. 9. NO ALCOHOLIC BEVERAGES ARE ALLOWED TO BE CONSUMED OR BROUGHT INTO THE POOL AREA. 10. DIVING,JUMPING, RUNNING OR HORSEPLAY IS NOT PERMITTED. . 11. NON-SWIMMING CHILDEN UNDER THE AGE OF SEVEN YEARS OLD MUST SWEAR A"SWIM VEST" BOTH IN THE POOL AND IN i i , • a ' — i i I THE POOL AREA AT ALL TIMES. SWIMMING "AIDS" SUCH AS j "SWIM CUFFS", BACK-PACK TYPE FLOTATION DEVICES, TUBES, ETC. MAY NOT BE UTILIZED FOR SWIMMING/SAFETY PURPOSES. FAILURE TO COMPLY WITH THE "SWIM VEST" � RULE WILL RESULT IN LOSS OF USE OF THE POOL. i12. CHILDREN UNDER 16 YEARS OF AGE MUST BE ACCOMPANIED i BY AN ADULT (18 OR OVER) THE ENTIRE TIME THAT THEIR � CHILD OR CHILDREN ARE IN THE POOL AREA. � , i 13. CHILDREN WHO ARE NOT ��TOILET TRAINED" OR WHO ARE � WEARING "SWIMMERS" ARE NOT ALLOWED IN THE POOLS. �I 14. RAFTS, FLOTATION DEVIC�S OR POOL TOYS ARE NOT ALLOWED IN THE POOLS. 15. BICYCLES, TRICYCLES, SKATEBOARDS, SKOOTERS, ETC. ARE NOT ALLOWED IN THE POOL AREA. 16. NO ANIMALS ARE ALLOWED IN THE POOLS OR IN THE POOL AREAS. ' 17. DO NOT DISCONNECT THE SAFETY ROPES OR HANG ON THEM WHICH COULD RESULT IN THEM DISCONNECTING FROM THE POOLS' WALLS. IF THEY ARE BROKEN OR DISCONNECTED, THIS WILL RESULT IN THE CLOSING OF THE POOLS FOR A PERIOD OF TIME DUE TO SAFETY ISSUES. THIS HAS BEEN MANDATED BY THE TOWN OF YARMOUTH. 18. A STATIONARY TELEPHONE IS LOCATED IN THE POOL AREA FOR EMERGENCY USE ONLY(CONNECTS DIRECTLY TO "911"). ALSO,A PORTABLE TELEPHONE IS LOCATED IN THE HITCHEN AREA OF THE CLUBHOUSE TO BE USED FOR EMERGENCY PURPOSES ONLY. 19. ALL RESIDENTS AND GUESTS ARE EXPECTED TO OBSERVE THE ABOVE RULES FOR OUR MUTUAL BENEFIT. FAILURE TO COMPLY WILL RESULT IN LOSS OF USE OF THE POOLS. BUCK ISLAND VILLAGE BOARD OF TRUSTEES i , � � • . . � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF FIEALTH PERMIT NUMBER: #08-007 FEE: $75.00 This is to Certify that Buck Island Villa�e Condominium Trust d/b/a Buck Island Village Condominiums 481 Buck Island Road. West Yarmouth. MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Village Condo. - OUTDOOR POOL 48 i Buck Island Road West armout This permit isgranted in con#'ormity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31,2008 unless sooner suspended or revoked. November 20,2007 BOARD OF HEALTH: ;��CIt SR.�� ✓�i../V., ��NLIu`L *Reshiction:Safety report must be submitted annually with application. ��p1L�D .�. .�i��f:�l�� ICS ��,�A.'�ill/1LlYIt Board of Health Hearing,OS/07/01-Do not need CPR, J��(it�1[� �.��LOtWt� (��.PJI� First Aid and Water Safety certifications. Qttit��E�t�'l�ltflL� �..N. ruce .Murp y, , . ., Director of Health _ _ _ _ _ _ _ TAE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #08-008 FEE: $75.00 This is to cenity r1�at Buck Island Villa�e Condominium Trust d/b/a Buck Island Village Condominiums 481 Buck Island Road, West Yarmouth� MA IS HEREBY GRANTED A PERNIIT To Oper�te a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa�e Condo. - OUTDOOR POOL 48 i Buck Island Road est Yarmou , M This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. November 20,2007 BOARD OF HEALTH: ��¢!Z Sf�R�� ..lV., ��Y�iuUt *Restricrion:Safety report must be submitted annually with application. {a�All� .�.��C�t�G� �tCS �iQIZ Board of Heatth Hearing,OS/07/01-Do not need CPR, ��1tQX��.��[4(Lt/L� (� First Aid and Water Safety certifications. Q/Z/Z�(L�q,U/1Z,� �,.1�. Bruce .Murp y, ,R. ., Director of Healt • 93u � � °f;;�R� TOWN OF YARMOUTH BOARD OF HEALTH � 3 e Y�� APPLICATION FOR LICENSE/PERMIT 20(�7` ��i ✓N 0 V 2 7 2006 � � w � � Please com lete form and attach all necess ddcuments b Decem� ' P �Y y ��0..�H DEPT. Failure to do so will result in the return of your application pack . NAME OF ESTABLISf�VVIEENT': ��Jlff � �b ' /�� ,1p�Wi,Ji JU-- TEL. #,�50�� 77$-`6S/3 LOCATION ADDRESS: �� /�K ou7ff R� a�673 MAII.,ING ADDRESS: p•o . Sox f1 'E MA� 0�6`l9 OWNER NAME:,��1GK�A�b i GL �i�v�?/�uS7 TAX ID (FEIN or SSl�I: � CORPORATIQN NAME�APP�., CABLE): ` ' ' MANAGER'S NAME: d/L7�,il l.A� �Y ST�7� ANq��! V� L. 5�8 S39"31� MAII.,ING ADDRESS: P• �- X �5,6 , /�'A�SffPl� N/A� v Z6Y 9 ' —� POOL CERTIFICATIONS: The poal supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a cQpy of the certification to this form. . __ � k 1- /�'�r��,�r��f 2. � Pool operators must list a minunum of two employees currently certified m basic water safety, standard First Aid and Community Cardiopulmonary Resuscitatian{CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments a.re required to have at least one full-time employee who is certified as a Food ' Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� , l. 2. . PEgSON IPd C�IA�GE:_ _ ___ _ ___ _ _ _ __ . ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operatian. ' l. 2. HEIlVILICH CER'TIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at all times. Please list your employees trained in anti-cholcmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' r�cards. You must provide new copies and maintain a file at your place of business. ' � l. 2. ; 3. 4• ', RESTAUR.ANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQiJII2ED FEE PF,RMIT# LICENSE REQUII2ED FEE PERMIT# _BBcB �50 _CABIN $50 _MOTEL $50 _,,; . . _ _ _ _ II�i1�T $50 _CAMP $50 +2-SWIlVIIvIING POOL$75ea. �� LODGE $50 _TRAII,ERPARK $100 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTf# LICENSE REQUIItED FEE PERMTI#f 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $I50 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: —RESID.KTTCHEN $75 LICENSE REQUIRF,D FEE PERMIT# LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _c50 sq.ft. $45 >25,000 sq.ft. $20U VENDING-FOOD $20 _<25,000 sq.ft. $75 " _FROZEN DESSERT $35 _TOBACGO $50 NAME CHANGE: $10 AMOITNT DUE _ $ /S�•00 I � •'•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••""" i �__ 'i as 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, OI�i CERT, OF 1NSURANCE ATTACHED OR � / WORKER'S COMP. AF�IDAVIT SIGNED AND ATTACHED 1� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT QCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling urvt 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 amendeci, sha11 generally be considered Transient. POOLS POOL OPENING: All swimming,wadin�and whirlpools which have been closed for the season rnust be ins ected by the Health Department prior to ogening. Contact the Health Department to schedule the inspecfiion five(S�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count . ___ by a�tate certified lab,.prior to openingTand quarterly thereafter. ; � POOL CLOSING: Every outdoor in ground swirnming pool Fnust be drained or covered within seven(7}days of closing. ', FOOD SERVICE I� i I CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen 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 OUTD40R COOKIlrTG: Outdoo�coolcing,P�eParation,or disp�ay�f any foec�prockect b�a re�o�f�s�r�is�establ;sh�n�t-is�4ibited, � , NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RET[JRN TI-�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ' ALL RENOVATIONS TO ANY k'OOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH pRIOR TO COMl��NCEMENT. RENOVATIONS MAY A SITE PLAN. DATE: /r 4 DC� SIGNATURE: PRINT NAME&TITLE: �8a27o�c1 C1�1J /�A��H��iNC� /�F�,c�7 ion��o6 ` : i � The Commomvealth of Massachusetts �. Depart�teat of Indrtsnial Accidents ' �� 600 R'oshiRgton Stree� ?t""Floor ; Bostor�,Mas� OZlll — -- Work�s'Com„�aatioa i=sm�aaee Affidav�t:Baii bi'�/Eleedricxl Co�traetors .._. , ._. .. _ ,.,� .. �, .� fi,. ,. n �. ,.. �. . , � . .�,, � ��,. .�� , name: U ! G� .C1T�/tif i.Cf/lf� aadress: 7 0/ �Vc-�t �,s�� F-� . �tv l.J• Y/�'/L�jOuTl.�- state' �"!�' z� '0��3 nhcxie#(��77��'6�/3 /`p � I/ � work site tocati�(full address)• 7d� ��C��/�4 �p., lV. (i9�?