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Home My WebLink AboutApplications, WC and Licenses� i �'�"'`4 CNrt'E t'0�r.��` � � � ��'Yak � � TOWN OF YARMOUTH BOARD OF HEALTH � � � � ' „ �, , � � � "��;�� APPLICAITON FOR LICENSE/PERMIT-2�0 � �� '�� - ^ ,J ` '�._ o�� . c . ,�" �� ` �4 ",r E��i,f - *Please complete form and attach a11 necessary dQc�me�t� ccefnber , 2007. ' � ,,..�.••° Failure to do so will result in the return of u� ��tion ack HEALTH U PT j ; YQ.�:�.'�P P E . ;. ,. �._, � NAME OF ESTABLISHMENT:' T h e C2 p e Pb r a t' fild'�C L TEL. # So&- 778-/5'0 G LOCATION ADDRESS: `�76 M�1 r�l S t-Qt P,t MAILING ADDRESS: ' OWNgR NAM�: p oc�sr e 1�1Ofi�1 (Ra uA TAX ID(FEIN or SSN)- CORPORATION NAME (IF APPLICABLE): (�a�N r hI� ,. MANAGER'S NAME: �a �� SW„R�'2- TEL. #SO�-3�_�l�l, MAILING ADDRESS• � s 7. P�ca s��`t p�NGs t1� rc+2. t� C� l�Lo d163Z . ,-_,_ POOL CERTIFICATIQNS: The pool supervisor must 6e certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and att h a opy of the certification to this form. 1. S�,J /� 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 eertifications to this form. The I�ealth Dep�artment will not use past yea�s' recort�s. Yo� t��st provide new copies and maintain file at your place of business. �. - � S 1/ _ 2. �� S��,1z, 3- 4. . ��l�l�� . 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 attaeh copies of certification to this applieation. 3'he�Iealth Department�vitl not nse pa�t years'rec��ds. You must provide new copies and maintain a fiie at your establishment. i. �� 4.��-T r��s.�-/ r. PERS9I�1 IN�'�A.I��`iE: Each food establishment st have at least one Person In Charge (PIC) on site during hour of operation. 1. � �� . � U�' �ts�/ HEIMLICH CERTIFICATIONS: All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of�mployee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �. ��-^� �s��J G% ��I�� 2, 3. 4. RESTAURANT SEATING: TOTAL � _, ^ � OFFICE USE ONLY LqDGING: LICENSE REQUIRED FEE PER'�IIT# LICENSE REQLTiRED FEE P£R'4IIT* LICENSE REQL'IRED FEE PER'1�IIT� ,B&B S50 CABIN SSO �MOTEL S50 g�OZy _INN $50 _CA:�IP S50 3 S��41'_�LYIIi�TG POOL S75ee. �R-6 S�� _LODGE $SO _TRAILERPARK 5100 �t�'HIRLPOOL S75ea. �p$-0� FOOD SERVICE: I __ _ -- ---- —---- -�_ _ _._ - -_ _ _ _ __� LICENSE REQUIIt£D FEE PERMIT� LICEl*TSE REQL�IRED FEE P£It�'+v11T� LICENSE REQUIItED FEE PER'�IIT= �0-100 SEATS S75 g'6�� ^:CONTINENTAL S30 _NON-PROFIT S2� �' >100 SEATS S1�0 �CO�ION VIC. S50 OS'��{S _V4�IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'� LICENSE REQUIRED FEE PER'�IIT� LICENSE REQLTIRED FEE PER'�III'� < 0 s . . >� _ 5 q ft S45 _ _5.000 sq.ft. S200 �ENDIlVG-FOOD S20 45,000 .ft. �a75 _FROZEN DESSERT S35 — �i TOBACCO SSO NAME CHANGE: sio AMOUNT DUE _ $__47S ,c�o *****PLEASE TL'R\O�'ER A\D CO�iPLETE OTHER SIDE OF FOR�Z***** �.-� --` - �. =;�+....� � , � ; ADMIlVISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ± of any license or germit to operate a business if a person or company does not have a Certificate of Worker's ; •Compensation Insurance. THE ATTACHED 3TA�E WDRKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR • z � � j . CERT. OF 1NSURANCE ATTACH�D�s. . � . i OR , ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts: PLEASE CHECK ; APPR�PRIATELY IF PAID: / YES ✓ NO 1 ; MOTEL5 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 ofresidence elsewh�e. 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)manth period. Use of a guest unit as a residence or � dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy 1 Excise, as defned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ; * NOTE: En�tosed Motel Census must be completed and returned with t�is app�ication. , ; � � � � rooLs � � � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to openulg. Contact the Health Department to schedule the inspection five(S�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 openin�, 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 P4LICY: , 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 obtasned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te 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. i OUTSIDE CAFES: ! Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval from the Board ofHealth. � OUTDOOR COOKING:' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NUTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETCJRN THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER�2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. REVOVATIONS MAY REQ RE A SITE PLAN. / '' DATE: � �� SIGNATURE: PRINT NAME&TITLE: �l�v�-��5�� .�� i� 10�0 n� \ — __ .�-- I —_ _ � _ � _ + ; ; � 1 I 1 Title: Schedule of Locations Remarks: Cape Point Hotel 476 Main St. W. Yarmouth, MA 02673 Cape Town & Country Motor Lodge 452 Main St. ( W. Yarmouth, MA 0267� I Mariner Motor Lodge Inc j 573 Main Street, Route 28 W Yarmouth, MA 02673 This endorsement is attached to the policy indicated below and is effective on ihe date stated herein,at 12:01 A.M.,standard Gme at the address of the insured as described in the intormatlon page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WMZ 8005077012007 0500 04/Ol/2008 04/O1/2007 Issued to Additional Premium Retum Premium Dockside Hotel Group,Inc.Etal ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY ��-�s'��(/�� //// Countersigned `--^� Authorized Representative ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF 3�ARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-024 FEE: $50.00 This is to cemfy that Dockside Hotel Group/Point LLC d/b/a The Cape Point Motel 476 Route 28, West Yazmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authoriry granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws ofthe Commonwealth of Massachusetts relatiug thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by ihe Board of Health,and expires December 31,2008 unless sooner suspended or revoked. December ll_2007 BOARD OF HEALTH: .`�F¢�¢IL S�[l�� ✓�.,./V.� ��llYlt �a�A'X�¢d .�.��.¢�1�4�1G �lCe��f1YHt�tlt �s. `J3�caru��t, C.�rP� ''',; �� ✓`�-�- , Bruce G.Murphy,MPH,R.S.,CHO Director of Health � ° TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-062 FEE: $75.00 ' In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Secrion 5 of the General Laws,a permit is hereby granted to: Dockside Hotel Group/Point LLC, 476 Route 28, West Yarmouth, MA , Whose place of business is: The Cape Point Motel I Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH; `.�E�tt$�[7� ,c��J�Z�,,�,N_Q._,��C!Rtai�cntaQa�� SEATING: 40 � .7�..✓1X.�G«[�!�L� �I�ICC�.�l�csN�/!L!X/L 5�?.v�rt �.�t3�rvca,rt, C:C.e�cl� Qrut C�ceen�cuun, ✓2.,N. December 11.2007 Bruce G.Murphy,MPH,R.S.,CHO Director of Health ; � f THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLTMBER: #08-048 FEE: $50.00 This is to Certify that Dockside Hotel Gour�/Point LLC d/b/a The Ca�e Point Hotel 476 Route 28 West Yarmouth MA IS HEREBY GRANTED A COMIVION VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers_ This license is issued in conformity with the authonty granted to the hcensmg authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto af�'ixed their official signatures_ BOARD OF HEALTH: 3Ee�en SR�arI� J2.,.Ar., Clfawrnux� SEArn�tG: 40 ('f�awcPea .`�..�'�e.�l1�G, `U[Ce C'fl�iXritQ.r� �to��xt 3.�3�v�n, ('.P�r/� Qrui 'C�cee�r�acru►i., J2.,IV. December 11.2007 Bruce G. Murphy,MPH,R.S.,CHO Director of Health , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-044 FEE: $75.00 This is to Certify that Dockside Hotel Group/Point LLC d/b/a The Cape Point Hotel 476 Route 28,West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Pubtic Swimming or Wading Pool At The Cave Point Hotel - INDOOR POOL " 476 Route 28 West Yarmouth MA This pennit 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. December 1 l.2007 BOARD OF HEALTH: .`�E¢�tt S/�R/t, �,./�/, (,�RlxlltlYlt ��O .��. �E�l�4�G �tGC��ptQlt 5�eact�.�(3acacuri, C� Qrt�C�ceerr�aurn, J`�..lV- Bruce .Murphy,MPH,R. ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-045 FEE: $75.00 This is to certify thac __ Dockside Hotel Group/Point LLC d/b/a The Ca�e Point Hotel 476 Route 28 West Yarmouth, MA ' IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool " At The Cane Point Hotel - OUTDOOR POOL 476 Route 28 West Yarmouth MA This permit is granted in eonformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires_December 31.2008 unless sooner suspended or revoked December 11.2007 so�n oF��,�: .�Ee�er�Sf�acf�, ✓t..lV., �Rurvunuuc �f�ar�cP.ee .��e�i1lrex `Uice C'�awrnca►�a 5�8Qac�s.�l��urrun, C!�ex� Qrui (�reerc8accrn, JZ..IV. � Bruce .Murp y,NIPH,R. ., Director of Health � ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-020 FEE: $75.00 ' This is to Cenify that Dockside Hotel Grouv/Point LLC dlb/a The Cape Point Hotel 476 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GNING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board ofHealth,by Chapter 140,Sections 51,ofthe General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and condirions,and to the rules and regulations in regard to the carryiug on of the occuparion so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner revoked. ve��,t�i i.Zoo� Boaxv oF��.�: .�'f.eeen Sll�a►�, ✓�t.�V.,C'f�ar�ixncarz C'�ea .�.3'�i�!'eifl�x `Uice CJ�awrnzaca 5�c+,8ext 3-�l�Corua, C'�ex� Q.�uz C�Cee��atcttt, ✓`�..lV. Bruce G.Murphy,MPH,R.S.,CHO Director of Health I � � THE COMMONWEALTH pF MASSACHUSETTS TOWN OF YARMpUTH BOARD OF HEALTH PERMIT NUMBER: #08-046 FEE: $75.00 This is to Certify that Dockside Hotel Groun/Point LLC d/b/a The Cape Point Hotel 476 Ro t 28 W s Yarm u MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point Hotel - WADING POOL 476 Route 28 West Yarmouth MA This permit isgranted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. December 11.2007 BOARD OF HEALTT-I: .`��¢�¢/t S�� ,�/v,� (�IXIfLQIt �� •��. .�E��'G� ��[CC��IXI�YtItlxlt J►2c�8�e�uE 3.J��ccuutt, C:Ce�r� (.�iu�C�,rr�a�un, J`�..N. Bruce .Murp y,MpH,R. Director of Health � � f i y � � .r - /J o-- R ` CC � � M � D � f:a �so TOWN OF YARMOUTH BOARD OF HEALT�,, � ;;� APPLICATION FOR LICENSE/PERMIT- �Ot�7'�; � ; D E C 1 5 2006 * Please complete form and attach all necessary documer�,ts�.�y `emb r Failure to do so will result in the return of your app�cation pac �� EPT. NAME OF ESTABLISHMENT: TI�2 (��„o �Jn r /UT TEL. # SO -�7$ ��O LOCATION ADDRESS: y? M�9�n! �S'i��,�j_�• �,r�a t}�-�� /�ry�Q Q�,�,� MAII.ING ADDRESS: OWNER NAME: K.s�d2. �.