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TOWN OF YARh#�O ARD f��'i�
APPLICATIUM R�D�LICRN " �
SE/PEI�_iT-2@l7
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Pieese
I' t�oauglerc�nrm�d att�h al! docatnaius �.
Failuce to do�will nsult in d�e r�c�f yourappli�on
I ! ESTABLISIIl�iV'FN�lME; uc san i age on omirnums
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� ' IACATION ADDRESS• 481 Buck Island Rd.West armou ,#. 408-420-0299
, MAILINGADDRFSS: Go First Pro ert Management 1 4 ain t. stervi e
E�MAILApi3RESS; an y pmcapeco .com
OWNERNAME: = 3 �
CORFORATTON NAME:(IF APPLICAHLE): �rt � (T'1
MANA(iER'SNAA�: Andrew Witter #. —��I N �
MATLING ADT3RES8;_ Go First Property Management 104 am t. sterw e = w �17
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, POOL CER'I�FiGATiONS: m o �"�
'�P�s�'�m�at be ecarW'i��s Poel dpe�tos as rayyaiered by State linv.Pl�a liat t�se daig�d � i
Pooi Opm�:{:)s�d attach a capy of t�e catifit�'+��cs tlds fann. �
l. David Stevenson 2
Pool operators must li�t a minimu:a of tvvcs�ployas cucr�nfly certified in sta�rd Fust Aid euci Community
��1�o�Y � � {CPR�b,a ' �e r�xti5ead � ' s�all timas, Please list the
I �P�ia�t�s�►d��s�'� ��is T� wiN�otvn� ��„";
� � r�r�. Ys�m���ew���a i'��;�P�
i, Davidson Stevenson Z Sergio Dahlem '�
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FOOD PROTECTIQAT It�ANAQrERS-CERTt�fCATTONS: �
All food savice estat�iisi�ue�tta ase�oquu+�d to l�sva�ta�t ca�e full-w�e eac�oaroe whas is cer�f�ad As a Foal �'�
Protectioa Msna,ger.as dt�aed ia the SiaLe S�mitay Code for FQod Se�++ice F.,�blia�ta,105 C�1�flt 59Q.�100.
Ptoase attach c�ue of certifieaticm�,ta thia 1'4e Ha�#h De�rtme�#w�fl�ru p�st ye�us't+ecort�. ��
You mast provi�e ne.�v c�apio�ssd maint�a lite at y�r rM�iiel��sat.
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P$RSON IN CIiARQE:
F.ach food ' mwt l�eve at Icast oa�c P�Iu t;�(PIC)c�site durit�l�c►�us of operatimi.
I. 2,
ALLERGEN CERT[Ft�AT'IQNS:
Alt food se�vicxestabii�uonaqui�m hnve a�t kastsme fidl-time ernployee wbo h�s All�c�atifit�n,
as de�d in d�e Staie S�itaEy Gode foor Food�Bwablist�a,1D5 CMR 590.t�9(Gx3j(a�. Please+W�c3�
copiea of cati6c�ion to thia appliaatian. Tks He� +�1 not me�t y�ars'�+erarda. Yae a�eat .
Pr+ovid+e uw'eopie��ad otabttsio a!ik st}�ar a�tt
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HEIML[GH CIItTI�ICAITONS:
AU faod�nvi�t e�abii�wi�2S�ta c�r ma�+e muat�ve�lasst ane�v�e trained ia tt�H�ch
Iata�uv�oa���t�21 t3enes, Ple�e+�l�t� �i:t� �asd
attach copiea of e�nployee cea�eations to ihi�fi�m. Ttie �i11 ao�t�past years'�srd�.