�ID�� fj' b�1,6� ❑ I am a homcownet performing alt wa�k myself. Project Type: ❑New C�structi��Re�nodei I am a sole 'dor and have ao one w in an ca Buii ' Additiaa I am an employer pmviding w�kets'compensati�mY emp�Yees w . o�this job. - s _� �/� — --- --- __- - — —� _ -- - --� �C/7��J�G�IU� *��. �,„.�-ti � ' , 5 !�%RD �J� '� .C�� C� �(�� v�el�'.�/G�� /�Ar 0 �3-�0�� 7�I--/E�oc� . tJ?v,g.l,.�.�✓SulL4�G� �� YwG �oa.Z,6�SQ/aOo�G , ❑ I am s sole proprietor,ga�eral cogtracter,or�ee�(earde aRe)a�l have}rired tbe contractors listed below who have the following wo�lcers'compensataon polices: ', coto�rrr� � .__ � ��" a�ae�lr�ure- ---- �• _ - - �. alw�t�; FaY�te a secm cvraase as req.6ed�.uer SSa1Ma uw.f AtGL 1S2 cu ina a ue hrpaitl...[a�wial pn.Nie..t:�e.p a u,sM.M aadv.r e�e y�eats'isprMauat as wU as dv�pwJtln ia t6e br�r ata 3T0!WORK ORDER a�d a Sae a[S1M.OS a day a�a6ut�e. 1�d that a apy�f tl�ie stsle�e�t�ay be firwar�d!o the Omce�[I�ve��t6e DIA tor aveiage verMalMe. L�o herYby ca�oify NYe NY�t t6e u�fonw�provlded abov�e!a bus as oe s;� nan �( � �6 Print narr� u� L��, �� Phone# �� S�'3(�O efficial ase�Hiy do aot�vrke�t�s ura te 6e cemplaed DY e31�'er bwn effiejal city ar t�: P�# �� ❑eked�if imme�le t+dpsase b rsqaired �'s O�ec �H�it6 D�ar�t cestact pet'seo: Ph��+ � tTM9iecd sq�r-2o�Ci) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-014 FEE: $75.00 � This is to Certify that Buck Isla.nd Village Condominium Trust d!b!a Buck Island Villa�e Condominiums 481 Buck Island Road, West Yarmouth MA IS HEREBY GRANT`ED A PERNIIT Ta Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa�e Condominiums -OUTDOOR FOOL 481 Buck Island Road est armout This permit is granted in conformity with Article VI of the Sanitmy Code of The Commonwealth of Massachusetts,and expires December 31,2007 unless sooner suspended or revoked. � Jan�y 23,Zoo� BOARD OF HEALTH: L�e�xs�t�S. �o�P.�,� it9.�S., . *Resiric6on:Safeiy report must be submitted annually with application. d�elest e)lu'r�i, R.�.� v�elu'u�luis�t Board of Health Hearing,OS/07/Ol-Do not ne,ed GPR, RGliwl�� B��Xu�t� �eh� First Aid and Water Safety certificafions. /+G�t[Cl�a/�C�Pl�NI� �! �j , R.N. ruce . Murphy ,R ., Director of Health . _ _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUNIBER: #07-015 FEE: $75.00 This is to Cerafy that Buck Island Village Condominium Trust d/b/a Buck Island Village Condominiums 481 Buck Island Road,West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At - Buck Island Village Condominiums -OUTDOOR POOL- 481 Buck Island Road est armou Tlus pennit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2007 unless sooner suspended or revoked. - Januaty 23.2007 BOARD OF HEALTH: Qes�rxsst�1. �o�o�,�Ll..�., . *Restriction:Safety report must be submitted annually with application. o�P.�ert c��u`i� R.N.� viCe e�IttG�s Board of Health Hearing,OS/07/O 1-Do not need CPR, R�� B�tlJukt� �� First Aid and Water Safety certifications. pG�Clja I�C�P!l�o� �4�_ , R.N. Bruce G. Murp y,MP :, H Director of Health ' ` � t ��?G�d,�Vc.1e-(StAND Vi t,t.AGE F_YA � }� �_R�o' TOWN OF YARMOUTH BOARD OF HEAL�$ �� :. _;�� APPLICATION FOR LICENSE/PERMT�'"=2�[l� `, ; �,..� � `�� * Please complete form and attach all neces docu�}ent�by��ecember 31, ��5.0 � Z O d 5 Failure to do so will result in the retu�3'our`'application packet. NAME OF ESTABLISHIV�NT: �l)C��G9N6 I (/f G� �p,uho k�'��U� �L. #� c��7�8'—6��3 LOCATION ADDRES S: �' Uc✓s .:�s c�o /2A. w. , ,�-��c�Zf! /t-t�- MAII.,ING ADDRE�S: �n � X �5� AS�fP,� a- o z6 y 9 OWNERNAME: uc/� ScA�v r` aG�c-C'J�t,�k9r,rlr�� /tcl s7 T A X ID tFF.I N o r S�1�� /��`� CORPORATION NAME(IF�'PLICABLE): MANAGER'S NAME: ��J�'S`7�-7� ��1�7 ��/ic� TEL. S3�'3 i� MAILINGADDRESS: v �a ��,"� /'�-S/�f�'�� /� Oa-64�� — POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator,as required by 5tate law. Please list the designated �ool 4p�ratar f s�an�attach a copy of the certification to this form. L rc�v L t'eEl-TG.�, _ 2. — _ _ __ __ Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1- 2. 3. 4. FO ROTECTION MANAGERS - CERTIFICATIONS: All food 'ce establishments are required to have at least one full-time employee who is certi as a Food Protection er, as defined in the State Sanitary Code for Food Service Establishments, CMR 590.000. Please attach copie f certification to this application. The Health Department will not past years' records. You must provide ne ies and maintain a fde at your establishment. 1. 2. PERSON IN CHARGE: _ Each food establishment must have at least on rson In C (PIC} on site during hours of operation. 1. 2. HEIlb��H CERTIFICATIONS: All food service establishments with 2 eats or more must have at st one employee trained in the Heimlich Maneuver on the premises at all ti . Please list your employees traine ' anti-chokuig procedures below and at�ae�i copies of employee certi tions to this form. The Health Departme ill not use past years' records. You must provide aew co ' s and maintain a file at your place of business. ' 1. 2. ; 3. - 4. RES T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIIZED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _B&B $50 CABIN $50 MOTEL $50 TINN $50 _CAMF' $50 vZ SWIIvIlvIII1G POOL$75ea. � ' LODGE $50 TRAII,ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE ItEQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 ' >100 SEATS �150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMT"P# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _QS,OOQsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE = S �60 •O O """*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••"" -—_ _ __� __ .__ _ E � R �. , , � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' CERT. OF INSURANCE ATTACHED OR / WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED t/ Town of Yarmouth taxes and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO � CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season�ustbe ixispec��d --� . by the�Iealt�Depar�r�t p�ior tv 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. 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 Depa.rtment. FROZEN DESSERTS: j -- - �i-azen-desserts-must be�-aa�a�t�l�basis b��Sta�e ce�ifiec�lab.--Test resul#s�st-b�se�ta�hg I�� ' Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: /2 � �� SIGNATURE: PRINT NAME&TITLE: f3v�?'to,J �� c(/�itIF�C�/'�Cr /�G�T 09/28/OS � � - i i_ � � � , � t �� _=--_==--� The Com�nonwealth of Massachusetls � _ � DepartMe�t of Indsstrial Accidents --_ ''= M�.'IN�1MMi � - -- 60(1 R'ashi�egtoa Stree� 7`�'Floor . � =�,�, Boston,Mass. 02111 _ Workers'Com�sahoa Ls�aaee w.;= __ , . � �r_ . � . : � .: . _ A1 Costratturs �:,.. �� .�� ;�.` w'" "�'� :..,,. ., �- �(��f�sc.�i�h /'�G�. �'�vrx�ur}�cJ�vu-�-� eaa�_ �/ �!1�K�SGh-,vb �?�. �� `l��t�7� . r�l/�- - . o�� =�s�� work site 1«xtian rrnu addressl- �/�� U�_L.S ls�".� �P., 4>. 7��[X��'�� j'ss ❑ I am a homoowne�perforniing all work my�elf. Project Type: ❑New Ca�aa�QRdnodel I am a sole 'etar and have no�e w in an Buil ' Addition - 1 a�an e.nwi�ver�yiding wa�kecs'compen�ation fa�r my e�mployee.s wadcing on this job. �v�:___ -5-�,,�. — _ ___ _ �: +�': ohe�c�- -�'�/ �u7v9G.l�vsc�Gq�c� �� v i,Jc. 6a�"a�g5"o t ac�o� ❑ I am a sole praprietor,geieral costmtor,or komea�vser(circli ou�)and have hired the caatractots lisced below who have the following workers'compensation polices: ... � d�s: �. #� �: �sc : �: ��- � Fail�u�e 1�secve . as oder 3ec�a ZSA�f MGL 152 cn lead b IYe ose yean'imptNos�eat a�wr8 as dv�pe�aNia ia t6e fsrs af a STOt WORK ORDER�11ae a[ai�Yd peall��f a��p b tl,3M.M aadl�r cepy of fib�ta�emmt nay be finvarded/o the O�oe ef lav�aa ef Ihc DIA for ��oe. 1»dastud tlut a e�vrrage veeiliadoi- I ro IYd+tby ce ' tNe of perjrrry tAr�t dYe iNfor9waAto�pro►�ded aboti+e!s trxe aed onmct s�� l�- < � Print name <//L70� �Q/x�8'•U /y/��G/�U�,- /�j�i��7 Phone#��/ �39—3 IOC� efficial nae only as aot write i this sra ta 6e c�pleted bY dtq�r lnva effici�l dly ar te�vn: �q �t ❑ehedc if�ie re,apsme is reqeed �Sdeets�s O�ee Phoae ��t �s�c� #' , 07/2012096 11:49 15867781905 BUCK ISLAND VILLAGE PAGE 02 ! Suc�Island Village Condomiri�um E 481 B+uck Xsland Road West Xarmout6,11�,A, 02673 S�f'�MMING FOO�.RUL�S 1- TH� PUOL IS�'OR'T�i,�EXCLUSIV�USE OF RES�DEN'�S(UN�'1' OWN�RS,A..NU '1'�NANTS)ANA THE�i GiJ�STS. 2- UPON�NTRA�TCE TQ THE POOL,�►REA WE AR� OBL�GED TQ SIGN�N ON THE DAILX SIGN-IN SHF�T W�CH TS LbCATED '�'�XEREiN. 