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� � TOWN OF YARMOUTH BOA�,�.OF��EAI�TI�-; -�,
� � APPLICATION FOR LICENSE E�I= -2Q14 ' ;�:� �� ��i�
.... � * :��'''�9� ''
Please complete form and attach all nece�,sary c��e�t-�by De' m .
Failure to do so will result in the return of your application .
ESTABLISHMENT NAME: GA PC ��'J1� �F}m � Ly �E�Cr�-f- TAX ID: `�}`7�-�3�S�t3
LOCATION ADDRESS: �i z /y��y;y� ��f: l,r�. U►�-,ernct_otG, /t�R a�73 TEL.#:.�p�r-'7"7r-�1 oi
MAILING ADDRESS: Pc, l3aX � �r w� �i q�r�tic��, 11��"W.r v L�-� �
E-MAIL ADDRESS: �I c�rc.`� . rn r4 oEs��m Fl � �m,4 t ( � c-v�-s
OWNER NAME: JQS r-� �l' I71�4�,2w n�`4
CORPORATIONNAME (IF APPLICABLE): ���DB�� /'y��� �'�C
MANAGER'S NAME: sJ���� f-I i1'1 A k e_�rv�.� TEL.#: �'1 S.f-3 7_5-S5K7 v
MAILING ADDRESS: PC� l�n�c �s-/ � ��r�vnv�:Y�. YY� w� : ���73
��.:
POOL CERTIFICATIONS: � � �� � ����� ` �� ���
The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool
Operator(s) and attach a copy of the certification to this form.
i. I�.�L�l��1.�ar, - ����� S��l��s� 2. �
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list
the employees below and attach copies of their certifications to this form. The Health Department will not use past
years' records. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food Protection
Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification, as
defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of
certification to this application. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your establishment.
1. 2.
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 certificatians 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.
RESTAUR.ANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
B&B $55 CABIN $55 �MOTEL $55 —037
—INN $55 CAMP $55 2 SWIMMINGPOOL $80ea. 64-063 06�}
LODGE $55 TRAILERPARK $105 �WHIRLPOOL $80ea.�
FOO�SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80
— —RESID.KITCHEN $80
RETAIL SERVICE:
LICEN�SE ft QUIRED $50 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
>25,000 sq.ft. $225 VENDING-FOOD $25
=<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
� AMOUNT DUE _ $ ��t�: L�
NAME CHANGE: $15 �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FQRM**'�** /'\�
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or reriewal 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� 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 use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an 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 shall
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.
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. Contact the Health Department to schedule the inspection three (3) days
prior to opening.PLEASE NOTE:People are NOT allowed to srt in 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, and submitted to the Health Department three (3) days 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
SEASONAL FOOD SERVICE OPENING:
Aii food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening.
�ATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department, or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable
Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 13, 2013.
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 REQ IRE A SITE P AN.
DATE: ���j3 SIGNATURE: �
PRLNT NAME&TITLE: d�\_ (V� ;,,�C ,,,,,,, � (� ������ M ��,�s ,�
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Rev. 10/08/13 1
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
� ` 1 Congress Street, Suite 100
. Boston,MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Le�ibly
Business/Organization Name: jc�n����. �'YIG% 2n�- DB,9 �����si2_2n Fu1rt��� �A��
Address: 5i� {'yy�-,� Sf
City/State/Zip: �,(o, d Phone#: ���-3�7�- -��
Are ou an employer? Check the appropriate boz: Business Type(required):
1.� I am a employer with�►r�_employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office andlor Sa1es(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 1 l.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No vvorkers' comp. insurance req.] 12.� Other ��L ��e,��
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �Cl��d �h s v2�n �� ��C� �,(��cL�,� u 7T�'�Gl t�,�.�.2,� flY�� a.�d�`-�
Insurer's Address: `�
City/State/Zip: _ I.V i:�T i/`�-�y�j v�. !�'14- - G�z(�,�3
Policy#or Self-ins.Lic. # j�1�� �f �7�l6 Expiration Date: /U �► I �5�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert' , under th pai andpenalties ofperjury that the information provided above is true and correct.
Si ature: Date: %�- ���-�'
Phone#: -3 75-�� 2-
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: ����1 Permit/License#
umg Aut circle one):
1.Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
Contact Person: Phone#: bDS 3�1�-223 t x I Zy J
www.mass.gov/dia
s T
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, '
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)ar Limited Liability Partnerships(LLP)with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the.affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fa�c number:
Th� Comrnon�ealth of Mas�achusetts
Degartment ca�Industrial Accidents
Office af In�estiga�ic�ns
1 Con�res� �tr�et, Suite 1 QO
Bc��to�n, M.A Q�114-�Q17
Te�. � f 17-727-4�QQ �xt 4Q� or 1-87'�-�IA��AF�
Fax## 6174727-'�"�49
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #14-037 FEE: $55.00
This is to Certify that Sandbar Mana „�ement Inc. d/b/a Ca�e Cod Family Resort
512 Route 28 West Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,
32B,32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed
as adopted by the Board of Health,and expires December 31,2014 unless sooner suspended or revoked.