� 6 T IN r � ' CORPORATION NAME (IF APPLICABLE): �h,Ci MANAGER'S NANN�: �tW Q j��j TEL. # se� �� a S�� MAILING ADDRESS: rn��i¢,,..�,,.. , .y.� ��y_� ,�y�r: i � ' POOL CERTIFICATIONS: The pool supervisor must be ceMified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. C�v�-�i S /`1/��`i�o;.J 2. , � Pool operators must list a minimum of twa 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. T6e Health Department will not use past years' records. You must provide new � copie and m�intain a file at your place of business. J 1. rR v rn�..,� 2. 7�� 3• " i' � � �r-� a>x' 4.��>--� � �o�J a � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food j Protection Manager, as defined in the State Sanitary Code for Faod Service Establishments, 105 CMR 590.000. � Please attach copies of certification to this application. The Heatth Department will not use past years' records. � You must provide new copies and maintain a file at your est�blishmen� j1. ��.�� ,T�s„��,� 2. l ' � PERSON IN CHARGE: ; Each food establishm t must have at least one Person In Charge(PIC) on site during hours of operation. , �_ ! ! " 1._�a�Q�� 5�� 2._ �� Z ��--� � � ,---- � , HEIMLICH CERT'IFICATIONS: 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-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. :/xt,�,,�1� i�s�"� 2. ; 3• � 4. ; � RESTAURANT SEATING: TOTAL# � � Lo�cnvG: OFFICE USE ONLY J � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRBD FEE PERMIT# LICENSE REQUIltED FEE PERMIT# _B&B �50 _CABIN $50 I MOTEL $50 —0 33 _INN $50 _CAMP $50 �SWIMIvIII1G POOL$75ea. �?—� #Q7-OS'7 � _LODGE $50 _TRAII,ERPARK $100 I WHIItI,POOL S75ea. 7-ay-N � FOQD SERVICE._ _ _ _ _. i � LICENSE REQUII2ED FEE PERMTC# LICENSE REQUlRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# �0-100 SEATS $75 - 6 �/(o _Cp��qi, $3Q NON-PROFIT $25 _>I00 SEATS $150 �COMMON VIC. $50 �}Q 7��'" _y�OLESALE $75 RETAIL SERVICE: ____RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# �<50 sq.ft. �45 _>25,000 sq.ft. $200 _VENDITiG-FOOD $20 _45,000 sq.R $75 _FROZENDESSERT $35 _TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE _ $ y 75,�Q ""°•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••"• _ � - ` � � , �_, � - ```��\ � -.�: i p �' !+ V ADMINISTRATION ` � i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewai 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 COMPENSATIQN INSURANCE AFFIDAVIT MUS�BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED , OR WORKER'S COMP. AFFIDAVIT SI�NED AND ATTACHED ' Town of Yarmouth taaces and liens must be paid prior to renewal'or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO _ - - _ ____ _ _ _ _ _ _ _ MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place af 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 i POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ect� , by the Health DepaRment prior to opening. Contact the Health Degartment ta schedule the inspection five(5�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 thereafter. POOL CLOSING: Every outdoor in ground swimming pool fnust be drained or covered within seven(7)days of � closin __ _ _ _ _- - � -- --— __ _ _ . - - -- ___ �-- � FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the 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. OUTD04R COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � e ; --- --- -- _ ___ _ -- _--- -_ _-- —- _., _ _ __ E NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIRILITY TO RETLTRN � TF�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ' ALL RENOVATIONS TO ANY �OOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPRO�ED BY THE BOARD OF HEALTH PRIOR � TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. t , ; DATE: C/� SIGNATLTRE: PRINT NAME&TITLE: '-U ion�ro6 �" ' � ' � ^-.. _�_ � _ i � � � • ^ WORKERS COMPENSATION AND EMPLOYERS UABILITY INSURANCE POLICY �' ` INFORMATION PAGE • Associated Industries of Massachusetts Mutual Insurance Company I • Burlington, Massachusetts NCCI NO 26158 I (800)876-2765 j POLICY NO. WMZ 8005077012006 PRIOR NO. WMZ 8005077012005 ITEM 1. The Insured po��Hotel Group,Inc.Etai Mailing Address: 476 Main St. W Yarmouth MA 02673 Route 28 (No. SVcet � Town a Ciry County � �� Shate Zip Code ❑ Individual ❑ Partnership � Corporation ❑ Other FEIN - Other work taces not shown above: P 2. The policy period is from�� to��2�� 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to yvork in each state listed in item 3.A. The limits of our Iiability under Part Two are: Bodily Injury by Acadent$ 50 0,fl00 each accident BodilylnjurybyDisease $ 500,000 policylimit BodilylnjurybyDisease $ 500,000 eachemployee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 O6A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Gassifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates ��e Es6mated PerS700 Es6mated � Total Annual of Mnual � �Remuneration Remuneratan Premium � INTRA 077516 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 231.00 Total Estimated Annual Premium $ 27,953.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 7,347.00 ❑ Annually ❑ Semi Annually ❑ Quarterly � Monthfy MA AssessmeM Chg. $32,033.28 x 4.4000% $1,409.00 This policy,including all endorsements,is hereby countersigned by �� 02/06/2006 Hutharized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY ' STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP DGP-Miles Insurance Agency MA 9052 804 0500 Inc WC 00 00 01 A(11-88} P.O.Box 1018 Includes copyrighted material of the Na6onal Counc7 on Compensation h�surarke, Taunton,MA 02780 used with its permission. - i ; Title: Schedule of Locations Remarks: Cape Point Hotel 476 Main St. W. Yarmouth, MA 02673 Cape Town & Country Motor Lodge 452 Main St. W. Yarmouth, MA 02673 Mariner Motor Lodge Inc 573 Main Street, Route 28 W Yarmouth, MA 02673 This endorsement is attached lo the pdicy indipted bebw and is etfecFive an tlie date slated herein,at 12:01 AM.,standard dme at the address of Me insirced as descn'bed in the infamafan page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorseme�No. WMZ 8005077012006 0500 04/Ol/2007 04/Ol/2006 Issued to Additionai Premium Retum Premium Dockside Hotel Grou ,Inc.Etal ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY CauMersigned ` `—�—Cxsr� Authwized Representative THE COMMONV�iEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-033 FEE: $SO.OQ This is to Cerki'y rhat Dockside FIotel Group/Point LLC d/b/a The Cape Point 47b Route 28, West Yarmouth,MA HAS BEEN�RANTED A LICENSE TO QPERATE MOTELS This License is issued in conformity with the authority granted to.the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subj�t to the pmvisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and e�ires December 31,2007 unless sooner suspended or revoked. March 28,2007 BoaxD oF��,�: B .��5. on�o�,�I.�., • ��s�, rv, v�e��-� Rad�t�1. B� Gl� p��1�� I��.�, R.N. Bruce G. Murphy,MPH, .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT 1VUMBER: #07-116 FEE: $75.00 In accordance with regulations promulgated under authoriry of Chapter 94,S�tion 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Dockside Hotel GrouplPoint LLC, 476 Route 28, West Yarmouth, MA Whose place of business is: The Cape Point Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 3 l, 2007 BOARD oF HEALTH: G��&�pis/�`h�. f�1'Io�n/��/�1./`�?/S.,�� . SEATING: 4O IL c7ilG�l� j`�� lJll7e CiKfi�I/L/flG�Jt R�t�B�, G'l� � P��1��,#t �lsui l�'�rr�ary R.N. March 28,2007 Bruce G.Murphy,MP , ..,CHO � Director of Health THE �OMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-075 FEE: $50.00 This is to Certify that Dockside Hotel Gour�/Point LLC d/b/a The Ca�e Point 476 Route 28, West Yarmouth, MA IS HEREBY GRAN'PED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: G��i�ed dE �Ce,�lsA�lr� G�lr�in�ri SEATING: 40 � S�� R./�.��U[�C�6 G��I11�it R��LO�I�IlL� �:(e/ilR • �� 4s�l�'�e�, R.N. March 28.2007 — Bruce G.Murphy, H,RS.,CHO Director of Health THE COMMUNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-056 FEE: $75.40 This is to Certify that Dockside Hotel GrouplPoint LLC dlb/a The Cape Point 476 Route 28, West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point -OUTDOOR POOL 476 Route 28 VVest Yarmouth,MA This pernrit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31,2007 unless sooner suspended or revoked. March 28.2007 BOARD OF HEALTH: B �. /��., ' a��i��s,��sce ��it�st � Rad�t�.B� � /��/�c`he�x�u,tt �!*� , R.N. B�u� .M��,�� Director of Health I � THE COMMONWEALTH OF MASSACHUSETTS TQWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-055 FEE: $75.00 This is to Certify that Dockside Hotel Group/Point LLC d/b/a The Cape Point 476 Route 28, West YarmouttL MA IS HEREBY GRANT'ED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At The Cape Point -IlVDOOR POOL 475 Route 28 West Yarmouth, MA Tlus permit isgranted in confarmity with Article VI of the Sanitary Code of The Commonwealth of 1vlassachusetts,and e�ires December 31.2007 unless sooner suspended or revoked. March 28.2�7 BOARD OF HEALTH: B �. /��., ' a�e��e��>l�la,�u�G�lu-�r�it�� R�d�`�. B� � � A��l��,tt �1� , R.N. Bruce .MuiP Y,MP ., H Dir�tor of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #0'7-057 FEE: $75.00 This is to Certify that Dockside Hotel Group/Point LLC dlb/a The Cape Point 476 Route 28, West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Pablic Swimming or Wading Pool At The Cape Point -WADING POOL 476 Route 28 West Yarmouth;MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31.2007 unless sooner suspended or revoked. March 28 2007 BOARD OF HEAI,TH: I� �. o�do.� A�I.�., . A d��,�:��'�1�, ./V., '�/�G�� . RoGerrl�. B�ou�si, � ��ieus�/�a�eyr� f4�.t R.1V. B�. Murphy,MP R ., Director of Health � . : . , 4 I � �co�vrn�or�wE�,�oF�ssAcausE�rs TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-024 FEE: $75.00 This is to Ce�tify that Dockside Hotel GrouplPoint LLC d/b!a The Cape Point Motel 476 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules�d regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Healtb,and expires December 31,2007 unless soaner revoked. March 28.2007 BOARD OF HEALTH: B .�. /N�., ' d�e ��io�i, ��ce el��s� Rod�t� B�u�, C� � ��l9o$e� �4.�!�' R.1V. 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N2Ifls�2t OZ A.LI7ISIS1�IOdS�2I?IIlOA SI.LI 'I£jaqu�a�aQ o� I �nuBr cuo.g�irenuu�uru s��uuad��I.LOI� O1�I S� � � ��d.