3• THE �OOL GATE.i.S OpE�1T�D BY THE ONE K�y DiS'�'RIBU'�'ED TO EVE�Y HOUSEH.OLU. ,A,GUEST CON[�NG TO THE POOL v�'��HtyU'�''rH�S�Y WILL B� 08L��AT�D TO iAENT�k'X WHIC�RES�DENT THE�ARE V�'SIT�NG. 4• NO QNE N�AY AAMI'1',A,i�TyONE TO �'HE PpOL Wi�4 DQ�S NQT kIAV�A I�X FO�i THE ppOL A�tEA GATE. 5. CIGA�tE'T�'ES�q,1�A CIG.A�R SUTTS S�i.OULD�E D�S�'OSE.A OF IN ,�4,SH T.RAYS OR `SUxT SUC�C,ETS"V�HiC�AR�LOC�II,TED iN THE POOL A�A. A�,L O'��iER.t'AP.�RS SI�OU�,D SF DEPOSITED ZNI'O TRASH CON'Y'AINERS. 6. FOR SAF.F.TY REASONS ABSOZ.UTE�.,'Y NO GLASS CON'�AINERS .t�RE PFRMI'�"Z'ED�V THE�'OOL,A,REA. 7. NU FOOU IS ALLOWED�N'THE POO.L ARE�,. 8. NO ALCQ:[�OLIC BEV�RAGES AR�ALLQWED Td S� CONSUMED OR B�tOUGHT IN�'O T�POp�A�A. 9. DIVING,.TUMPING,RU�TNY1vG OR.i�ORSE�LAY ZS NpT �E�Nf.iTTE�. �0• N4N-SWIN.�N�ING CHILDRCN.t�,ND C�LDR�ri'UND�g�,6 yEARS O�1�,GE 1�UST�E ACCUMP,A,1vIEn BY AN ADU�,T T�ENT�RE �'IME TI�AT SAID CHILA�2EN,�,RE �N THF�QOL A,�E.A,. 1!. CHI�,DREN WHO ARE NOT "'�OILET TRA�NED"OR W�O ARE WEA�ING "SWIMMERS"AR�NOT,�,LOWED IN THE kpOLS. 07/26/2806 11:49 158B7781065 BUCK ISLAND VILLAGE PAGE 03 ; I � ; � ; �2• RAFTS,FLOTAa'ZON DEVICES dR POOL'�'OYS A,RE NOT � A�LOWED IN THE pOOLS. .13. B�CYCLES,�CYCLES,SKA'T'�BOA�tDS, �'�'C. A�NU�' � AL�.OWF,A IN�'k�E�'OOL A�tEA. � � � 14• NO ANIMAL3 ARE,�LLOWED�N THE POO.LS UR�N TH�PpO�, AREA,S. 15- DQ NO'�'DISCONNECT TI��SAF�TY RpPES OR H.A,NG ON TH�M V�'H.�CH COULD R�SU�,T IN THEIV�DISGpNNECTIn'G FROM TH� �'OOLS' WA�,�.S. T,.F THESE RU�ES A,i.tE SRUKEN OR DISCONNECTEA,TH�S W��,L R�SULT�N Ti� CLOSING 4F T.�� 'dOLS �'O;�t A PF.F►IOD OF T,�ME DUE TO SAF�TY�SSUES. 16. A STATiONA�Y TE�,,EPHONE�S LOCATED�N T�POO�.ARF;A k'dR EMERGENCY USE ONLX(CpNNEC'�'S Di.RECT.LY TO 911). ALSO,A�'OR�'ASLF, 'I'ELFPHONE IS�,,pCA'�'�D�1V THE KITC�IEN ,A�XtEA OF TI�E CLUBHOUSE. �7. ALL ZtES.IDEN�S AN,p GU�STS .A,RE EXpEC�'ED �'O 0�3SERVE �HE A��OV�RU.LES FOR OUR 1v�UTUA�.BE.NEF�'�'. FA��URE TO COMPLX Wiz,L R�SUL�`IrT LOSS OF USF OF'I'�E PpaLS. ' , ' ' THE COMMONWEALTH QF MASSACHUSETTS a TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NUMBER: #06-054 FEE: $75.00 � This is to certify that Buck Island Villa�e Condominium Trust dlb/a Buck Island Village Condominium 418 Buck Island Road West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Village Condominium - OLJTDOOR POOL 418 Buck Island Road West Yarmout , This peimit isgranted 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. January 27.2006 BOARD OF HEALTH: Qe�sst�. (��,/��., *Restriction:Safety report must be submitted annually with application. � d�P.le�L e��lG�t� R./V� �/[Ce(�s2!!�S Board of Health Hearing,OS/07/Ol-Do not need CPR, Q��B7(1[uti, �¢/tl�, First Aid and Water Safety certifications. ��/N�p� fYIL/L � . ce G.M H,R ., Director of H th THE'COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiTMBER: #06-055 FEE: $75.00 This is to certify that Buck Island Village Condominium Trust d/bla Buck Island Villa�e Condominium 418 Buck Island Road West�armouth� MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa�e Condominium - OUTDOOR POOL 418 Buck Island RQad est armout This pemut isgranted in confornuty with Article VI of the Sanitary Code of The Coxnmonwealth of Massachusetts,and e�ires December 31_2006 unless sooner suspended or revoked. January 27.2006 BOARD OF HEALTH: L�est�i�s �. �o�d.o�z,�9�., • *Restric6on:Safety report must be submitted annually with application. �P.lP.�L e��u-r�i� R,/�1,� �/iCe(�l�C[l�yur�y Board of Health Hearing,OS/07/Ol-Do not nced CPR, ROGe/��B�tyg (� First Aid and Water Safety certifications. n�/�� 4 � , R ruc� .Murphy H,R ., H Director of Heal �� Y��' TOWN OF YARM � IUTH � ` O 0(/� � �"'� ]146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 " MATTACHEES� � � ��A�ORA1f0�bfl'� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 B O A R D O F H E A L T H To: Yarmouth Boazd of Health Permit Holders G3f� � (� r1M (�' (� ` ��'R � '� 2005 From: David D. Flaherty Jr., RS. � � � { Health Inspector � �r � "�` __A�� r„;-•� Town of Yarmouth Re: Federal Ta�c ID Number Date: Mareh 22,20Q5 The Massachusetts Department of Revenue is now requiring fhat we furnish detailed informa.tion 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 Empioyer ldentification Number(FEIN}otherwise knovm as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Nnmber (SSN} 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 Yazmouth Heaith Department I I46 Route 28 South Yarmouth,MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to cati. The o�lfice hours aze Monc�y to Fric�iay, 8:30 a.m to 4:30 p.m Th� telephone number is(508) 398-2231,e�. 241. f -� �/- Establishment: �/V�� b i �� IN or SSN: Location Address: �� v��''�'�� p`� �' ��°u7� Signa.ture: Print: 47�//t�UN l�i�� Title: �/�iU��R��' /� G��7� 9 � I ��[ Recyc edn i ��y Paper � , ��.7�� raa a� ` �� 0��--�'�R � J _ .S� L� � .� � TOWN OF YARMOUTH BOARD OF '� F`: -s APPLICATION FOR LIC �P �A , . ��,+ NOV 2 4 2004 ..• � * Please complete form and attach all neces � ,docu��by Decemb r�-}��Qt�,,.l DEP Failure to do so will result in the return��off your applica.t�on pac . T• NAME OF ESTABLIS�IlVIENT: �J � l�N� TEL. # ?7�' 3 LOCATION ADDRES S: / �'• kt�7'�ff a 73 MAILING ADDRES S: ��C ��L �f P� O� OWNER/CORPORATION AME: G� A��r��°'"� T�s1' MANA ER'S NAME: �4' �T� A��E� sl�+��-- TEL. # � �S' —3!� MAII,ING ADDRESS: Ao X �5� /`IA�E. � G��f4 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. SGoTT �o�JG� 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applica.tion. The Healt6 Department will not use past years' records. You must provide new copies and m�intain a fde at your establishment. 1. 2. PE�SOI�IN£H�RGE: _ _ . _ -- -_ _ _ _ - ---- Each food esta.blishment 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 employe� e tra.ined in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 _INN $50 _ CAMP $50 2SWIlvIlvID1GPOOL$75ea. *�� LODGE $50 TRAII,ER PE1RK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUII2ED FEE PERMIT# �,ICENSE REQUIRED FEE PERMI'P# LICENSE REQUIREA FEE PERMIT# <50 sq.ft $45 _>25,000 sq.8. $200 TVENDING-FOOI7� �2U �Q5,000 sq.ft. � $TS FROZ�N�ESSERT $35 �TtJBACCO $25 �� NAME CHANGE: $10 AMOiJNT DUE _ $ 150•�O ■f1 A A 1tpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"'• � � I i `�-r 1r � , ADMINISTRATION ' s Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Gompensation :Insurance. �T�:A,�TACHED .$,�AT�. �ORKER'S' CUMPENSATION INSURANCE AFFIDAVIT MU�T BE COMPIr�T�D AND SI�NEI�Y OR"..: �' * . ` ,� 'CERT,.�F INSURt�NCE ATTACHE� ", . ._ . ' . OR � f. WORKER'S COMP. AFFIpAVIT SIGI�ED�ND ATTA�HED�;._.--% Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIB�.ITX TQ R.ETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ES TABLI SHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEAS4N. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY; Each food estab �shment which serves or sells ready-to-eat,raw or undercooked animal products are required ta post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth rnust 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 Heaith Department. _— FRA2��-#-3�E�S�R�'�: _ ._ . . __- __ _ _ . __ 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 ha�e prior approval from the Board ofHealth. OUTDOOR COOHING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: � SIGNATURE: PRINT NAME& T ITLE�/�Tb�/y�l,fl�, /�/�i4'W�4' �{4,E,cr7' 10/22/04 , � . . � � __--_� The Commonwealth of Massachusetts = Dtpairiaent of Indushnial Accidents �t' _--- -- �Mr� ' � - - 600 Washington Stne� �`Floor � =-��,` Boston,Mass. �2111 � wurk�s'eom au■I.sn�aace.a►ffia..