JanuarX 17,2014 BOARD OF HEALTH: J[zru�a l�p[l�.rteau�t, �iavlrliait
.���vcd J3v�s��.M..1�., `�Jice C'Piacvc�ncr�t
*Motel:71 Units;1 Manager's Unit.(8 Units Closed:Units 75-82)
Back Cottages: 5 Units—Housing Rentals �J.
C'Pcavc�eo J
Bruce G. Murphy, P , .S., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #14-063 FEE: $80.00
This is to Certify that Sandbar Mana�ement Inc. d/b/a Cape Cod Familv Resort
512 Route 28. West Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Cape Cod Familv Resort - INDOOR POOL
512 Route 28
West Yarmouth MA
This permit is ganted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2014 unless sooner suspended or revoked.
January 17,2014 BOARD OF HEALTH: J Ac�tc�,AG 1`�A�ic�.rteau�t, �.�iawcrttart
��avcd J3c���.lY�.1�., `Uice C'Piai,cxnacrz
�J�
Bruce G. Murp y,MP ,R. ., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT NiJMBER: #14-027 FEE: $80.00
This is to Certify that Sandbar Mana�ement Inc. d/b/a Ca�e Cod Familv Resort
512 Route 28, West Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE BUSINESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued in conformity with the authoritygranted to the Board of Health,by Chapter 140,Sections 51,of
the General Laws, and amendments thereto, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the
carrying on of the occupation so licensed as adopted by the Boazd of Health, and expires December 31,2014 unless
soonerrevoked.
Januarv 17,2014 BOARD OF HEALTH: J 1�C��tel�t �uClivL�t,Cxtt
:���'��J3c��.1�.1�., `Ur.ce
�J•
Bruce G. Murphy, MP , . ., CHO
Directar of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #14-064 FEE: $80.00
This is to Certify that Sandbar Management Inc. d/b/a Ca�e Cod Familv Resort
512 Route 28. West Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Cape Cod Familv Resort -OUTDOOR POOL
512 Route 28 �
West Yarmouth, MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31,2014 unless sooner suspended or revoked.
January 17,2014 BOARD OF HEALTH: J p�ftl�,Cr 1�CY1�'xtel7CU�� ��t.lrft
�'��J3o���.lYL.1�., `Uice C'Purvcrrtart
J.
J.
Bruce G. Murph , MP , R. ., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
, TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #14-037 ' FEE: $55.00
This is to Certify that Sandbar Manag�ement Inc. d/b/a Ca�e Cod Family Resort
512 Route 28, West Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140, Sections 32A,
32B,32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed
as adopted by the Board of Health,and expires December 31,2014 unless sooner suspended or revoked.
Januarv 17.2014 BOARD OF HEALTH: J afu�,cr 1`�a[�teau�t �iab[frtaft
;��fi�F.�vcd 53c��.1Y�.1�., `l1 i.ce C.Paai�crrta�z
*Motel:71 Units;1 Manager's Unit.(8 Units Closed:Units'IS-82) ���7�����'Qi3
Back Cottages: 5 Units—Housing Rentals .I.
C'Pcax�e� J
r
Bruce G. Murphy, P , .S., CHO
� Director of Health
<;
�
r
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLTMBER: #14-063 FEE: $80.00
This is to Certify that _ Sandbar Management Inc. dlb/a Ca�e Cod Family Resort
512 Route 28, West Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Cape Cod Familv Resort -INDOOR POOL
512 Route 28
West Yarmouth, MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2014 unless sooner suspended or revoked.
_January 17.2014 BOARD OF HEALTH: J q�iZl�,Cr 1�C�tep�t (,�tp.%�[rftqfiZ
�cd J3o�s��r�, _./l�.l�., 21ice(.�iavu�zaxt
�i«
Eu�cJaz J.
Bruce G. Murp y,MP ,R. ., CHO
Director of Health
�_
�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
,
BOARD OF HEALTH -
PERMIT NUMBER: #14-027 FEE: $80.00
This is to Certify that Sandbar Management Inc. d/b/a Ca�e Cod Familv Resort
512 Route 28 West Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE 1N THE BUSINESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued in conformity with the authority granted to the Board of Heaith,by Chapter 140,Sections 51,of
the General Laws, and amendments thereto, and is sub�ect to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto, and upon such terms and conditions, and to the rules and regulations in regard to the
carrying on of the occupation so licensed as adopted by the Board of Health, and expires December 31,2014 unless
sooner revoked.
Januarv 17.2014 BOARD OF HEALTH: J 1�A:G�f2e�C�� �.�lai�pnl�'t
�����J3c��.lvl.l�., `Uice
�J.
Bruce G. Murphy,MP , . ., CHO
Directar of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #14-064 FEE: $80.00
This is to Certify that Sandbar Management Inc. d/b/a Cat�e Cod Family Resort
512 Route 28. West I'armouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Cape Cod Family Resort -OUTDOOR POOL
512 Route 28
West Yarmouth MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31,2014 unless sooner suspended or revoked.
Januarv 17,2014 BOARD OF HEALTH: J afu�.a l�ai�!rtep.uQt, �iabtrrl�c�clt
J.�'�J3a���.1Y�.1�., `Uice C'Piavurcac�z
J.
J.
Bruce G.Murph�, MP ,R. ., CHO
Director of Health