�1�'I�.I.�d02Idd�' i �I��I��S�'�'Id 's�iuuad ino��o a�ue�ss�io�nnaua.�o�ioud prred aq�snuz sua�pu�sa��q�nouue��o unnoZ � Q�I��.LZ�QN�d Q�I�IJIS ZIt1V�33V 'dY�iO� S�2I�I2IOM � � i � �Q � . � a��ii�a��ns�u 30 �ixa� E � xQ`a�u�Ts Qu�Q�i��a�o� �g zsn�� l�i�'2IIISI�II l�IOIZ�Sl�I�dI�IO� S�2I�}I2I�AA �ZV.LS Q�H�H.Ls.� �H.L 'a��jnsuI uoi��esuaduio� ; s�la�.�om�o a��gi�za� e an�q �ou saop �uedcuo� io uosiad �3i ssauisnq � a��iado o� �iuuad .zo asua�ij �cre�o Ternauai so a�u�nsst pjoq o�pannbai nc�ou st�nouuB��o un�os au�`9 uoi��asqns `�SZ uoi�as `ZS i ia�dEu��apun I�IOI.I.�2IZSI�Q�' Title: Schedule of Locations Remarks: Cape Point Hotel 476 Main St. W. Yarmouth, MA 02673 Cape Town & Country Motor Lodge 452 Main St. W. Yarmouth, MA 02673 Mariner Motor Lodge Inc 573 Main Street, Route 28 W Yarmouth, MA 02673 This endorsement is attaci�ed to Mie pdicy indicated below mid is effeciive on Uie date stated herein,al 12:01 AM..starWazd Mne at the address oF 1he insured as de.5aibed in tl�e u�forma6on page. Policy No. Group Expiration Date of Poiicy Effective Date of Endorsement Endorsement No. WMZ 8005077012005 0500 04/O1/2006 04/O1/2005 Issued to Additional Premium Retum Premium ' Dockside Hotel Group,Inc.Etal ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY CauMersigned 'ed Representative i i � � - � � - �'HE COMMONWEALTH OF MASSACHiJSETTS TOWN QF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-048 FEE: $50.00 This is to Certify that Dockside Hotel Group/Point LLC d/b/a The Cat�e Point Motel 476 Route 28, West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ' _ _ OPERATE MOTELS This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws af the Commonwealth of Massachusetts 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 31,2006 unless sooner suspended or revoked. December 7.2005 BOARD OF HEALTH: Gest�,r�tist�. �i�o.�,�I.�S. - ��r��, v,�� a�t�. a�, �!� � s�, arv ,��, R.�v. Bruce .M ,MP , .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISffiY�NT, PERMIT NUNIBER: #Ob-Q43 FEE: $75.00 In accordance with reQulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the�eneral Laws,a permit is hereby granted to: Dockside Hotel Group/Point LLC, 476 Route 28, West Yarmouth,MA Whose place of business is: The Cape Point Matel Type of business: Food Service ' To operate a food establishment in: Town of Ya.rmouth Permit e�ires: December 31, 2006 BOARD oF HEALTH: L�essr"y�'-��r�ss`2S. C�'o�ois�,J/�Ll._`21,,.� � ' SEATING: 40 nG�vuCl2��@hlll4�� v�(;�lG�[l�ylls�y �s�R.�v ��r , R.�. December 7.2005 ruce G.Murphy, ,RS.,CHC) Director of Health THE COMMONWEALTH OF MASSACHUSETTS - — TOWN OF YARMOUTH PERMIT NUMBER: #06-037 FEE: $50.00 This is to Certify that Dockside Hotel Gour�/Point LLC d/b/a The Cape Point 476 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE i _ ___ I In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless ; sooner suspended or revoked for violation of the laws of the Commanwealth respecting the ; licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. ' BOARD OF HEALTH: Gn�� _�d� 'ds� �Ce�ie2,nG�'�viaaass SEATING: 40 !'�7�R�'(C�� v�� Rc+le��. �nuurrc, C� ' �s�, R.n�. ,Q� , R.N. December 7,2005 ruce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NCTMBER: #06-016 � FEE: $75.00 � This is to Certify that Dockside Hatel GrouplPoint LLC d/b/a The Cape Point Motel 476 Route 28, West Yarmou�h,, MA IS HEREBY GRANTED A PERMIT To C)perate a Public, Semi-Public Swimming or Wading Pool At The Cape Point 1Vlotel - INDOOR POOL 476 Route 28 ' West Yarmouth MA This permit is granted in conformity with Article VI af the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31 2006 unless sooner suspended or revoked: December 7_2005 BOARD OF HEALTH: �esr�siuss�S. 4'o�osi,/��• �ic�rrc� n��c.$�, �/Bce��vusacrs � Radent�.B�, G� �� sl�, R./V. �1� , R.N. ce . urp, ,NIP Director of Health i � � i � � ! ---- THE C4MMONWEALTH OF MASSAC�I�SETTS TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NUMBER: #06-Q17 FEE: $75.00 I ' This is to Certify that Dockside Hotel Group/Point LLC d/b/a The Cape Point Motel � 476 Route 28 West Yarmouth MA ' IS HEREBY GRANT`ED A PERMTT To Operate a Public, Semi-Public Swimming or Wading Pool _ _ At The Cape Point Motel - OiJTDOOR POOL 476 Route 28 West Yarmouth, MA This pemut is granted in conformity with Article VI of the Sanitary Cale of The Commonwealth of Massachusetts,and expires December 31,2006 unless sooner suspended or revoked. December 7.2005 BOARD OF HEALTH: Qe��ti�ts�. Ef'o�c,J��. e�u'ari�t�st n��r��, v�� R�t� a�, �� s�, �.� � . � , R.�v � ruce .M p y, R ., Directqr pf Hea1 � � 'THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #06-018 FEE: $75.00 This is to certify that Dockside Hotel Group/Point LLC d/bla The Cape Point Motel ' 476 Route 28 West Yarmouth, MA ': IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool ; At The Cape Point 1VIote1 -WADING PQOL 476 Route 28 • West Yarmouth, MA This pernut is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31_2006 unless sooner suspended or revoked. December 7.2005 BOARD OF HEALTH: Be�rti�ss$. (�'o�osi,l��5. e�i�iusc /�ctnic�(z/l�lc�` �, ?/ice��c�vusr,c,�s Rod�t�B�, � � s�, R.N. Q� . , R.N Bruce G. urphy, R ., H Director of Hea1 � . . ' � THE COMMONWEALTH OF MASSACHUSETTS - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-007 FEE: $75.00 � � This is to ce�tify that Dockside Hotel Group/Point LLC dfb/a The Cape Point Motel 476 Route 28, West Yarmouth MA j � ; HAS BEEN GRANTED A LICENSE TO ENGAGE IN-T�-IE BUSINESS 4R PRACTICE OF -- - GIVIl�TG OF VAPOR BATHS This License is issued in conforxniiy with the authority granted to the Board of Health,by Chapter 140,Sectious 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the CommonwealthofMassachus�etts 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 31,2005 unless sooner revoked. December 7.2005 BOARD OF HEALTH: Be�tss��S. �a+�st,/��., G��t�st nc.�iic�/1/l�`.�5�, ?/sce G�lsai�iu�s R��B�, Gl�k �s�, R.�. �1� , R.N. Bruce G.Murphy, � ,RS.,CHO Director of Health � � � I I I , 1'`�`^�uC • o�.�� ,N: .�'o T O �T 1`T O� F Y A R 1VI � U T' H 0 - . � —y �, �,�_, � 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 MATTACMEES /)�e7 Telephone {508) 398-2231,Ext. 241 — F� {508) 760-3472 � M��9�01IATE0�6�,1�— (�- B OARD OF HEALTH �_._._ x r ,�- - { � t� i' � To: All 2005 Yarmouth Board of Health License/Permit Holders MAY 2 ^ 2005 � � HEALTH [�EPT. , From: Yarmouth Health Department � � Re: Tax Identification Numbers � Date: March 22, 2005 � � 3'he Massachusetts Department of Revenue is now requiring that the Health Department furnish to them detailed information regarding all permits and licenses that we issue. One of the required � details is to provide a tax identification number, whether it be an establishment's Federal Employer ldentification Number (FEIl� or, in the case of an individual's license, a Social Security Number (SSI�. This information will be used by the Health Department purely for administrative purposes only. Would you please fill out the fields below and return this letter to: � Yarmouth Hea.lth Department � 1146 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 ca11. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is(508)398-2231, ext. 241. Establishmeni: 7rlh e C4 p� po t N'T FEII�T or SSN: Location Address: �7� M�r n� S�R�"I� Signature: �� Print: >A u� I. S W A 27 v Title: �Rt. � , ' :� �� Print� �� P� �� a � _ �...��--_ � � �a553 ,ay o�._YaR �,��6" 7� G9P� PO/NT 2 r �o TOWN OF YARMOUTH BOARD OF HEA � APPLICATION FOR LICENSE/PERMIT �� '� G� C C� `� � NJ (� �o 0.� �y � F ' ..•••;;2' * Please complete form and attach all necessary documen�'by De�nb r 31��60�. 4 2004 ' Failure to do so will result in the return of your�plicatiqn'pac ; � �HEALT;t vtPT. NAME OF ESTABLISHMENT: T�+� �'°�I°O a'"'r � - TEL. # So8- » -/ a u j LOCATION ADDRESS: MAILING ADDRESS: y76 MA►N S?RtG ? OWNER/CORPORATION NAME: 'D c c k S1Cl,e QA4 C� MANAGER'S NAME: '�i r�� 1. S wA R,t 'L TEL # So d'�� '` 1�,b MAILINGADDRESS: to� P��s�� PrN�S l9V P �P�uteR..��tl-� iw•c�., Oa6s a POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool erator(s) and attach a copy of the certification to this form. 1.__ v/�'Z" S�c7N 2. . Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid ; and Community Cardiopulrnonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � / { • 1. U �v -t��' 2.--�l�[Jr� � �l/ 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. Yoa must provide new copies and maintain a fde at your establishmen� � i 1. ��,Ui� �SS�� 2. � - PERSt3N�N£I-�ARFr�: _ _— _— __ —_ _ ._ Each food esta.blishment must have at least one Person In Charge(PIC) on site during hours f operation. �-^ � /' I l.U��_T /�/SS�/ 2. �/ / ✓`-� J HEIMLICH CERTIFICATIONS: , ' All food service establishments with 25 seats or more must have at least one employee tra.ined in the Heimlich ' Maneuver on the premises at a11 times. Please list yaur 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. �,��i 1�i s c,� 1 , z. /%s.�,��T� .5�,�� '7/� . 3- 4. RESTAL)RANT SEATING: TOTAL# LODGING- OFFICE USE ONLY LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B�s sso _cr�n�t �so /Mo�L $so �oS-4� �INN $50 _CAMP $50 .3 SWIlVA�IIIIG POOL$75ea. �5-03 �EL0�3 _LODGE $50 _TRAII,ER PARK $50 �WHIRLpppL $75ea. �p�-�Ic� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQUIIZED FEE PERM(T# �0-100 SEATS $75 d S�'�� _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $ISO 1COMMON VTCT. $SU OS�OS� _WHOLESALE $?5 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU7RED FEE PERMIT# LICENSE REQUIRED FEE pgRMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 �VENDING-FOOD $20 �45,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOITNT DUE _ $ !� ��Q ' '"•""PLEASE TURN OVER AND COMPLETE OTHER 3IDE OF FORM ilRYIf�R . I - i . � �� ADMINISTRATION . i � 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 Comp�nsaxior� Inswance. TRE ATTACHED��S�TATE WORKER'S� COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � , . . � • OR , ' , WORKER'S COMP. AFFIDAUIT SIGNED AND ATTAC�IED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEL�IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISHMENTS ARE TO CONTACT THEHEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR TI-� SEAS4N. ALL REN4VATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HE.ALTH PRIOR ' TO COr�IlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. f ADDITIONAL REGULATIONS � � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to operung. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, prior to opening, and quarterly thereafter. i POOL CLOSING: Every 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 undercoaked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the ; required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be ; obtained at the Health Department. � k �+'RO�EN H�SSERTS: __ _ I 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.,outdo�r seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING• '�' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: a2 lJ SIGNATURE. pR1NT NAME& TITLE:��„�-i�'��/ � /'�� 10/22/04 � A_L:�� 4,��tf f 6P'IL:H! I� t,J�' t�t�t��...� w x ��`��vnr+��o�ti:. ��,�=�;-1 o6Jz� o--- ` ;�� `�� _. --"��'� 1'H!S CERTiFfCATE f5 4S5UE0 A5 A MAT7"P_k OF d�l��1R1�7(O!1 i Ot�f,Y!WU CO�IF'�RS 1�0 RIGHTS UP�CaN THE GEATlFICA°f� JGIy-�t+fi la�st I�uranae Acjency,Tnr HOLAEiC TFi1S CERi'IFBCATE DQ�S pi07�YlEN�,EXTE�1]C1R � nCdloal Stzas,t �.Q. Hcix. ].0't8 8►LTFR THE CAVCltAfi�AF'�qRDEC�Y�PISi,IC]E��C�Y�l. Caurx4ozs 1s�4 0278C?-D85'7 � P'hrrne:3(�9-92�4-996g Fax:�d�-�BU-�'734 ;INSURER5II�WR[39NGCAVE4tAGE ��N/UGA� ��_.__,_ __.-- .__.._.__—_,,.- �__ —.__�fa�ur�1A: Ail� l�ilitu�2 InsuzanCr3 �a. � INSIJRERB: � -^�___. Doak3id�i Hotel Group xnG. �Nsurel9tC; w_, „� d�7S �u St �k 1� e � +ksurFar.: �� l�(est�ax�nou�Y�s Mm, �267� ��uaE�tE: � _ '- ' --- - �. 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AGCIRD 25(20D1198) _,. � �11COR0 CC1RP'I�ItAATCON T�88 � TOTAL P.J1 II I i i � I � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-019 FEE: $50.00 This is to certify that Dockside Associates d1b/a The Cape Point Motel 4'76 Route 28,West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authoriiy granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commanwealth of Massachusetts relating thereto,and upon such teims and conditions,and to the rules and regulations in regard to said Motels so licensed as adapted by the Board of Health,and expires December 31,2005 unless sooner sus�ended or revok�. 1��y Zi.aoos so�oF�ai.�: Be��. �o�o��b1.�5. ' P��Nc`.?S�, ?/r•c��'�i�rr�� d� Sl� RJV� �4.�(j R.N. ruce G_ urphy, H .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT �' PERMIT NUMBER: #OS-072 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permrt is hereby granted to: 3 Dockside Associates, 476 Route 28,West Yannouth,MA ; Whose place of business is: The Cape Point Motel Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2005 BOARD oF HEAI.Tx: Besr�ml�`h. �o�a�J1�1.`�1. ' s�'ru�rG: 40 /��iic�a/yc`�s�ri�, �/su�e�ic�x��t � �S�R.%V.� l� �1.� � , R.N. I J�uazy Zi.Zoos s.,cxo Bruce G. Murphy, , Uirector of Health � , a i THE COMM�NWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #OS-O51 FEE: 50.00 This is to Certify that Dockside Associates d/b/a The Cape Point 476 Route 28, West Yannouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: G��i�u�ed dsf. �C'el�i�i, G�lr��t 5��: ao A��Ll�� ?/�� R�t�B� � �!��, R R.N. � Januar�21.2d05 Bruce G. urphy, H .,CHO Director of Health THE COMMQNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-032 FEE: $?5.00 This is to certify that Dockside Associates d/b/a The Cape Point Motel 476 Route 28.,West Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point Motel - OUTDOOR POOL 476 Route 28 West Yarmouth,MA This permit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31_2Q05 unless sooner suspended or revoked. J�,�Zi.a�s Bo�oF�.�: B��$. �j�don,�N�h. L'�� A�til��tt, v�G�l�.,� R�t� B�, Gl� ��S' R.N. ,Q� , R.N. I a . ce G.Murphy, ., � Director of Health i i � i . s I � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-031 FEE: $75.00 This is to certify that Dockside Associates d!b/a The Cape Point Motel 476 Route 28 West Yarmouth,MA IS HEREBY GRANTED A PERNIIT �'; To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point Motel -INDOOR POOL 476 Route 28 West Yarmouth, MA This permit isgranted in conformity with Article VI of the S�itary Code of The Commonwealth of Massachusetts,and eapires December 31.2005 unless sooner suspended or revoked. J�,�Zi,aoos so�oF�.�: B��5. Q�M.�S. G�l�� p�� v�� aaa�t�a� et� ��Sl�k R.N. ,�,s� , R.N. � ruce G.Murp ,MPH, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEAL1'H PERMIT NUMBER: #OS-033 FEE: $75.00 This is to certify that Dockside Associates d/b/a The Ca�e Point Motel 476 Route 28�West Yarmouth}MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point Motel -WADING POOL 476 Route 28 West Yannout -MA This peimit is granted in conformily with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ir� December 31.2005 unless sooner suspended or revoked 1�,�Zi.Zoos Boa�oF��.�: B �5. gard�,�1.�. G'k�.� I l��e��A9c_`?S�u�tt, ?/u;��'l�i�u-� i Rod�t�.B� Gl� ; � �Sl�&, R.lV. � �� , R.N. 1 , ; � , � ruce G_Murphy,MPH, - , Director of Health � i � w . THE COMMONV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-014 FEE: $75.00 This is to c�y tt�t Dockside Associates d/b/a The Cape Point Motel 476 Route 28 West Yarmouth. MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS This License is issued in cot►formity with the suthority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�ires December 31,2(?04 unless sooner revoked. 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'a�uemsui uoi��suadu.To� s�.�axio��o a�E�t�i�a� � an�q �ou saop �fu�dcuo� �o uosaad ��t ssautsnq � a��.zado o� �tuuad ao asuaoti �Cu�30 rennaua.�.zo a�uenssi pjoq o�pannbai nnou st y�nouu��o unnos au�`g uoi�oasqnS `�SZ uot��aS `ZSi �a�d��aapun I�iOI.L�'2I.LSI1�tIb1i(I� � . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY I INFORMATION PAGE r Associated Industries of Massachusetts Mutuai Insurance Company ' ,�--- Burlington, Massachusetts NCCi tvo 2s�� (800) 876-2765 ' POLICY NO. �Z��012003 PRIDR NO. NEW BUSINESS " ITEM 1. The Insured Dockside Hotei Group,Inc. Mailing Address: 476 Main St. W Yarmouth MA 02673 Route 28 � (No. Sireet Town a Gry Camty Slate Zlp Code ❑ Individual ❑ Partnership � Corporation . ❑ Other FEIN Oiher workplaces not shown above: 2. The policy pe►iod is from 08/01/2003 to �� 12:01 a.m.standard time at ihe insured's mailing address. 3. A Workers Compensation Insurance: Part One of the policy appGes to the Wakers Compensatio�Law of the states listed here; MA B. Employers Liability Insurance: Park Two of tl�e policy appGes to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 ��h employee C. Other States Insurance: See Endorsement WC 20 03 06 A D. This poGcy includes these endorsements and schedules: SEE SGHEDULE 4. The premium for fhis policy wiN be detetmined by our Manuats of Rules,Classifications,Rates and Rating plans. All informatlon required bebw is subject to verification and diarxJe by audit. Classifications Premium Basis Rates Estknaled Per 5100 Estimated �e Tolal Annual of Annual �• ��p� Remuneradon Premiwn INTRA 077516 INTER 999999999 SEE NStON OF INFOR TION PAGE Mnimum premium a 223.00 Total Estimated Mnual Premium $ 15,403.00 As indiqted,interim adjusbr�nts of premium shaA be made: Deposit Premium $ 5,344.00 p ,a�,�ny 0 s��,a�,�,auy � c��c�r � �� nnA a��sm�►,�cr,�. $17,059.41 x 3.7000%0 ��•� 08104/2003 This policy,incbding all endorsements.is I�ereby countersigned by oaee nuCarizea signanue ' GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP DGP-Miles Insurance Agency MA 9052 14 804 0500 P.O.Box 1018 WC 00 00 01 A(11-88) Taunton,MA 02780 Includes copyrighted material o(tl�e Nationel Council on ComPe�aao^Msurance. used with its pertnission. i �_ _�___— :.� �� .� ,� �... � • � �:� Title: Schedule of Locations Remarks: Cape Point Hotel � : 476 Main St. Updated OS/O1/2003 W. Yarmouth, MA 02673 Cape Town & Country Motor Ladge 452 Main St. Updated 08/O1/2003 W. Yarmouth, MA 02673 Mariner Motor Lodge Inc 573 Main Street Added OS/01/2003 Route 28 W Yarmouth, MA 02673 mis�fs attac�d to u�e pou A,a�calea below ano a sNecuve on�h�da�esl�ea i�a,.at�r.o�aM..sta�ro ume at ihe address d the 6�sined as des�in the iMam�ion page.: Pobcy No. Group tion Da#e�Pali�y Eife�tive Date of Endorsement Endorsemer►t No. 13VMZ 80Q50770120Q3 O�U� (�4/41/2004 Q�/01/2403 001 Issued to . � _ �tional F�emium Ftetum Premium � � I�ockside Hot�l E'i�ou ,I�a ��''�.. iSSU�D BY: ASSOCIATED 1NDU$1RIES OF MAS�SA�Ii� � TL�A�t' . CE�(DMpANY` � j , q � � �� `�� -�i � 'zed RepreseMa6ve � 1 �- � � � 1 � � . � � � �e� .� � ;�.: � ,� -,. _ K� � s _: � ,n . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-011 FEE: $50.00 , This is to Certify that Point LLC d/b/a The Cape Point 476 Route 28,West Yannouth, MA HAS BEEN GRANTED A LICENSE TO �PERATE MOTELS This Licen.se is issued in canfoanity with the authority graated to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is sut�ject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,�004 unless sooner suspencled or revoked. November 28.2003 BOARD OF HEALTH: B��`n. �A��. p��1�s� v��. Rod�st�. B3ou�c, � df� Sl�k, R.N. `� �, -�=� � ruce G.Murphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-036 FEE: 75.00 In accordance with re ations promulgated under authority of Chapter 94,Sectian 305A and Chapter I i l,Section 5 of the Laws,a pemut is hereby granted to: Point LLC, 476 Route 28, West Yarmouth, MA Whose place of business is: The Cape Point Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOA1tD oF HEAI.TH: Be�ryr.�,r�r.i.`n. C�'°�do�/yl.-`2�• ' SEA��: �o p�� v�e�� I �� , �� November 28,2003 ; 'B��G.�%hy, ,x.s.,cxo ; Director of Health � . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #04-026 FEE: 50.00 This is to Certify thax Pourt LLC d/b/a The Cane Pourt 476 Route 28, West Yazmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2004 unless sooner suspended or revoked for violataon of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornuty with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereaf, the undersigned have hereunto a,ffixed their official signatures. BOARD OF HEALTH: C�ia�ed d� �Ce�, G�l�ar�i«tar� s�,�rn�tc: 40 /�atnicr6/l�c`.��N�I�Jce L��aut R��8��. � ,,,,,o:�i� �lia./ j� �. November 28.2003 Bruce G.Murphy, ,� ,R 5.,CHO Dir�of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUI'H BOARD OF HEALTH PERMIT NtJMBER: #04-019 FEE: $75.00 This is to certify that Point LLC dlb/a The Cane Point 476 Route 28�West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cane Point -INDOOR POOL � 476 Route 28 West Yazmout _ MA — Ttris permit isgranted in conforinity with Article VI of the Sanitary Code of The Cammonwealth of Massachusetts,and expires December 31.2004 unless sooner suspended or revoked. November 28,2003 _ BOARD OF HEALTH: ��/yc�y��,��(.'