�s.ii • kd�rfcal co■a�actors � ,.��. _. . . .. � _�_� �!.,� � . „ � � �� - ��.�; _ - ;�, . .... . , , , � � .� - name: l�i�f�l� V' /�dE. 0�1'Yj/Wv� address: �� (/�/� � �� Ym'�'� w . �i��G d'a'if" �- �' zip•O?l.�i n�hanc# s� ��`"G S�!� vwrk site locati�ffnll addtessl• y�S/d��//!�d /� G�, �j��-[f�' O�i7'3 ❑ I am a homeowner perfoaning all wak myself. Ptaject Type: ❑New Ca�a��Remodel I am a sole 'e.tor and have no a�e w in an Buil ' Addition I am an employer pi+oviding warkeas'compensatia�fa�r my e.mploy�s working a�this job. �,...,��. �uG4'�..5�A �l2llA�� itld�s�l�I�>�,r.r, _ :�iF�/ C A�D /�/ w. �',4�Fr o�r�- �ac a: StaP` ��' cs'r3� !�( _It'�,�7�,�t��U��w� � �us��oo�8 5'0l?� ❑ I am a sole propric�or,8eaeral cwtractor,or komeewta�(circle o�e)and have lrired the cornractors listed below who have the following workers'compem4ation polices: e�ry�r�• � � —�� c��r�: s�rr�• t�tv- n�e�' Fa�m�e�.�ecere eewera�e a.req.ired.�da S«If�.2SA.t 111GL 1S2 n.le.a a Ite h�p.�ilMa.ccriwid pe�.11ia.f a�e�a s1,3M.M a�l.r oue yws'i�prbo�ment as weY as dvY pmiltla h�e fsrn�f a 3TOr WORK ORDER aid a A�e e[316li.N a day a�aimt�e. I mdaslagd t6at a cepy ef thb�tatemmt m 6e forwardcd b t�Omce�f lm�of tie DIA t�r asv�ra�e v�rUiatlN. t do ber+eby cer� + dar �nd lties of perjxry tl tot tlYe i�for�eedon providad aboro�e ia texs Rwd �� l�r /e'�.�� Date l P,�;�� ati7��/ �A,A�4�J P�� 5ap r3 9-�3�� aa.��o�y ao a�c.�i cr��a ne�a ny a��.eaa� �y or c�: r�a �c a...�a p��c�k��y�a p�'�� ce�t p�ssn: ��; O�' �+�s�� ;I ` THE COMMONWEALTH OF MASSACHUSETTS T�WN OF YARMOUTH ' BOARD OF HEALTH ' PERMIT NUMBER: #OS-022 FEE: $75.00 This is to Certify that Buck Island Villa�e Condominium Trust dJb/a Buck Island Village Condominium 418 Buck Island Road,West Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Village Condominium - OUTDOOR POOL � 418 Buck Island Road est armout This pennit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31.2005 unless sooner suspended ar revoked. January 19,2�05 BOARD OF HEAI.TH: Besr��r�t�. �j�,��., e�� 'Restriction:Safety report must be submitted annually with application. !'��e�1W�u��Ce�GNII�Git Board of Heatth Hearing,05/07lO1-Do not need CPR, Q��B��/ y First Aid and Water Safety cerkifications. ��i R�•/� A' 1QIlIL��@/L�G�tN1t� K./,. Bruce .Murphy,MPH,R. ., Director of Health � � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-023 FEE: $?5.00 This is to Certify that Buck Island Villa�e Condominium Trust d/b/a Buck Island Village Condominium 418 Buck Island Road, West��rmouthn M,� IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Village Condominium - OUTDOOR POOL 418 Buck Island Road est armout This pennit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachuset[s,�d e�ires December 31.2005 unless sooner suspended or revoked. January 19.2005 BOARD OF HEAI,TH: Be�csic�. �j�,/��., e��x�rc sRestriction:Safety report must be submitted annually with application. nG�JIiCI�/� �/sl:e�Gih�l4ry Board of Heatth Hearing,OSl07lO 1-Do not need CPR, ROd ellt�i�. Bhftu/lg First Aid and Water Safety certifications. d�eit c��G�F� K,N f4�l�/L C�?8@�N�iHll� K./I. Bruce . MuiP Y,MPH,R ., Director of Health ' - �i�lo�3� �/6?�°'°��c,�.�n.v,�,� o..�qR �� C� �`9 C5 DD ' 2 � � TOWN OF YAItMOUTH BOARD OF HEA H i o�o G� C ��; -� y APPLICATION FOR LICENSE/PE ; � �... ....:�_ ��;. � � Nov 1 s 2003 * Please complete form and attach all necessa�r�`� ��s.��`` �cembe 31, 2003. Failure to do so will result in the return 4f�o��li ation packe . HEALTH DEPT. ; I -��GY .�stk,va ;/ACE ucl4o�9'/,�� 778��GS�� T N S : � d�KSt�� a tJ, oe►7�F" � o �� jla �ox r'S� �fv.�€ /�-�s� o:�6c�9 R/ T • �d��s' �o ;/,ac� C'a�o«Ytwr��w T�sr MANAGER'S NAME• �v27��c/ .¢/��/ B�S19-� .�'�i��> �r/rc� TEL S�� 3�-3��d �I�ING ADDRESS: �° 86 x � /�f+s�+�, ��4- a�c�9 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ogerator(sl and attaeh a evpy of l:he f:,erti��acian ta this forrri. 1. 7�' ��c/t�o P2%� � o�� 2. iPool 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. T� 8� /�R'c�ul/Yco F+?%�c- � aPr��r�� 2. 3. 4. FOOD PROTECTION MANAGERS - �ERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. .- P�R�OIv'R3��: � -- -_ _ _ _ _ __ _ _ _� _ __ _ Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. I�STAURANT SEATING: TOTAL# �.oncirrc: QFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $30 CALiITr' $50 _MOTEL $S€1 �� _INN $50 _CAMP $50 Z SWIMMTNG POOL$75ea. ��—�a'7 _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRGD FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS �75 _CONTINENTAL a30 NON-PROFtT $25 >100 SEATS $150 _COMMON VIC"I'. $50 _WHOLESALE $'75 RETAIL SERVICE: LICENSE RGQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# <50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZEN DLSSl:R'1' $35 _TOBACCO $25 IYAME CHANGE: $to AMOUNT DUE _ $ I 50.OD **"**PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM****" f 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 permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOI2KER'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 annualty from January 1 to December 31. IT IS YOUR RESPON5IBILII'Y TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 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 RFGUI�ATIONS POOLS POOL OPENI1�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: 1'he 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. �ATERING PO�.CY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. F�Q,,7.F,N D .�'�FRT� . _ _ _ � — _ __ _ _ 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 Perrnit until the above tetms have been met. 9UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. QUTDQOR COOKING: Outdoor cooking,preparation,or display of any food product b a retail or food service establishment is prohibited. ', DATE: �r � �� SIGNATURE: PR1NT NAME&TITLE: �/�°��`5�� %NG thi G��7' 10/22/03 •� . , � _ The Commonwealth ojMossachusetts � � Department oJlndustrial,-iccidents ; Olflceollerestlost/iis : 600 Washington Street ' ,,= Bnston. Mass. 02111 �~ �� W'orkers' Compensation Insurance Affidavit n�mr� ,�'/�/��5�� i//� �GE'J�'!tldrt/�-. L�cati�n. �� lK��(,�.C/6 �(� � � cit� �• //�'alCX1�7� �l�^ ��73 ehone��7�� 65/� � �' �.. � I am a homecwner pert�rmin,all w�ork myself. � I am a sole proprieror�r.� ha�e no one��orkin_ in am•capaciry am an emplo�er�ro�idin�w�orkers' compensation for my empioyees workin�_on this job. _ - -- - �. . _ . �/�� comaan�• name: �`.��" �� 7�� ""��'�'� � Address: �� / citv: ��S7e��, /�'�f�' o �-aY��'O�S'�� nhone q•�� .�7� insurance co. �'��'•lu �'�'1C✓7t�i�1�s Fo�.CY# VG�G 6��6SSo�� ov � I am a sole proprietor. generai contractor. or homeowner(circ/e onel and ha�•e hired the contractors listed below «ho ha�e the follu��in: �.orkzr�� ,:ompensation polices: s4mpanv name• address• ' cin•• uhone It• insu��nce co. �olicy!� eom�ny name• - - -- - -- address _- - __ c�y: ohoee M• insurance co. �y�f t Failu�e to sccure coveraee as required under Secnoo 2SA o(MGL 1S2 ea�lead to tht iopaitioa o(erieiafi peaaltle�of a 6�e ap to 51,500.00 a�d/o� one yean'imprisonment a�w•ell a�eiril peaaide�io the form ot a STOP WORK ORDER aed�liee otS100.00 a day Kaiost me. I a�dertta�d that a copy of th'n statement may be fonvuded to the Office of Investigfuom of the DIA tor eoven=e verifttador 1 do hrreby cerr' er rhe p n cnall'a ojperjury rhat 1bt injormation provid�d abovt is tnre ond centd Signaturc ��/'/ a' Print name �`��'�� 'v ��'� 'A``�7 Phone�,��-�i�/o� .- olTicial use onh do not M�ite in this area to be compietedby eitv or tm+�n oAiti�l ciry or town: Y�M�� _ permiMiceau k nBuilding Departmeat — �Licensio6 Board �cheek if immediate response is required 261 QSeleetmen'e Ot�ce �HealtA Departmeet contace person: pbo�p�_ (508� 398�2231 eat. nOther .. .�. ��,,, � � C� I� �' Mf� D Buck Island Village Condominium �,,��,`Y � � 2004 481 Buck Island Road West Yarmouth,MA 02673 HEALTH L)EPT. (508) 778—6513 Mr. David Flaherty Board of Health Town of Yarmouth Town�-Iall 1146 Rte. 28 South Yarmouth,MA 02664 Re: Buck Island Village Condominium 2004 Season Dear Mr. Flaherty: This letter is to reconfirm our variance with the Town of Yarmouth regarding our swimming pools. 1) Scott Houle, our pool operator is CP$certified. 2) Florence Incerto, our onsite Property Manager, is First Aid certified. 3) The pool gate is kept locked at all times. Residents can gain access by using the key which we have assigned to them and which they may not duplicate, at our request, and which is imprinted on the keys. 4) Last season,2003,there were no accidents or incidents at the pools. 5) The number of guests per day is approximately 15. 6+ Childrezn ur�der the a�e of 16 *n�st he�:e��►��ied�*y an ��u�t< 'n Dave Stephenson is our poal`tech. 8) We have an updated first aid kit and new CPR mask which are readily accessi6le. 9) A telephone is accessible to contact"911",if necessary. 10)Pool chemicals are kept stored under lock and key. I hope this information complies with your standards. Since y, � �� Florence Incerto, Property Manager , � . + THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH ; � BOARD OF HEALTH i PERNIIT NUMBER: #04-027 FEE: $75.00 ; This is to certii'y that Buck Island Village Condominium Trust dlb/a Buck Island Village Condominium � 418 Buck Island Road West Yarmouth,_IVIA � IS HEREBY GRANTED A PERMIT ; To Operate a Public, Semi-Pubtic Swimming or Wading Pool r � At Buck Island Villa,�e Condominium -OLJTDOOR POOL ( 418 Buck Island Road est armout Tlus permit isgranted in confonnity with Article VI of the Sanitary Code of The Cammanwealth of Massachusetts,and e�cpires December 31.2004 unless sooner suspended or revoked. D�t�s ,zoo3 Bo�oF�ai.Tx: B��`n. �ozd�,M.`?s., G�l�� "Resiriction:Safety report must be submitted annually with application. l+r.�sicR�C�e�lI1lO�� vke e�G%hNu'sI� Board of Heaith Hearing,OS/07/Ol-Do not nced CPR, RO�� BAt9itAft� � First Aid and Water Safety certifications_ d�elelL�i�� R.N M , H, -, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARM4UTH BOARD OF HEALTH PERMIT NUMBER: #04-026 �E: $75.00 This is to Cerafy that Buck Island Villag,e Condominium Trust d/b/a Buck Island Villa�e Condominium _ 418 Buck I land Road, West Yarmouth. MA IS HEREBY GRANTED A PERMIT Ta Operate a Public, Semi-Public Swimming or Wading pa�� At Buck Island Vill e Condominium - OITTD40R POOI- 418 Buck Islan oad est armout This pernut isgranted in confornuty with Article VI of the Sanitary Code of The Cammonwea.l�of Massachusetts,and expires_December 31_2004 unless sooner suspended or revoked. Dece�iber 5 ,2003 BOARD OF HEALTH: Be��ik�. (��.��., �� •Restriction:Safety report must be submitted annually with application. p�-,�'��i v�se e��lNtG�It Board of Health Hearing,OS/0�/01-Do not need CPR, Ro�iigJ��. B�� First Aid and Water Safety certifications. �g,�y ��, Q.�• B • •, Director of He�alt�ti � /3ucK lscANO ��cACr� .. ' ,. �..� _�,_ of=Y'`R TOWN OF YARMOUTH BOARD OF HEALTH � ; � `_ , m _;--� ,r ".o �� c � , �, � � �� " -'�� APPLICATION FOR LICENSE/PERMIT -2003 ' `� ` I �'. �r �S� R g � ��'`! ..�: �. ,a ;, �'�:4_ * Please complete form and attach all necessary documents by Decem r 31, 2002 � Failure to do so will result in the return of your application pac t��°�, , „ :,'� � :�,-�- � U Cµ,c►0 �" 0�1o'�t��utwn 77 ! �/3 �/ u4r(�S'�0 D !.�l. fi� /4 G7 .O. S4� A5flP�E O G • UQS ND t 6F o�p�W�N t u� R u S7' x�s a TE ,�'��r s�« S�d 539--3�� .o. �o `'sS'� �l.FE �.tLY 9 POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s}anc�a�#ach a c�py of tl�� certification t�thzs form. - 1, 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Communi Cardio ulmonary Resuscitation (CPR). Please list these employees below and attach copies of tY P � employee certifications to this form. The Health Department will not use past years records. You must n maintain a file at our lace of business. ew co ies a d rovide n y p P P l, 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN�HARuE• _ __ . . - --- -- _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2• HEIM •ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at 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. RF,�TAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FEr PERMIT# LICENSE REQUIRI;D FEE PERMIT# _3&B $50 _CABIN $50 _,MOTEL $50 03� _INN S50 _CAMP $50 2-SWIMMING POOL S75ea � LODGE $50 _TRAILER PARK $50 _WH[RLPOOL $75ea �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRGD �EE PERMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS S75 _CONTINENTAL S30 �NON-PROFIT $25 >100 SEATS 5150 COMMON W[CT. $50 _WHOLESALE $75 R�TAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# r _<50 sq.ft. $45 >25,000 sq.ft. 5�00 _VENDING-FOUD�$20 -e-- — . , _<25,000 sq.fi. � �$75 � � '_FROZ'I;N DFSSER'f S35 _TOBACCO $25 NAMECHANGE: $�o AMOUNT DUE _ $ /Sa-�O *****PLEASE TURN OVER AND COMPLETE OTHER S1DE 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 permit to operate a business if a person or company does not have a Certificate of Worker's �ompensation Insurance. THE ATT�ICHED STATE, WORI�ER'S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED,'`OTt £. � CERT. OF INSURAI�ICE 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 N�TICE:Permits run annually from January ] 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 INSPECT'ION 7-10 '. DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE C'ONSUMER 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. FRAZF,�T DESSEB�__-- - -__ —_- - i Frozen desserts must be tested on a monthly basis by a State certified lab. Tesf results must be sent to the Heaith Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Perrnit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mu�t 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�G ��- SIGNATURE: ' PRINT NAME&TITLE: ,c�v�l�yA'p � !-/AF�AGj�G t`'I�� 10/18/02 � ` � � The Commonwealth of Mossachusetts � � Department ojlndustrial.-iccidents T a Ofllceollevestlostliis ; 600 Washington S�reet ' ` Bnston, Mass. 02111 . V " v� W'orkers' Compensation Insurance Affidavit Anolicant intormation: PieasepRip7`Te�.'Wic n�mc� lJ�.y�L�ilr//� V�1(�� ...`rlv�"y�iv�V�"' locatian: �D� (cJv��'s��l+'N� �/� . \ �tj• !/g/lt'rIOUT�f" Q�.73 th�� 78"��/� � I am a homecwner pert�rming all work myself. � I am a sole propriz�or��,', ha�e no one��orkin_ in am•capaciry am an emplo�er pro�idin_ w�or4.ers' compensation for my empioy�ees w•orkin¢on thisjob.__ ___ - -- - - - -- � � �j-/ -,. comnan�• name• �.��Arr� f/fl�A�� yll�lc/�► �ddress 7�� "�.,/7 �� D ci�c G�l. ��wiGaJTK. �f} 0�47,� hone t� �J 77��6Sj3 insur�nce co R•�" •�T' vT�/�C"�SJRI�l,C"�- �o yolicy t! ✓��701�GO� � I am a soie proprietor. generai contractor. or homeowner(circle oneJ and ha��e hired the contractors listed beloµ �ti ho ha�e the follu��in� ��orkzr� �ompensation polices: sompanv namr address• , �t�•• Rhone N• insur�ncc co Folicv# comRany namr --- __ - . _ _ _ -_ ___ _ _ �d d res•• --- Sjjy• nhoee M• - inenr�n��n �p(�t�r� _ 1 failure to secure coveraet as requ�red under Secnoo 25A o(MGL 1S2 n�lad to tbe iepo�idoa o(erisi�al pesdtle�of a 6�e op to 51,500.00 a�d/or oae yean'imprisonment as w•efl a�eivil penaida io the[orm of a STOP WORK ORDER aad a tiae otS100.00 a day tpiost me. t a■dersa.d:m.e a eopy of thh statement may be fonvarded to the Ofiiee of lavntigadom of tbe DIA for eovenge veritiatia. I do hrreby cerri der rhe 'ns i fnalti ojperjury that�he injorn�ation providtd above is tnte and orrt . Signature e�' � � ��} QO Print name�v�7o� � Phon�i��3 q�� .. olTicial use onl� do not..