�t� Rade�st�. B�o�.� G�lm�{a d� Sl�, R.N. �� . � ' ;�-G` � ��'�, � Dir�tor of Health ' '� �' . THE COMMONWEALTH OF MASSACHUSETTS TOWN QF YARMOUTH ', BOARD OF HEALTH � �i PERNIIT NUMBER: #04-020 FEE: $75.00 � � This is to Certify that Point LLC d/b/a The Ca�e Point - ; 476 Route 28, West Yarmouth MA - ; IS HEREBY GRANTED A PERMIT � To Oper�te a Public, Semi-Public Swimming or Wading Pool , At The Cane Point - OUTDOOR POOL 476 Route 28 West Yarmou MA This permit isgrurted in conformity�'aith Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2004 unless sooner suspended or revokad. November 28,2003 _ BOARD OF HEALTH: B��a�l�a$�, ��G'�ea',rh�i.ir.��t � Rod�nt�. 8�rou�u, G�le� �fsle� Slr�l,y R.N. �� r �� ,.�,�y_,� :��' ruce .Murp , ( ., , Director of Health ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-021 FEE: $75.00 This is to Cercify that Point LLC d/b/a The Ca„�e Point - 476 Route 28,West Yarmouth,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Ca e Point -WADING POOL 476 Route 28 West Yarmouth, MA This permit is granted in confonnitY with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2004 imless sooner suspended or revoked. � November 28,2003 — BOARD OF HEALTH: B ' �• �j�i��. e��' � n 1/y/��, �/icae�Hytait ' Rode�t� B�wa, � � �f� Slw,k, R.N. I ��_ �� ,. ��I..,� - ; � . �_ ruC . urP Y, , •� ; Director of Health , a . , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' BOARD OF HEALTH �I PERNIIT NUMBER: #04-010 FEE: $75.00 ,, This is to Certify that Point LLC d/b/a The Cape Point 476 Route 28, West Yannouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI-�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the suthority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the pmvisians of the Laws of the Commonwealth af Massachusetts relating thereto,and upon such terms and conditions,and to the rules�d regulations in regard to the carrying on of the occupation so licensed as adopt�i by the Board of Health,and expires Decc,�mber 31,2004 unless sooner revoked. November 28.2003 BOARD OF HEALTH: Besa��. �j�,/y�. 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Dockside Hotel Group, Inc. Renaissance Insurance Agency, Inc. 476 Main Street, Rte 28 981 Worcester Street West Yarmouth,�MA 02673 Wellesley, MA 02482 FED ID Number: - NCCI Carrier Code No.: 24562 Risk ID No.: 000000 Other workptaces not shown above:See attached schedule Entity: Corporation � 2. Policy Period:08/01/2002 to 08/01/200312:01 am standard time at the insured's mailing address. � 3A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law and any occupational disease law of each of the states listed here: MA 36. Employers Liability Insurance: Part Two of the policy applies to Employers Liability Insurance for work in each state listed in Item 3A. The Limits of Liability are: Bodily Injury by Accident $500,000 Each Employee Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $500,000 Each Accident 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ' ND, OH, WA, WV, WY and states designated in Item 3A of the Information Page. 3D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will b�determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information below is subject to verification and change by audit. Adjustment of premium shall be made at: Policy Expiration Classification of Operations: See attached schedule Minimum Premium: $273 Expense Constant: $244 Deposit Premium: $6,611 Total Estimated Annual Premium: $26,411 Countersigned 08/05/2002 gy ��-��-- � f DATE Authorized Agent This Information Page with the Workers Compensation and Employers Liability Insurance Policy and Endorsements, if any, issued to form a part thereof, completes the above number policy. Date of Issue: 07/30/2002 Insured Copy RENAD001 WC 00 00 Q1 (12/981 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUNIBER: #03-013 FEE: $50.00 This is to Certiry that Cane Point LLC d/b/a Caue Point Hotel 476 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 Heatth,by Chapter 140,Sectians 32A,32B, ' 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealdi ofMassachasetts relating ; thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked. _ _ December 13 ,2002 _ BOARD OF_HEALTH: _.�a�cleQ`,� i��. (�awc __ . . S"t�c�ricGic?�. CI"m�doec, nl.?�.. 2/ic� ,�o�it�, $ra�c, elark �a�tck'l�cD� s'��c Slak. ,�.�l. t Bruce G.1t�� y, R.S.,CHO : I}irector a�� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #03-052 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 ofthe General Laws,a permit is hereby granted to: Cape Point LLC, 476 Route 28, West Yarmouth, MA � Whose place of business is: Ca�e Poirit Hotel � ype o usiness: __ _ _ �oo- ervice --- -__ __ _-- -- To operate a food establishment in: Town of Yarnmuth Permit expires: December 31, 2003 BOA1tD OF HE,�,TH: �� elPi'ka�, ��a�c SEATING: 40 ��w_-.�D• ��' �'9'' �� i�0avu�. �4AdYa'l, u0'l� �at�rEe��'�D� ��s�. �n. December 13 ,2002 ruce G.Murphy ,R.S.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERIVIIT NLJMBER: #03-030 FEE: $50.00 This is to Certify that Cape Point LLC d/b/a Ca�e Point Hotel ', 476 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensmg authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo�the undersigned have hereunto affixed their official signatures. _ _ _ _---- BOARD OF HEALTH: ekanlem�. ��i. �a�__ ___ . . s�'1'nvG: 40 �ewcfayrt�c D. G�lo7do.�. �1lG.D,. `l/ice �o�rt� �sota�,c, �k ' �atetc�7�Dar�catt ; �ele�c . ��l• � ; December 13 ,2002 T11Ce . LiPp . ., Director of Heal THE COMMONWEALTH OF MASSACHUSETTS � TOWN QF YARMOUTH = BOARD OF HEALTH � PERNIIT NUMBER: #03-022 FEE: $75.00 ; 'rhis is to certify that Cape Point LLC dlb/a Cape PQint Hotel . ' ' 476 Route 28 West Yazmouth MA IS HEREBY GRANT'ED A PERMIT To 4perate a Public, Semi-Pubtic Swimming or Wading Poot At Cane Poixrt Hotel - -INDOOR POOL , ., 476 Route 28 ��_Yarmnnth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31 2003 unless sooner suspended or revoked. December 13 ,2002 BOARD OF HEALTH: ��f, i��, (�au $'eu�ci�c D, �jimrdo�c. '!x?�.. `l/lca �oBr�t�. �'�roca�c, (,flark �a�rtck�X�'Desr.�co�tt s�eee.t Slak, .7Z. B�� .M� y, , Director of Health r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLTMBER: #03-009 FEE: $75.00 This is to Certify that Caue Point LLC d/b/a C�Point Hotel 476 Route 28 West Yarmouth_ MA HAS BEEN GRANTED A LICENSE TO � ENGAGE IN TI�BUSINESS OR PRACTICE OF ; - GIVING OF VAPOR BATHS T6is License is issued in conformity with the authority gcanted to the Board of Health,by Chapter 140,Secfions 51,of the General Laws,and amendmems thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the carrying on of the occupation so licensed as adopted by the Board ofHealth,and e�ires December 31,2003 unless sooner revoked. December 13 ,2002 BOARD OF HEALTH: (�� elfi�aC. (��*c _ --- __ _. _ __ �eu1a.n�f.,c 9: _ - __,_,�_ ,., � : , ,�o�e+rt 3. �no�rac, Llark �a�tck�De�ri�cotS r'i�ePea.S�k. �:.�1. Bruce G.M hy, .S.,CHO Director of Health ' I , - � i f ! f THE COMMONWEALTH OF MASSACHUSETTS ; � TOWN OF YARMOUTH - ., I � BOAR.D OF HEALTH � � ` ; PERNIIT NUMBER: #03-023 �EE: $75.00 i 1'his is to Cercify that Ca�e Paint LLC d/b/a Ca�e Point Hotel _ ; 476 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Pubtic Swimming or Wading Pool. ..R � At Ca�e Point Hotel - OUTDOOR PQOL, ` ; 476 Route 28 This permit is granted in conformity wi�'Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31.2003 unless soonet suspended or revoked. December 13 ,2002 BOARD OF HEALTH: �anled`�. i�a(�llkaz. ��a.� ,�eAc�tlwc D. G��oada�c, 'l11G.D.. ?/lee �aB�at�. b'aoaoa,c, el.ark ' �aa�tek 7�cD� � .S� .7Z. ruce G.M ,MP . ., Director of Health . , , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH � PERNIIT NUMBER: #03-024 FEE: $75.00 This is to Certifythat Cape Point LLC d/b/a Cape Point Hotel 476 Route 28, West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Point Hotel - WADING POOL 476 Route 28 � West Yarmouth MA . Tlvs permit is granted in conformity with Article VI of the Sanitacy Code of The Commonwealth of Massachusetts,and e�ires December 31.2003 unless sooner suspended or revoked. December 13 ,2002 BOARD OF HEALTH: �aale4� i��. (�au ___ _ - — -_ __ _ _ _ �e.rjaMtla�. Cl�rde�c. �?�.. �/lee �a�aat jl. �'aoQaMc, � �a�r�ek'�D� � S� .?Z. .wt ,lvtP Director of Health •�r � f. s��s�cL1I2I03.�IO�QIS 2I�H.LO�,L�'IdL1I0�QNV N�AO N2III,L'3Sb�'Id.��,�,�� 00•o.g� $ _ �I1Q.Ll�tll0� oi$ -�� w�u i s£$ixass�a x�zox� ooz$ �u��000`sz< s�$ •u•bs os> ' oz$ o��d$oi sc$ �u•bs 000`sz> oz$ o��daoi � #.LII�I?I�d ��3 Q32IIf1d�I�S1�I��I'I #.LIY�i?I�d ��3 Q�Ifl��i ��I'I #.LIY�RI�d ��d Q�IIf1a�2I3S1�I��I'I j A f SL$ �'T�'S�'IOHM OS$ '.L�IA 1�IOY�IY�IO�� OSI$ . 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Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) WORKERS'COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY INFORMATION PAGE Po[icy Nrarrtber: ; WC85 695094 Bureau File#: 077516 FederallD#: 1:N�m�d.ins[�redllVlailfin��Qr�dress: Dockside Hotel Group, inc. Legal Entity: Corporation 476 Main Street Rte 28 West Yarmouth, MA 02673 ir�sur.�:dlocaticrn Adcf�esses: See attached Schedule of Named insureds and Locations 2:P�Eicy Peric�tl:, ' The policy periad is from 08/01/2001 to 08/01/2002 12:01 A.M. Standard Time, at the insured's mailing address. � Crt�uerages: A. Workers'Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Massachusetts B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except those listed above in item 3A and ND, OH, WA, VW, &WY. D. This policy includes these endorsements and schedutes: Refer to Attached Schedule Total Estimated Annual Premium: �38,940.00 Countersigned: Dowling 8�O'Neil Insurance Agency 222 West Main S±reet, P.O. Box 1990 Hyannis, MA 02601 By Date: 07/05/2001 orized representative) KB i I i . THE COMMONWEALTH OF MASSACHU5ETTS � TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT NUMBER: #02-018 FEE: $50.00 'rhis is to Certify that Dockside Hotel Grou�d/b/a Cane Point LL ; 476 Main StreetlRoute 28,West Yarmouth_MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformih'with the authority granted to the Boazd of Healt�►,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to tlie provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upan such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or revoked. March 25 ,2002 BOARD O�'HEALTH: ��dat. .