�ite in this area to be completed by city or town oAleial city or town: Y�M�� _ permiNieeeu k nBuildiog Departmeot �Liceasiog Board �cheek if immedi�te response i�required 261 �Selectmen'�OlTice �Healt6 Departmeat contacc person: phone p:_ �508� 398�?231 eat. nOther .. ._� : ,,,, � " ' 1 1 _ � � (� r:.-:. : �..? �r� �� a r . . f%a '�f) � �/ ± MAY 2 8 2003 i Buck Island Village Condominium � . ' 481 Buck Island Road ' � � ' West Yarmouth,MA 02673 , May 23,2003 Mr. David Flaherty Town of Yarmouth,Board of Health Town Hall 1146 Rte. 28 South Yarmouth,MA 02664 Re: Buck Island Village Condominium 2003 Season Dear Mr. Flaherty: This letter is in response to your request for the following information: 1) Jim Houle, our PPO is CPR certified. 2) Florence Incerto, our onsite office manager, is First Aid certified. 3) The pool gate is kept locked at all times. Residents can gain access by using the key which we have assigned to them and which they may not duplicate at our request and which is imprinted on the keys. 4) Last season,2002,there were no accidents or incidents at the pool. 5) The number of guests per day is approximately 15. 6) Children under the age of 16 must be accompanied by an adult. � Dave Stephenson is our pool tech. 8) We have an updated first aid kit and new CPR mask which are readily accessible. 9) A telephone is accessibie to cor�tact"911" if necessary. 10)Pool chemicals are kept stored under lock and key. I hope this information complies with your request. Sincerely, Florence Incerto, BIV Office Manager T ' i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #03-041 FEE: $75.00 This is to certi�y tt�at Buck Island Villa�e Condominium Trust d/b/a Buck Island Village Condominium 418 Buck Island Road, West Yarmouth, MA j IS HEREBY GRANTED A PERMIT I To Operate a Pu6lic,Semi-Public Swimming or Wading Pool i At Buck Island Villa�e Condominium - OUTDOOR POQL � ! 418 Buck Island Road � West Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonweaith of Massachusetts,and ; expires December 31.2003 unless sooner suspended or revoked. � ; December 19 ,2002 BOARD OF HEALTH: ��. i��, (�aac *Restriction:Safety report must be submitted�nually with application. �. �f4�o�. ��.. �/iCG � Board of Health Hearing,05/07/01-Do not need CPR, ��. �+toarr�, �� First Aid and Water Safety certifications. �eZac��e�c�aut�` ,Zr� IF.ak .'12 .M ,MP , . Director of Hea1th THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #03-040 FEE: $75.00 This is to Certify that Buck Island Village Condominium Trust d/b/a Buck Island Village Condominium 418 Buck Island Road, West Yarmouth., MA IS HEREBY GRANTED A PERMIT To Operate�Pub6c, Semi-Public Swimming or Wading Pool At Buck Island Village Condominium - OUTDOOR POOL 418 Buck Island Road 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 19 .,2002 BOARD OF I-IEALTH: ��, i�el�'e�. (�xa� *Restriction:Safety report must be submitted annually with application. b�� . �la�, ��.. �/ite Board of Health Hearing,OSl07/O1-Do not need CPR, i�a��. �4ocair, �� First Aid and Water Safety certifications. ��e7trxo� � s �� ruc .Murp y, ,R. ., H Director of Health � ' '""� +��..._�t,,�,�,�. p (�� rr� (_ ,� ��y -; i� i i , a � WN OF YARMOUTH BOARD OF HEALTH ' � ''`' � �' PLICATION FOR LICENSE/PERMIT-2002 � ` � ' �, �g >� ��,a�. ' "' ` — `f e ,` * Please c-om let�form and�tt�ach al�l necess documents b December 31, 2001. Fail e�Is�ld�iCl��lt i P �'Y Y the return of your application packet. AME OF ESTABLISHMENT: i � V TEL. # � -'�'�; S: g! d �'S A�MO ( �• A�Rl4o�7jK /4� 0�73 MAILING ADDRESS: � !�'��C �'S'Y P� /�'/�4 ��ILY R� ORA IO E: Aw0 i wtN��r '�'�t�T A E 'S N �YS7�7'�.. R � j TEL. # .� �3 9"3l�0 LING D SS:' .., P� +� S'S'�O ASKP�: �'► OaGy POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as�equired by State law. Please list the designated � --- �ke�ificatien te t,�iis ft>r�. _---- - 1.(f��l 1 l� PRv�k�A�iO �G�'FbK�E►��' 2. �,�1 � AI��'��d�RE. �Af.+�iNG 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 fde at your place of business. 1. �t/ � ��I�/OdP ��ARG. 4JP�1�' 2. �i�� .Ato�A� �� Nv 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• _ PERSOIV I1�fi�HARGE. _ _- - _ _ _ __ _ - __ 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 a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at�your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 — — C� z-o INN $50 _CAMP $50 �-SWIMMING POOL$SOea�1�oZ-022 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 $I50 COMMON VICT. $50 WHOLESALE $75 � — — RETAIL SERVICE• ,� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# .. . � v. .. 'a _TOBACCO $20 ` • _QS,Q(f(�sc�'`� $75 _TOBACCO� �� `'` $20 _<50 sq.ft. �; ;,,k. �,$45= 4 `.,,,�,; ., �,;�».�2 ;§�(100 sq:ft. , . $200 _FROZEN DESSERT$35 NAME CHANGE: $i o AMOUNT DUE _ $ !�O.Oo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** li I i , ; .,-c a ��g * � � w � J ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yatmouth 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 Cdrnpensatioii"=Insurance.: °t'I�EYTATTACHED=�STATE WQRKER'S COMPENSATION INSURANCE AFFIDAVIT°�I�S'I`'BE ��i�IP�'�'i'FsD-•i�H SIGNED,E�R r =`�. �� ` � '� � � � � �` �� +�� , ,t,,�.;�,';'4; ,'� ,�� . , � . �� '�- � „�°-'' �� ,'`� C�R`I'; OF IA1�UR�NC�=A'I'�'TAC�IED :, . . . _ � ,� „ :•:: � , ',, . ....� . � a� .;x�,'; .#,_3_ e A. ��d �•< ,�`fr�+� ., WORKER��'�4MP. �F�ID,�AV��S�I�NED AATD�1T`FA�HED�' Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �/ YES t/ NO , � "`l`F�CE:Pe�r�fis�run�tlal�}�+�ro3��<Jantiary 1 to December 31. 'I'Ia I'�.Y4ITR,R�SP.'Ot1��i�Y,T_0►�,�E'�'IJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISF�NTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. .:. �,;�,�. .� . � ALL �NO�t�`I"�bNS�'7'� t�I�T� �UD ESTABLISHMENT, FN°�b�EL OR POOL`��i�.; pY�r�v�, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS __ POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. __ FR�ZENDE�SER'TS: - -- _ _ _— - _ . _ 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishrnent is prohibited. DATE: /�"" �'� d� SIGNATURE: PR1NT NAME& TITLE: �d�I� �f1��, /�/f+wA��G' 14Gl��t1l)"` . 09/11/O1 � ` y _ � The Commoawealth of MassQchusetts � � Department ojlndustrial.-lccidents � a 011lce oll�es�lOstfiis 600 Washington Streel ' ` Bosron,Mass. 02111 �'" ��y' V4'o�kers' Compensation (nsurance Affidavit �,m� �l�C/�.�SR�� %l f� �4ticlrv�r Lucation: �6� �� /i.a�� . , �.�t. �'''/�+Cko°�rr'd'c !�l�4 ��673 � �)s�y—3�00 � 1 am a homeowner pert�rming all work myself. —� � I am a sole proprizror _-,'. h��e no one ��orking in anv capacit}� ____��em�lo�r_pr � � � w�tbers' compensation fo�my employees workine on this jpb: m a n • n a m : :�•!�'f, �CyT�RL.:.�'��IG�C,� �'E�{f P/!'�C� _ — ddres : l�'� �Id�J6i � (,�d x y070 sit�.: �l��+/�/JC�'�IJ s � (�' 0��3 C�g� ahone q• 7��'��"' ��o�� insur�nce co. policy# VW�'�'��L��a�� I zm a sole proprietor. generai 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• citv�: phone t�• insurancc co. o�i �•# zomnanv name• _ _ _ _ _ - _ - _ _-- - -- _ _ --. - - address:_ �� nhoee li• insuran�tso. �j[�y� t Failure to secure coverage as requ�red under Seenoo 25A of MGL 1S2 n�lad to tbe i4paitios ot erioiv!ptadtla of a O�e op to 51.500.00 a�d/or one yean'imprisonment a�w•ell a�civil pendtles io tAe form of a STOP WORK ORDER aed a tise otS100.00 a day apinst ma I a■dena.d e�at a eopy of thh statement may be fonvarded to tht Oliice of Inveatiguions of tht DU for eoven;e veritiatio�. /do hrreby cenij}•u rhe poi /��al�' ojperjury that t6t injor►netion psovidtd abovt is tnte wtd eorrtet Signature � f ?��/ Print name �!1/C7i�/v �i�� l�i�i�6livG' e'4G'�tl'y' Phone�Y '��q 3l� ., olTicial use oNv do not+.rite in this�rea to be completed by ciry or town oflleial ciry or town: Y�M�IITR _ permifAieenu N nBuildiog Departmeet �Lieeasiog Board �theck if immediate respoose ie required 261 �Selectmen'�01Tiee �HeaitA Departmeot contacc persan: phoncM;_ �508� 398�2231 eat. nOther � CC� (� � M[� D MAY Z O ZODZ BUCK ISLAND VILLAGE CONDOMINIUMS HEALTH DEPT, 481 Buck Island Road West Yarmouth,MA 02673 May 20,2002 Town of Yarmouth Board of Health 1156—Suite 28 Soath Yarmouth,MA 02664 Dear Sir: In compliauce with your recent request, I am writing to confirm that as in the past we shall continue to conform with the Board of Health's recommendations pertaining to the operation of our Condomiaium's swimming pools. The minimum age requirement to use our pools is 18 years of age when not accompanied by an adul� Signs prohibiting swimmiwg alone for safety reasons are displayed. The pool is available for use daily from 9:OU AM until dusk. The pool area is ch�ined and padlocked every evening, asually b� 7:30 PM. Locks have been instalted on the entrance gate of#he pools and corresponding keys stamped "Do Not Duplicate"have 6een distributed, one key to eac6 of our residents. Thank you for your cooperation. Very truly yours, �� ,��'�. "' �_--�l�`"��,.� �Condon Chairman Y � BIV Board of Trustees t i � � " THE COMMONWEALTH OF MASSACHUSETTS ; TOWN OF YARMOUTH � BOARD OF HEALTH ; PERMIT NUMBER: #02-022 FEE: $50.00 '� 'rhis is to Certify that Buck Island Villa�e Condoxninium Trust d/b/a Buck Island Village 418 Buck Island Road West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a PubGc,Semi-Public Swimming or Wading Pool At Buck Island Village - OUTD40R POOL 418 Buck Island Road West Yarmouth.MA This pernut is granted in conformity 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: �i(canPed� i�e�ox, �avr.xa�c *Restriction:Safety report must be submitted annually with applicarion. �R�ti�c�, Cf�a�, �D,, �/u;e Board of Health Hearing OS/0'7/Ol-Do not need CPR, i�� b�`�, �e�t� First Aid and Water Safety certifications. �et�tie��CDeZi�tot�` ?fe� .Skak. ,�.72. Dire tor of H alth� � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERIVIIT NUMBER: #02-021 FEE: $50.00 This is to Certify that Buck Island Villa�e Condominium Trust d/b/a Buck Island Village 418 Buck Island Road,West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Buck Island Village - OUTDOOR POOL 418 Buck Island Road West Yarmouth,MA This permit is granted'm conformity with Article VI of the Sanit�y Code of The Commonwealtfi of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. �h is ,Zoo2 BoaRn oF�,�,�: �a�eea� xe�. C'�a� *Restriction:Safety report must be submitted annually with application. �Q�xta�. �l47�0�. ��., �/lee Board of Health Hearing,OS/07/Ol-Do not need CPR, ��j? �, � First Aid and Water Safety certifications. �it�tie��e7�oh` � S�. � Director of Health � � ' i � cFs63 ��'tCIC IS�Gti41C1�/I ( �C��• i �- ... C,h' �!�' C��G�C:�m i n i u vYl � .- ' ' TOWN OF YARN�U`�T�BpARD OF HEALTH (� � (� (� � M (� D i a APPLICATION"�p��,IC�NSE/PERMIT- 2000 � � '= N 0 U 3 0 1999 � * Please complete form and attach al1 necessary�c�ocuments by December 31, 1999. Fail e d �lt i � the return of your application packet. �A��`�• i ------------� E---------------------------�UGY�',4�p � --�-7�occri�cJ�V�---------------L#�-��--�6S'i.�_. l LOCATION ADDRES��IP/ f3U� s�� Lb a �t�t��.►r,�. /Y.4 0�673 L n�� X SS"'� .SH�E' .4 o.z6i� 1�j vc:�-TS A�s �'/AG-�- �acJpowiiaJiu�—'Z'—uST ' S'�7� �i9��w1f�/T �(/'ic�, S� 53�J'3�oa D • �c�. $o)C 5'S� AtSfFP�E. 0�16�f POOL CERTIFi_CATT_ON�.;, T ' The pool supervisor must be certified as a Pool Operator, as required by new State lav►�. Please list the desi�nated Pool Operator(s) and attach a copy of the certification to this form. L 2. _ Pool operators must list a minimum of two employees currently certiSed 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 ptace of business. � 1. 2. 3. 4. HEIlbiLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list y�ur employees trained in anti-choking procedures below and � attach copies of employee certifications to this form. The Health Department wilt not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. I,I . . ' RESTAURANT SEATING. TOTAL# NON-SMOKING SEATS. TOTAL-# - ----- — - -— ----------------------------------------------------------------------------*----------- ---------•---------------------------------------• QFFICE U�E O�� LODGING: LICENSE REQUIRED FEE P�RMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 _CABIN $50 INN S50 CAMP $50 LODGE $50 TRAII�ER PARK $50 MOTEL $50 �. SVVIlVIMING POOL (o� $SOea. �� WI�LPOOL $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 $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ I�'` "*"""PLEASE TtJRN OVER AND COMPLETE OTI�R SIDE OF FORM""'" S ' . �` _: . ADMINISTRATION • ITNDER CHAPTER 15�, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR :GOMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANeE. 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 TA7�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF Y4UR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TCl RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FE�(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIVVIEEN'TS ARE TQ CONTACT THE HEALTH DEPART'MENT FOR INSPECTTON 7-10 DAYS PRIOR TO OPENING FOR TF-� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONIlV�NCEIV�NT. RENOVATIONS Mt�Y REQUIRE A SITE PLAN. ADDITIONAL REGULATION5 POOLS POOL OPENING: ALL SVV'aVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND'THE WATER TESTED FOR - PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE C4UNT BY A STATE CERTIFIED LAB, _ PRiQR-�'-6-4FEIVIPdG, TER�,Y THE�tEA�'TEii. PC10L CLOSING:EVERY OUTDOOR IN GROUND SWINIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYOl�TE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQCTIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPAR.TMENT. �� N�..� S� FROZEN DE5SERTS MUST BE TESTED ON A MONTHI..Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN TF-� , SUSPENSIDN ORREVOCATION OF Yt�URFROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE _ - ----___ _ - - _ _ - _ _ _ ___ -- - __ __ BEEN MET. QUTSIDE CAFES: Oi1TSIDE CAFES(i,e., OtJ'TDOOR 5EATING 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 RETAII,OR FOOD SERVICE ESTABLISHIVIENT IS PROHIBITED. DATE: � � SIGNATURE: rR�rrr NaME& TITT.E: �v�zo,�/ ��c�,J ��G��G- ,,�G�� ,• 11/12/99 ; � ��. � . The Commonwealth ojMossuchusetts = Departmenl of Industrial,-1 ccidents � f � J 011lceo/%ves�los�liis � `� 600 Washington Street : '' ' �` Bosron,Mass. 02111 �,N �� W'orkers' Compensation Insurance Affidavit Annlicant informallon• p►easepR�t"T�,'� �..� - - _ n�mc� �V� �.�,v� �«G o��Zb�y��i`c��-�..� �/-, �on� �� v�--CS�-9o�b ��jq-n • . cS7 � �€�-r� �- o2-C7�3 �,'� �7��'—��'�3 � I am a homeo�ner pert�rming all w�ork myself. � � I am a sole proprieror�::� h��e no one ��orkin; in anv capaciri• �I am an emplo�er pro�idi�g w�orkers' co ensation for my empioyees workine on this job. m a n • n a : Dr�` �,y5._ j � - _. _�Da'�ff,E�� _- --- -----__ -- -- _ - - - �ddress: �� v��LSCI��/� /CD�f� cit�•: U✓E.S`7' l�,`�t Ov7t� � l�}- C3��•�� 1 77�' �S!� , nhone#• �i�r sur�nce co G/�'�' �i(�.�/Z9NG� � A_o�lSY� � �v/��`�� I am a sole proprietor. generai contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu«in� �.orker� �ompensation polices: s9moanv name• address �h" ohone H• insur�ncc co. �olic�•# comoanv name• address: �'� ohoee A!• insurance co. ��n,� � Failure to secure ceveraee as required under Secnoo 2SA of MGL 1S2 ea�lad to tbe iopaidoe o(crisi�ai pe�dties of a O�e op to 51,500.00 a�d/or one yean'imprisonment as w•ell as eivil penaltia io the form of a STOP WORK ORDER aed a tiet of 5100.00 t dar tpinst me. [a�dersn�d ma�a copy of thy statement mav be forwarded to the Ofiice of[nve�tig�Gon�of tbe DU for eovenge verifiutio�. /do hrreby cerr� der r p rn pe lties ojperjury thot t6r i�rfornration providtd above is trr�e and corrtct Signaturc 1�� Print name ��70� .�� 1��'�� .t3�/� Phone� .