��lee �o�iact� �'7ota�• ef,�rk �a�rtek�e7.,rotl ?� S�4 ��l. ruce G.Murphy, S.,CHO Director of Hea1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #02-094 FEE: $75.00 In accordance witl�regulationspromulgated�.mder authority of Chapter 94,Section 305A�d Chapter I 11,Section 5 of the General Laws,a permit is hereby granted,ta nockside Hotel ('Yrou�,476 Main Street/R�ute 2R,West Yarmouth,MA Whose place of business is: Cane Point LLC Type of business:_ Food Service To operate a food esta.blishment in:_ Town of Yarmouth Permit expires: December 31,2002 BOARD oF HEALTH: �a�� xdl�if�z, �al,curau s�a�rn�tG: 40 �a.xu�c D. C�o7daNc 7�BG.D., 2/cee ,�ode�rt 3 �roaw�c. L� �a�tek�Da� s?�e�e�c,.S�k ��l. Mazch 25 ,2002 ruce G.Murphy, H, .,CHO Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NiJMBER: #02-063 FEE: $50.00 This is to Certify that Dockside Hotel Gro�d/b/a Cane Point LLC 476 Main Street/Route 28, West Y�rmoLth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thiriy-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confomuty wrth the authonty granted to the licensing authorities by General Laws, Chapter 140,and amenclments thereto. In Testimony Whereof,the undersigned ha.ve hereunto affixed their official signatures. Bo�oF�ai,Tx: �� z�, G�� s��G: ao �ja.,�D. C�� 71L.�.. �/� ,�o�rt�. �rota�c, � �a�tlek'�ezawat� � Skak. ,��l. March 25 ,2002 ruce G.Murp ,MP RS, O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-031 FEE: $50.00 lhis is to Certify that Dockside Hotel Grou�d/b/a Ca�e Point LLC 476 Main Sireet/Route 28.West Yarmouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Pnblic Swimming or Wading Pool At eP ' L RP L 47 Main Street West Yarmouth,,MA This permit is granted in conformity with Article VI of the S�itary Code of The Commonwealth of Massachusetts,and expires D�ember 31.2002 unless sooner suspended or revoked. March 25 ,2002 BOARD OF HEALTH: 's�f xe�rex, a. ��. �v� �3 �, � P�� s�. .�t Director of H alth THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � BOARD OF HEALTH I PERMIT NUMBER: #02-032 FEE: $50.00 This is to Certify that Dockside Hotel Crrou�d/b/a Ca�Point LLC _ 476 Main Street/Route 28�West Yarmou - MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or VVading Pool At C�*�Point LLC -OUTDOOR POOL 476 Main Street West Yannouth MA This pernnit 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 25 ,2002 BOARD OF HEALTH: �r�, zdli�i, �� D. �mraloK, D., `l/kkece ,�oBert� ��c, �rk �� f S �?Z. ruce . Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-033 FEE: $50.00 This is to Certify that Dockside Hotel Grou�d/b/a Caue Point LLC 476 Main Street/Route 28.West Yarmouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Ca�Point LLC -WADING POOL 476 Ma.in Street West Yarmouth,,MA This pennit is granted in c.ox►formity with Article VI of ffie Sanitary Code of The Commom�vealt�of Massachusetts,and e�cpires December 31,2002 unless sooner suspended or revoked. March 25 ,2002 BOARD OF HEALTH: ��r�. �e�"ret, ��e.�a.xG�c D. �j�aiala�c. �?Ilce �o�ert� �ro�c, L�latk �a�rtek��t� � Skak ,?Z. ruce . utp , . Director of Health r � TFIE COMMONWEALT'H OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH ! PERMIT NUMBER: #02-012 FEE: $25.00 1 ? This is to Certify t�,at__ Dockside Hotel CTrouu d/b/a Cane Point LLC ' 476 Main StreetlRoute 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 confornuty with the aut�ority g�anted 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�d regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and�pires December 31,2002 unless sooner revoked. March 23 ,2002 BOARD OF HEALTH: �r�e4 ,r�, i��u�Z, ��C �r,ac1a.nt.a?�. C�ianda�c. 711.2�., �j/ice ,�a�rt� �raaw�, ��erk �a�tick�er�rat� `�eP�c S�uk. Z?�l. 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t xo`a�u�is Q�Q�z�zarn�o� �g isn�iin�ai,�� ' ��l�i�'2iI1Sl�ii l�IOIZ�SI�t�dylt0� S�2I�I2IOM �,L�.LS Q�H��'.L,L� �H.L 'a�uemsuI uoi��suaduio� ' s�.zax.�o��o a��t�za� � an�� ou saop �ueduzo� io uosiad��i ssauisnq � a��aado o� �iitu�c�.zo as�za�i��fi�:��o ' jEnnaua.z ao a�uenssi piou o�pa.zmba�mou si u�nouu��o umoZ a�`9 uot��asqnS `�SZ uoi}�S `ZS I �a�d��apun� I�IOI,L�2I.LSIi�tIL1IQ�' � : y � , r:. : a � The Commoawealth ojMassQchusetts � W Department of Industrial riccidents � ; Olflceol/�st/�stNis � � 600 Washington S�reet � Boston,Mass. 02111 , �,, �'" "� W'orkers' Compensation Insurance Affidavit Annlicant infermafinn- PICBseYRINI''�t'if�ii n1mr� 1 A e CGl.P2 PO/'at �„��on� �7� M Ci/�v S''t'R,2,2'1' W• �/AQ�u.��J�'� �� phone# � I am a homeowner pertorming all work myself. � I am a sole proprietor�r� ha�e no one«�orking in anv capaciry � I am an employer proti i�ing workers' compensation for my employees working on this job. com�anv name• 1ddre�5� citv• ohone�f• insur�nce co policy# � I am a sole proprietor. general contractor, or homeowner(circle one) and ha��e hired the contractors listed below� «ho ha�e the follo��in��+orker�' �ompensation polices: gQmp�v name• ��dress• _ phone#• insur�nce co Do�Y# company name• - - - _ _ _ _ _. -—_ --- --- - ---_--- _ --- --- -- — - -- ---- --- - --- addr ss• �y• phoee#• insurance co t�6Y� Failure to secure coverage as required under Seerioo 2SA of MGL 1S2 eaa lad to t6t iopoailioo ottrisi�fl peaaltia of a Ooe op to 51�00.00 a�d/or one yean'imprisonment aa well aa civil penalNes io the[orm of a STOP WORK ORDER and a tine of 5100.00 a day ataiost ma I a�denta�d t6at a eopy of thy statement may bc for.varded to the ORce of Invatigatioa�of tbe DU for eovenge veri0alio�. I do hrreby certijy�u rhe poins and penalties of perjury tha[the rnjor►nation provided abovt is tn+e ar�d eoneet Signaturc � / 2- �3 ` � 1�� . 7 �8_ �'�d Print name �t�_/11 R'1' �� Phone# ., o(Ticial use onh� da not w rite in this are�to be completed by city or town ot'lieial ciry or town• yA��TR _ permit/lieense p nBuilding Departmeot �Liceasiog Board �check if immediate response is required 261 ❑Sdectmen's Offite pH-alth Department contact person: phone#;_ �508� 398�2231 est. nOther Irerised 3;95 PJA1 . �. f ,,� Ead�er�Ca.dccal�y 325 Donaid J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) AMENDED DECLARATIONS ENDORSEMENT Policy#: WC87 323543 Effective date of Endorsement: 8/1/2000 Effective: 8/1/2000 to 8/1/2001 Issued to: Cape Point,Atima Etal 476 Main Street W.Yarmouth, MA 02673 1. To be used for premium transactions In consideration of premium of$ subject otherwise to audit it is agreed that Item 3 of the policy is amended as follows - : . _ . r.. , . � #� � .: .. ��' > �� 1�� s �� !A� � '�,'+��'�' . d „ ,. � �� C�`�5��3�14.�f'1 � �� f � ,� � , �s e . �� f?��lU�,�, . ' ,,� " � � � ' ' _: � � � �"F �� k � - y : � �, �, ; � : ....� , � , �- , � NI��S�„�1iS��t�S,1��tC�g'` �tat�l n��i'�mp)oyee�,a�[�sp��`��$�:I�ir �1�2 $ i�,��t3E3`�t �:.. 2:2� $; 1a,i2�i, � �[,erical=C.�ftc�x�mpla��t�e�Nc�c- �8�t� � ��,��sfi $ � �� : '1�9 Cc»r�s:�� 5U()!5(��I�OtI �g��}7 ��: ��e�e�lc��tt�'�r��1/��`I�#{��S��ar��j k & ��' : 5��r��rtl�r�rr�l�h�: � . � � .+Q�1; i� , . � ��: V ." Atl Pasl��+�j�s#rri�nt�i�a�ram#.3��5ut�h�g�� 5;�43Q �� `,��. i :�° . �� I, �' _ ,� : �: - E�t{�er��a�is#atrt . � '� � �� :ft�iule��ttr��j�re � �:_ �: � . ,' � , �i. , `JY . � v-F � .._ y� 1 ; ^ 4.v , ,- , — �+i��.s Pr±emium=Dasct�unt {��; dir��n�s�f�r��ustriai�ctd+en��rn�nf . "!"c�t�l�t�na�ii�►nnu��P�r�� 8 � q� � r �,�t;: E, F� E � �� `� r � �� *� � � �- „� - �x N �� 4 ; a ' . � �� , � . � �. e ;;,� . ,� , . ^� . - — � The minimum premium applicable to this policy is $206 2. To be used for non-premium transactions Changed legal status to read LLC All other terms of this policy remain unchanged. Agency: Dowling & O'Neil Insurance Agency 222 West Main Street, P.O. Box 1990 Countersigned by Hyannis, MA 02601 695 uthorized Representative SM 10/17/2000 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER:_ #O1-092 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: Panl Sw rt�„ 476 R� in 4tr /Ro� e R, �x�e�t Yarm�� h, 1��A Whose place of business is: T'he Ca�e Point Type of business: _ Food ervice To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2041 BOARD OF HEALTH: �d 11L �, j� ��i�!�rra� sEa�G: 40 � �� L'�� . ?/iee Z'�x . C?�� Z �� . L'� ��'r'�a�E d '.G' ��,�� . �D. Februarv 16 ,2001 Bruce G. Murphy, R .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #O1-027 FEE: $50.00 This is to Certify that Paul Swartz dlb/a The Cane Point 476 Main Street/Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confomuty with the authority granted to the Board of Health,by Chapter.140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2001 unless sooner suspended or revoked. Februar�l6 ,2001 BOARD OF HEALTH: �� jrek`ed, �iavt�x�t �ianeed r�i�. %��l�i. �/iCe ,�,`iatJton�c �4(i� � t��OGRIIt, (� I��cC�iRt� V ,� �� . �%�. � . r� �LC_ Bruce G. Murphy,MPH .S., O Director of Health � tl�iEaH�o lo�oaiiQ OH� `. `H `,Cqdany� •rJ a�ru �� IOOZ` 9I �9ad '¢'„�/• �"`u� � !T. 0 ��i �� e"»o�g ��°a` a►�re�rr�ss� ��i ��i �1�i��'� Ob ��t•tr.r.das "�°u'�� ?lG p3 �x1.��3o ax�og •sa.in��u�is reio�o�ta�pax�o�una.�au aneu parz�isaapun a�`�oa�a��iuouzi�saZ uI •o�a�a�s�uacupuaure pu� `p�i .za�d�q� `snn�e7�aaua��q sat�uo�n��utsua�ii a�o� pa�u�.z��uo�n�at��inn�tuuo�uo�ui panssT st asua�Ti sn�,I, •s��ai��in uou�.uo��o�utsua�ii a��uT��adsaa t��annuoLuuzo�a��o snn�i a�3o uot��join.zo3 paxonaa.zo papuadsns iauoos ssaitm j OOZ�s�g-�.j tn��aquza�aQ sa�i xa pu��iuo a��Id��e��pue c�notu.��o unnoZ pres ui �SI�I��I'I S�?I�'I'I�'f1.L�IA I�IOb1iI�t0� �'Q3.LI�IV?IrJ 1�S��H SI �uiod � au.L�/9/P��+ I �d ��3i�a� o�si sn,�, 'OS ��3.� tiS -i0# �?I�gY�ifirl ZIY�I2I�d H.Lf10L1I2I�A 30 l�tA�O.L S,L,L�Sf1H��'SS�i 30 H.L'I��AAI�IOL�II�1i0� �H,L THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #O1-046 FEE: $50.00 This is to Certify that Paul Swartz d/b/a The Cane Point 4�6 Ma.xn Street/Route 28, West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Caue Point -OUTDOOR POOL 476 Main Street West Yarmouth.MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. Februarv 16 ,2001 BOARD OF HEALTH: �� etred, ��xQ� ,(�,��a�ed s�, xa!P,ikaa. ?