- olTicial use onl� do not Mrite in this area to be completed by tity o�towa o111eia1 eiry or town: Y�M�IIT� _ permitAleense M nBuildiog Departmeot �Lieeasiog Board Q cheek if immediate respoese is required 261 �Seieetmen'�Offee (508 3 QE1ea1tA Departmeat contact person: phone N:_ __� 98'��31 e7[t. nOther .. . � ,�,: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-18 FEE: $50.00 This is to Certify that Buck Island Village Condominium Trust d/b/a Buck Island Village Condo 418 Buck Island Road West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Villa�e Condo -OUTDOOR POOL 418 Buck Island Road West Yarmouth. MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. December 7 , 1999 BOARD OF HEALTH: �d�1L, 3et�, ��a.� �a.t� Sallluau. �?2.. ?/tee �raar.xa�c ,��ert� �, �k C'a��le.Sa�lek�-�o�ea d' oug�6ltu . Director of He�alth � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-17 FEE: $50.00 This is to certify that Buck Island Village Condominium Trust d/b/a Buck Tsland Village Condo 418 Buck Island Road. West Yarmouth. MA IS HEREBY GRANTED A PERNIIT To Operate a Public,Semi-Public Swimming or Wading Pool At Buck Island Village Condo -OUTDOOR POOL 418 Buck Island Road West Yarmouth.MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. December 7 , 199� BOARD OF HEALTH: �d'11t �et�"ea. ��a.s �Oawc E Sulltva.�. ,�.1Z.. �/lee ��a.t �a�it� �io�c. elatk C�a�u�Sa��-�ia 0' Director of He�altyl�i � .� , 3t.cc��sic�r�d V�11cu�e(.c�-,r.1� _� � � = `- n ', � ' � << �� +r �� TOWN OF YARMOUTH BOARD OF HEALTH� '`S `� � , �.' ` �� ` � APPLICATION FOR LICENSE/PERMI - 1999; MAY 2 4 99Q9 ! � � � g�; . ! ; t �.� � � � M: �, ��, r . * Please complete form and attach all necessary docu�n�' c �1 998.�F,��uC�-�.o�dc�sQ:�ui�.�esult in � �'3 �. � . ,� " the return of your application packet. _\, �� ,o ---------------------------------------------- -- ------ ---- ---�="`- �D--------------------- -- TAB I - � - -- /�- -- --��I�1%�W L # ��S/3 A I D S: d D �� ,o . ljo oEE t► a a6 T N �'.stA�v.D ' aJ�o�rJ,cliuw+ /�v-rf' ER' �"r d�. L. # 3 —3/�0 .o. SS sHAtE � a�6�F POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designa�,ed Pool Operator(s) and attach a copy of the certification to tlns form. 1. ��'s �ovL'� 2. Pool operators must list a mi�,timum of two emp loyees currently certified in basic water safety, standard First Aid and Commumty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus 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. f 1/-�i� S 6CT�U��. 2. /�� 27b 3. 4. , HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department witl not use past years' records. You must provide new copies and maintain a file at your place of 6usiness. l. 2. �� 3. 4. RESTAURANT SEATING: TOTAL# � NON-SMOKING SEATS: TOTAL# ,t/ -- ---- -- --- -- ----- ----------------------- ----- -------�---------------- ------------------- -------___w______- � --- - - _ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN S50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $SO - MOTEL $50 �SWINIlVIING POOL $SOea. q� WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NUN-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII.SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# <50 sc�.ft. $45 TOBACCO $20 ^<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 , AMOUNT DUE _ $ ��-- "'""""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 STA7'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR — � CERT. OF INSURANCE ATTACHELr �----�� 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 APP RIATELY IF PAID: YES NO NOTICE: PERNIITS RU�t ANNI��I,�,Y FRaM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 3 i, 1998. SEASONAL ESTA,BLIS�-IlViENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVV:IaVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY Ti�HEALTH DEPARTMENT,AND TI-�WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEI�iING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERIl*TG POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING TF-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO 'THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT 'TI-� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TE5T RESULTS MU5T BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN THE SUSPEN5ION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�AB�VE TERMS ---_ _- ---- -- ------ __ ---- __ _ _ HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR ' APPROVAL FROM TI�BOARD OF HEALTH. 4�JTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLISf�VV1EENT IS PROHIBITED. DATE: �{, '� SIGNATURE� PRINT NAME& TITLE:BG/Lid�f�� , �`l��"��''��7 l" . : ' ; � , �� The Commonwealth of Massachusetts � W Department ojlndustrial,-�ccidents W o Olf/ce ol/eres�l�s�is � 600 Washington Street ' „•` Boston, Mass. 02111 � ��` Workers' Compensation Insurance Affidavit ARnlicant information: P'►e9sePRiNTT�d."i.T� nam�: �lJC��/�SC4•vb V I(!/3Cc�. �o�U�Oue��tlitJw- y�i .� �' �� vcc�f�sc..�a �� ic. �. ��2kt�7N� �' a�5t��,77f�r'-6S'/3 phone� � I am a homeowner pertorming all work myself. � f am a sole proprieror�r� ha�e no one��orking in am�capaciry am an employer pro�idin� w�orkers compensation for my emptoyees working on this job. _ � —_ - - _�� , — -_ . _ _ #-�. _ comoam� name: (�J��L+�'b ��ri� �OR'f/N/v�1 address: Td� �U«�L,s� �P ciri•• �• / /9"�K/O�� { �A- ohonei�•\ �� 770 �'�0�13 -- � insur�nce coC��g' ��'v�ES �.4�Cy� G-��3�f�O�9 � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below� ��ho ha�e the follu��in� ��orker_� �ompensation polices: companv name• address: citv: nhone#�� insurancc co. policy# s4m a�ny name: __ - ---- . _ _- --------- -___ -- --- _ _ _ -___ --- a�dress: __------- eitv: nhoee#• ie�yrance co. A�y{� Failure to seeure coverage as required under Sectioo 25A of MGL 1S2 na Iqd to tbe i-poritioa of trisl�al pesdtles of a d�e op to 51,500.00 a�d/or one yean'imprisonment as w•ell as eivil peaaldes io the fo�m o(a STOP WORK OItDER aod a liae of 5100.00�day qaiost ma i a�dersta�d tiat a copy of thy statement , fonvarded to the OfTice of Invatigatiom of the DU for eovenge verilfatiw. I do hrreby ee i r ih pu'n p tlies ojperjury thar�ht injorneation providtd abovt is t�ue and eo Signaturc � �l��p Print name /'�1�� .A'�� G''r�G'�"J Cb'�'7 one#� /�3 9 3�'`�� .- ofTicial use only do not N rite in this area to be completed by ciry or town olffeial ciry or town: yA�DIIT� _ permitAieeau N nBuildiog Department pLiceasiog Board Q checic if immediate response is required 261 �Seleetmen'�Ofliee �HealtA Department contact person: phone le:_ �508} 398t?231 egt. nOther �,e„sed;;os v1A� " THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-97 FEE: $50.00 This is to Certify that Buck Island Village Condominium Trust dlb/a Buck Island Villa�e Condo 418 Buck Island Road, West Yarmouth}MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Buck Island Village Condo - OUTDOOR POOL 418 Buck Island Road West Yarmouth, MA This pemut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31. 1999 unless sooner suspended or revoked. May 28 , 1999 BOARD OF HEALTH: �d�11, �ctYea, ��a�c ��'. Sufltaa�c. �72.. `I/iee J(�avr.na�s �Ott? �roarwc, (�far� Cfa��Uc Se��-s�oo�re¢ 0' Director of Ha lth�� THE C�MMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NUMBER: 99-98 FEE: $50.00 This is to Certify that Buck Island Villa�e Condominium Trust dlb/a Buck Island Villa�e Condo 418 Buck Island Road, West Yannouth, lVLA IS HEREBY GRANTED A PERMIT To Operate a Pu61ic, Semi-Public Swimming or Wading Pool At Buck Island Villa�e Condo - OLJTDOOR POOL 418 Buck Island Road West Yarmouth, MA This pernut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31. 1999 unless sooner suspended or revoked. Mav 28 , 1999 BOARD OF HEALTH: �d�1Z. �eA'ea, ��ct� � �� Su�tua.t. �7Z.. `I/lee C�a� � ,�art� �racor�c, �k Cja(vrialle Sak�(a�gc-�oa�cQ �Jlieka�0:� k� Director of H�1t�Yi