/ice ,(�,`iaGu,ra� Z'�t� ��ou�, �'� 7��ic�� d '1' � �, , Director of H alt.h� � - THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #O l-047 FEE: $50.00 This is to Certify that Paul Swartz d/b/a The Cape Point 476 Main Street/Route 28 West Yannouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At The Cape Point -INDOOR POOL 476 Main Street West Yarmouth. MA This permit is granfed in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. February 16 ,2001 BOARD OF HEALTH: �� e�ed, �taGt�� (�,`ia�rle��. �e��. �/ice �i��i�xa� �a�t� i'aaw�c. C� 7�� d '.C' � . ��. D ector of Ha lth � THE CONIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #01-048 FEE: $50.00 This is to Certify that_ Paul Swartz d/b/a T'he Cane Point _ 476 Mam Street/Route 28 We t Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At The Cane Point -W ING POOL 476 Main Street West Yannouth, MA This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. 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Mass. 02111 �'" ��y W'orkers' Compensation insurance Affidavit n m• V)'�' � lucation: %�� /'�/'rIl N �� , � �/yl�t ��, ,� c'�� a %�'c��'�.��0 � I am a homeowner perturming a 1 w�ork myself. � I am a sole proprieror �:-,: ha�e no one��orkin� in am•capacit�� I am an emplo�er pro��in� w�orkers' compensa[ion for my employees workine on this job. ��/ y� � ` sqmnan�• name: l'Y/�'/y� eddress: ��t�" nhone t1• i uranc � � �v ��U.�� j ��- � I am a sole proprietor. general contractor, or homeowner(circle oneJ and ha�•e hired the conttactors listed below «ho ha�e the follu��in� ��orl:zr� �ompensation polices: comoanv n�me• address• ciri• ohone k• insur�ncc co. Rolic��# comDanv name• ad d ress: �'� �hoes�� insurance co. ��n,* a Failure to secure coverage�s«quired under Secnoo 25A of MGL 152 n�iad to tbe iopaidoe o(erivi�ti peedtla of a Ooe op to 51�00.00 a�d/or one yean'imprisonment a�w•ell a�eivil penalNa io the form of a STOP WORK ORDER aad a Ase of SI00.00 a dar Kaiost ma I asdersta�d tbat a copy of thy ststement mav be fonvarded to the Otiice of lnve�ti��tiom of the DU tor eoven`e veritiutio�. I do.hrreby certif}•under rhe porns and nal ies j rjury ke!tht i�jorniation provrdtd abov[is tnte and c rrect Signatur � Print name �� /� � one N ��iSs'�� .- afTicial use onl� do not+.�ite in this area to be completed by eiry or towa olllcial city or town: YA��IIT� _ permit/lieense w n8uilding Departmeot �Lieeosiog Board �eheek if immediate response is required 261 �Selectmen'�Otrce �Health Departmeot cont�ct person: phone It;_ �508) 398�2231 ext. nOther .. < �.x: � � i � Ead�err�Cczdua��y AMENDED DECLARATIONS ENDORSEMENT Policy#: WC87 323543 Effective date of Endorsement: 8/1/1999 Effective: 8/1/1999 to 8/1/2000 Issued to: Cape Point,Atima Etal 476 Main Street W.Yarmouth, MA 02673 1. To be used for premium transactions in consideration of RETURN premium of$1,114 subject otherwise to audit it is agreed that Item 3 of the policy is amended as follows � s�: �� ificat�can : �� " '� � �a R�r :Estrmate� ; � t � x � �� f�rahr �t�� T � �� 4�� annuai �� e�rt�th�;�'�ti�n Prer�it��ns �� ; £� , � �� .� d ' ; >.'�....�6>c. '�...�..,��., T .eF„ ' > �' r 4� % � � '�d S' ��... .�v ,., - , , '�¢� - . '. ,.. . ... __ . ..s,.. ,� -,Y . , ; t��1�/� �tS��j��8�.�t'" � � � ��"��`� � �� :51: ° � � , �� $` 1.4,�� ; �le�'� ;� � � � Q� �Q �h`�":� ��.,�L � \ � 3 ��2'�f� � ,' ��- �7� ��Jf/: , f%�'y �+ . .- ✓� �� .fi (��# wi7{y�G1� � �+�� v# �'`" °�7f�� .. . .. , ��' �c��e�,�e h�tS�i�c;��M�a��#11t1999j��09{�9°lo SureFtarg�� `: � } � 1�.�� ,� � �� . . .�jr�Rd��'K��Pt�i1�111111'1 � � �'� � :' � � 1�,�1'�- � ��1`Rrsk�tidjusftile�rt�F�t'�jram't:32�—�2%�urcharge) u ` . 5,(�31 ;s � � � ,�.r. � � � � ,ti„ �_ „.. : ... � � 21 Q(�0 �� .� :; . ._. .. � � �xp�r�se.�c� t��it �. � � zt� �chedu�e��a��c��r�dt� ,� � F �Y� . ��i��.. F(��1(!1`ll tiSC�� ;s z �. '' : , �� a� � �v (��_ .,�ar� . _ r r _ i � t� r��r�a� � a.��: � ' �� , � � �� es�nri�r�t �� 3� , > �� ' �� : � � �. .� �� t� �"'��. R �xr ��' �S � �� jH�'�'I�! �`�: s��'��;�'�a a � � �� "� �.� �� "�� ,� ��z��`�r ^�� ;re�b; ��,�� 6 ��'t�'" s�"�� a `� ��` - ,,.. �� ,� ��d <. a,.,_.. .,... ,. �� - '�,'3 �.�'. ... �. d .. �� ,,,. .� .. „<.: �.; . .,.. .. m.. :, _ The m:nimum�rem'sum appiir,;�ble t�this�u!ic�i� �22'! 2. To be used for non-premium transactions Changed Scheduled Rating Credit of.13 to.20 All other terms of this policy remain unchanged. R�C��V . ED AU6 0 � �999 �n��►�ncJ��'��!f Y, In� Agency: Dowling�O'Neil Insurance Agency 222 West Main Street, P.O. Box 1990 Countersigned by Hyannis, MA 02601 695 uthorized Representative KR 08/04/1999 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-25 FEE: $25.00 This is to Certify that Cane Point LLC d/b/a Cane Point 476 Main Street, 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 authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner revoked. January 25 ,2000 BOARD OF HEALTH: �i`� �`elfe�, ��iai�man . �oan G. �ullivan� K.//.� Vice (��irmun Kobert� 4,rocun, C..lerh ,abrielle�ako(.�hc�-.�/d�ooped ///� L 0� �[ia Bruce G. Murphy, , . ., CHO Director of Health ' THE COMMONWEALTH OF MASSACHUSETTS . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-64 FEE: $50.00 This is to Certify that Cane Point LLC d/b/a Ca�e Point 476 Main Street. West Yannouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Point -INDOOR POOL 476 Main Street 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. Janu ,arY 24 ,2000 BOARD OF HEALTH: �c�� elfee, ��xairmait �oan G. �u[[ivan, K.//., Vice C��irman. Ko�erf,}. �rown, �[erk . a�rie[!e�a�ol��r�-.�tooPe L � h[in ruce . urp y, , •, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-65 FEE: $50.00 T'his is to Certify that Cane Point LLC d/b/a Cane Point _ 476 Main treet, West YaLrrr�outh, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cane Point -W IN POOI 476 Main Street _ West Yarmouth M 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. Januazy 24 ,2000 BOARD OF HEALTH: �d� �e�, C�,,��,,,,�,� �oan� �u[�ivan, ��, Vice C.�irman. ,�o�e�E� �,�w�, c�� a�vie[!��a�ol.��y-✓�ooPe� l � o [in Dire tor of H altyh � � ' THE COMMONWEALTH OF MASSACHUSETTS �, TOWN OF YARMOUTH PERMIT NUMBER: Y2K-76 FEE: $50.00 This is to Certify that Cape Point LLC d/b/a Cape Point 476 Main Street,�Vest Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authonty granted to the licensing authorities by General Laws, Chapter 140, and amenciments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. � BOARD OF HEALTH: �� `�ettea, C'�a��„�� SEATING: 40 �oan� �ulLivan, K.//., Vice C,hairmah obert.}. �rou�n, �[er� a6ri�t�e�a�ofa�iy-✓�toopee hael oCo h[in Janua,ry 24 ,2000 ruce G. Murphy,MP , ., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-63 FEE: $50.00 This is to Certify that Ca�e Point LLC d/b/a Cane Point 476 Main Street. West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Ca�e Point - OUTDOOR POOL 476 Main Street 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. January 24 ,2000 BOARD OF HEALTH: C d ///. �elfe�, ��iairman �oan G. �ul�ivaa, ��/-, Vice ��i�man Kobert� O�rown, �ler� a�rielle�ako(��y-../�tooPea l '�� ruce . urp y, , ., Director of Health ' THE COMMONWEALTH OF MASSACHUSETTS , TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT NUMBER: Y2K-40 FEE: $50.00 This is to Certify that Cape Point LLC d/b/a Cane Point 476 Main treet West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the pmvisions ofthe Laws ofthe Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked. January 24 ,2000 BOARD OF HEALTH: �c�� effee, ��cairma►z �oan� �u6divan� �//., Vice (�hairman KoberE� 4.�rown, (�lerh a�rielle�a�ol��c�-�ooPe� a��10 oC'o�� Bruce-�.:��y, H, .S.,CHO � Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-136 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: C:a�ne P�int T.T.C;, 476 M in St_ree , West Yarmo � h, 11�A Whose place of business is: Cape Point Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�'��/. �gt��, C'��„�,� SEATING: 40 �oan� �u[li:van, K.�, Vice (,�irma Kobert� �rown, ��rk C�//briel��a�o[�k�- oo�ve� �� [�� , Januarv 24 ,2000 `�`�j�ough �� Bruce G. Murphy, H, . .,CHO Director of Health � � l'! , �1 y� �� l� �v'�j Ca.pe.�a�n�- }�to 1-e.� ...... . � � a� �� G3 [� (�� .� :��) TOWN OF YA O H BOARD OF H ALTH D E C 3 0 1998 ` + APPLICATION FOR LICENS��'��VIITp = 999}` ) pi A' � � � � { �r � HEALTH DF..PT. * Please complete form and attach all necessary documents h�-�ecie�� ,'' 1�� F �"t`S'�'s sS vv� t in th+e return of your application packet. NAME OF ESTABLISHMENT:C� �.�` M�iw�'-�i��----------------------TEL. #^7��-/S�v-- �O�ATI�ON ADDRESS: `'�!�,f'l��;� � i�� •� �, , zs� ,��4, Ovl� C eJ� � � � � MA,NAG R'S NAME: � '` � "�-// TEL. #7� � -�d��L MAII.,ING ADDRESS:3� �c'�°�'T� �, .�.v �.�.v�;s�o�.`r �� o�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. -� �o- � / y_ .. - - _ _ 1_ �'�.�� s/!o� �.is%'�'�'� " _�:�" 2 _ C � _,.._ j� /� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of emplayee certifications to tlus form. The Health Department will not use past years' records. You must provide new ; copies and maintain a file at your place of business. i L �� /�� , 2. 3. �',��/ �.5��.�.;� 4. HEIIVII,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained 'm 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 frle at your place of 6usiness. 1. c 3��T- /��s,�� 2. +` 3. v 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#�� ----- --- ----- - - ---- ---- -- --------- - --- _ __ -- --- - - - - - - - - - _ .__ _- _ -- -__ __ ___ -- —�E-I�SE ONLY _ . _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT # I � B&B $50 CAB1N $50 , INN $50 CAMP $50 LODGE $50 TRAII.ER PARK $50 i -7n 9 -�2 �MOTEL $50 �- .3 ,3 ��G;S�OOL $SOea. 9Q-71 �WHIIi,LPOOL $25ea. � ) ER LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# ; f 0-100 SEATS $75 �/"-t$� CONTINENTAI. $30 >100 SEATS $150 NUN-PROFIT $25 � COMMON VICT. $50 9- WHOLESALE $75 1�ETAIL SERVICE: LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIltED FEE PERNIIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 �25,000 sq.ft. $200 �T�1ME CHANGE: $10 AMOUNT DUE = $ `,�c�-Q--` """""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•"" _ � , � ,�- � . , ADMINISTRATION . � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOUT'H IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHEC APPROPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 3 i, 1998. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION ' 7-10 DAYS PRIOR TO OPENING FOR THE 5EASON. i i ALL RENOVATIONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARI� OF HEALTH PRIOR ' TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGLILAT�ONS � i POOLS � POOL OPENING: ALL SVVIlVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR E THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTIV�NT,AND THE WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT B�A STATE CERT�F�D LAB,- ' PRIOR TO OPENIl�iG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR 1N GROUND SWJI�IlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAY5 OF CLOSING. � � � FOUD SERVICE E CATERII�TG POLICY: ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST NOTIFY Ti� YARMOUTH HEALTH DEPARTMENT BY FII,ING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FR�N DESSERTS: FROZEN DE5SERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MU5T BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN T�-�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL AB�VE TERMS ` _ _ _----- ----_ _ _ _ — — - - - -- _ _ __ ( - - -- - ---- -- . �� HAVE BEEN MET. k OLTT�IDE CAFES: OLTTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS 5ERVICE),1VILTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. i � OUTDOOR COOKING: ' OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD ', SERVICE ESTABLISf�biViEEN'T IS PRUHIBITED. ' I DATE: /=l- +7-�g 5IGNATURE: � PRINT NAME& TITLE: �� C- �rcIQ,2'f� �n� • . ; ' � :� � , � �; _ ' _ The Commonwealth of Mossachusetts ' � W Department ojlndustrial.-1 ccidents W ; Offlce ol/�estlosd�is � 600 Washington Street ', .-` Bnston,Mass. 02111 �~ ��y W'orkers' Compensation Insurance Atfidavit n m� ��N � �?j � . location: 7 �� ai:�/Jdl.�-J �/ cit� tiC/ /`X/.EI�✓6u 1l a�:�� v�� phone# ��.S �O � I am a omeow�ner pertorming all work myself. � f am a sole proprietor�^,� ha�e no one ��orkin� in am�capacity �I am an emplover pro�idino w�orkers' compensation for my employees working on this job. � - - - . �/ �7 / - / comaam• nam • l�J'�'.Lr �-/�"l�' /'�/ %.��Q / y�0 Oc.'��3 t"ilb�� SC O�/ C>YJ� address: 7 �s� i��•�' •—�' � 1 cih•: GC� �r�.�la✓O�T's� i��/7v �.,�16 /�� hone#• 7��`�J�� insurance co.�G iOS��ti� �--�'-��Jk'�� N� Aoficy!s/�c.l� �� d�� I am a sole proprieror. general contractor, or homeowner(circle onel and ha�•e hired the conrractors listed below� �+ho ha�e the follu��in� ��orker� �ompensation polices: companv name• address• _ citv• nhone#�• insurancc co. Qolicy# �om a�ny name• — -- _ . _— _----_ ----- —_-- —--- —_ __ - --- - address: — ---- - citr ohone M• insurnnce co. notiey if • Failure to secure covenge as�equired under Secdoo 25A of MGL 1S2 ea�lad to tbe iopaidoa ot erioi�al pe�altla of a d�e op to 51,500.00 a�d/or I oae yean'imprisonment as w�ell a�civil penalda io the lorm of a STOP WORK ORDER aad a fiat of 5100.00 a day a��iost ma I s�dersta�d trat a copy of thi�statement may be forwarded to the Otlice o(Inve�tigation�of tbe DU for eoven`e veri6esdo�. I do hrreby cerrijj• rhe p 'ns pena ties ojpery'ury thut�ht injormation providtd abovt is trut and contcG , Signaturc l/ �p�/�/�O —T , Print name ��1/ ��'��' � Phone it �� /`J U � .. o(Ticial use only do not w rite in this ares to be completed by city or town oRitial city or town: Y�MDUTQ _ permit/lieense M nBuilding Departmeot �Licensiog Board �eheck if immediate response is required 261 �Seleetmen's 011iee OHealt6 Departmeot contact person: phone N;_ �508} 398-2231 egt. nOther Irc.:�sed 3;os P1A� I . . �— �� I�u,�an.ce Co�z a� Ea.�te�� Ca.� p y WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY � INFORMATION PAGE r NCCI Carrier 16942 Risk I.D. # 077�i b Policy No. WC 87 323543 Federal (.D. # � 1. The Insured/Mailing address: � Individual � Partnership ; CAPE POIl�lT. ATIMA. A/0 ' fi pOGKSIDE ASSOC. REALTY TRUST DCiA � Corporation or 47b MAIN STREET ; W. YARMOUTH: MA 0�673 Y � ir Other workpiaces not shown above: 2. Policy Period: The policy period is from 03la 1/98 to 08/O1/99 12:01 A.M. Standard Time, � � at the insured's mailing address. � 3. Caverage: ` A. Worker's Compensation Insurance: Part One of the policy applies to the Workers Gompensation Law of the states listed ; ° here: Massachusetts � B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our ` tiability under Part Two are: Bodily Injury by Accident 5�0�Q00 each accident � Bodily Injury by Disease 500.000 po�icy limit � i Bodily lnjury by Disease 5pp,p0o each employee ; + C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except those � ; listed above'in item 3A and NV, ND, OH, WA, WV & WY. , ,� : . . � :! D. This policy includes these endorsements and schedules: WC122b, WC242, WC332, WC367, WC441. � See Information Page III for other applicable endorsements. ; � � � t Total Estimated Annual Premium $ 1 S .�94 Pro Rata P�emium (If Applicable)$ , ;, M :� ' Countersigned DOWLING Sc 0'NEIL TNSURANCE AG�NCY ;`; �2i F2E5T f1AIiV STREET 4iYANNIS� MA 02601 �� Date 07-2�-9� BY - M�H Authorized Representativ THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AN�EM YE LIABILIN INSURANCE POLIC AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POUCY. • in�c��4cn rnov > + • � -; THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: � 99-43 FEE: $50.00 This is to cerafy that Dockside Assoc. d/b/a Ca�e Point Motel � 476 Main Street, West Yarmouth,MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is iss�cl 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 provisians of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and canditians,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31, 1999 unless sooner suspended or revoked. February 12 , 1999 BOARD OF HEALTH: Gc`� ._tetta�, c..`iair.naa �oaa C�. �ul�ivarc, ��/•, Vice C,�irman Ko�ert.}. p�rown� l.,ferk a�rie�le�aho(�k�-J`�too�ve� ' �e[0� ou�h[in. Bruce G.Murphy,MPH,RS. CH Director of Health THE CUMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUlV�ER: 99-70 FEE: $50.00 This i�to ce�tify that Dockside Assoc d/b/a Ca�,e Point Motel 476 Main Street,West Yarmouth 1VLA I5 HEREBY GRANTED A PERMIT To Operate a Public, Semi-PubGc Swimming or Wading Pool � At - L 4 6 M i Street West Yarmouth, MA This permit is granted in conformily with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and earpires December 31. 1999 unless sooner suspended or revoked. February_12 , 1999 BOARD OF HEALTH: �c`� ._tetfa�, l.�iai+vnan. • �oan� �u[livan,K.//.� Vice l..hairmaa Ko�rt J. �iwwn,� C�lerh a�rie6[e�ako[��Srf-..J�ooped ' �ae�o oC ��in Director of Health � � . � � THE COMMONWEALTH OF MASSACHUSETTS ` ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-71 FEE: $50.00 This is to cerafy that Dockside Assoc d/b!a Ca�e Poir�t Motel 476 Main Street,.West Yarn�outh,MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cane Point Motel - INDOOR POOL 476 Main Street 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. 1999 unless sooner suspended or revoked. Februarv 12 , 19�9 BOARD OF HEALTH: �c`� �elta�, C�iairman �oaia� �ul[ivah,K.�/•� Vice l.�irman . Ko�ort� /�rown� �lerk abrie6f�e�a�ofa��-.J�too�vea el O� ou�� ' D11'eCtOIOf��1 � � . � THE COMMONWEALTH OF MASSACHUSETT5 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-72 FEE: $50.00 This is to c�tii'y that Dockside Assoc. d/b/a Cane Point Motel 476 Main Street,West Yarmoutl� MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cane Point Motel -WADING POOL 476 Main Street West Yarmoutl�,MA This permit is granted in confornuty with Article VI of the Sanitsuy Code of The Commonwealth of Massachusetts,�d expires December 31_ 1999 unless sooner suspended or revoked. Februat�_, 1999 BOARD OF HEALTH: �c�� ..tottee, l��Zai.rman . � �oaa� �u[tiva�c� �//•� Vice l,hairman � KoberE�}. 6�rorva� �lerh a�rie�le Ja�ofe�ic�-.�tooPed '�Ql O� ou��lin Director of H alth � � , � . THE COMMONWEALTH OF MA5SACHUSETTS � ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-30 FEE: $25.00 This is to Cercify that Dockside Assoc. d/b/a Cane Point Motel 476 Main Street, West Yarmouth„ NLA 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 suthority granted to the Boazd of Health,by Chapter 140,Sections 51,of the General Laws,and amendmenis 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 iules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�cpires December 31, 19 99 unless sooner revoked. Februarv 12 , 1999 BOARD OF HEALTH: Gc`� �ettaa, �`caerman �oan� �uLlivare.�K.�/•� �ice l,hairma�c �obevE,}, p�rown� (.,farh a�rielle�a�iofe��-..l�tooPee • �e�0' �� ruce G.Murphy,MPH,RS. H Director of Health —�.a.- ' TOWN OF YARMOUTH � BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-150 FEE: $75.00 . In accordance with re�tions promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section of the General Laws,a permit is hereby granted ta _ nncksid Asco . , 476]l�ain Street, ��lect Yarm�u h, 1��A Whose place of business is: Ca�e Point Motel Type of business:__ Food Service To operate a food establishment in: Town of Yarmouth Permit expires:�?ecember 31 1999 BOARD OF HEALTH:�d�f. �el��, C'��„�,� SEATIlVG: 40 . � �oan� �ut�ivan�{C.�� Vice C„�racrmran , ' �o�erE,}. /�rown� C.lerh . a�Piedie�a�ofdhc�-.J�tooPed /�fichae oCou �lire. � _ F�rua�y 12 , 19 99 ruce G.Murphy,MPH,R .,CH Director of Health • THE COMMONWEALTH OF MASSACHUSETTS � ' TOWN OF YARMOUTH PERMIT NUMBER: 99-88 FEE: �50_00 This is to Certify that Dockside Assoc d/b/a .ape Point Motel _ 476 M in 4 r et, West Yarm�Lth� 1��A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��Yy/. �et��, C,��. SEATING: 4U �oarc � �ulfivan, K.//., Vice Crhairmaa Ko�ert.}. �rown, C,fer� a�rieG[e�aholdhcf-.J�{ooPsd ' �ae�� u�� ' February 12 , 19 99 ruce G.Murphy,MPH,RS. H ' Director of Health NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 95— 8 �75_�0 ...�WA1. ......... of ....YARDQOiJ�H.... ...... ........ .. . Board of Health of PERMIT TO OPERATE A FOOD ESTABI.ISHMENT Permit No. .��.-�$..... ,,DECEMBER..29. 1994 .. � In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: .. ........ .. .... .. ...CAPE POINT INC-..d/b/a CAPE POINTE MOTEL..... ............ . ..... . .... .. ... . . ... Whose place of business is .......476,ROI7TE.28�.tiJF.ST YARNIOUTH .. .. ... .. ... .......... Type of business and any restrictions ...�D.SERVICE. . To operatea food establishment in .. ...Y��, , ,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,, (City or Town) Permit Expires .. D��, ,31 19 95 ...... . � .� . ...... i� JBoard .... . � .. ;,�2� of , .... . . .. — er4 � .� ealth � fORM738 A.M. BULKIN COMPANv - �� • •�� - � I