You mnst Prov�e asw ee�i�s ud mai�l�In a#�e at y�r�n bsde�eu, '
1. 2
3. 4,
RE3TAURANT SEATtNti: TUTAL#�
i.onGnvc:
(3FFICE USE ONLY
� ��ss r.�urr r��arqu��� r�n�r� ��Qu�� ��
• �,►iu�p� s�� _�r�aE,�i��g�o$2
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' � r�wurr �c�� � e�rr �t�.r�rt��� �'�ti�r�
a�se���� s�o —
c,�orr vrc. s6o
x�r,►g.�tvrcx: _'—��
��� Fes re�rrr uc�
`30°�' ts° '_^�,��� �rra ���� ��
_Q3. sq.A. fl� T SM! �taUHACCO ii10
r�c�n�ca: sts AMOUNT DDR = �_��(�j
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�rr��tp�,�y 7VRN OVRR Ai11D L�T$1377IER$ID$OFl�OlfM��sr• '
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Und�r Ci�apter 2 52,Soctian ZSC,S�b,t�Town ofYmnaouth is oc+w csquiKsi tu lwl�!' ot'ra�n+evval
of mry license or pexmit to aperate a bvsin�eas if a pc�cso�a�caatgany d�mat t�a G�e�f W�csr'e
Compea�satian Lnssuaa�. THE ATTAG�D �'i"ATE WUItKEIt'3 C�MP'�NSATit?PI I1+�URAAiGE
AFFIDAVIT MLTST SE�UIVIPLET�D,lAt�!SIG]'fT�p►UR
GERT.UF INSURANGE ATTAiGGI�D
OB
WC1I�KER'S COMP.AF�iDAYTT Sit#NED AND ATTACFi�D
Towa of Yarmouth taaces�i l�s musE he p�iti pa�i�r io rc�ewat�issuancc of yo�r peAnits. FLEASE CHEGK
APPROPRtATSi.Y IF PAID:
X�s X rro
�o�'�s uvn o�ton�n+r��s�r,�a�ss�twrs '
TRAN5SIEIVT UCCUPANGY: For purposes of ttts limitafivas of Mo1ei or Hotel u�,Transir.nt occupancy shall be �
limited ta thc �d�i�nn �r������te!�nd hotsd ux.
Tr� mss�1�►a�d be d��i �ut`� : " ' '�s�
�.Tiaasia►t acc�ncy sh��mallY ref��o��ae�y�not mute�f�+C��re►�d
an aggregatn of nat morcthmn srindy{90)days within any six(�mas►th� U�e ofaguest tmit oam�ce aa�
dwelling unit shall not be contidered transiait. C}xupatsc}*tlmt is subject to the calla��af Room Oc�ancp
Excise„as d�fined in M.Ci.L.c.b4�G or$30 CMR 64f3.��d,ehall�one�ally be con�dered T�.
POOLS
POOL OPENING:All ' wa�iing at�I ' �hm�clooed f�t�e saac�muqt be i�pecmd
by the Heaith D�tm�r�t�'to o ng. C,�mc�# Hs�th pD� actm�t��odaie ffie tlurse(3)
dsyi Priar to o PLFrSr�E�:P�C mra NQT allowed to sit in dme paol�imdii poed]s�a bs�n
inspxted and op�ed•
POOL WATER TFSTING: The w�er�be tcs�for��tat�l a�tifoarn aed�ip}�e c�►t
by�ce�Aifiod lek,>�ud submittad to the He�1.th�t t6rte(3)dmrys�tQ openiag,scd s�t�ly
�L GI.O�IN6;Eveay oucdoor in graunci swimmisg paal must be dtain�d ar cc�vez+ed vvittun a�w�(�daya of
usinB•
FU(1D SEBYICE
SEAt�ONiAL FOOD SF.RVIG`�QFEI'�TI1VG.
Ali faod service establ�st�►�m�bc ias,�aaed by d�i�k�alt�D�prior te op+�Lg. Pleese�t#he '
Heahh Dcpartmmt to acheduk�inspocqcn dget(3)dsys p�iar to apeaq�g• ,
GATERING PULICY: �
A�nyone wha cakrs within the Town af Yaa�th m�at notify tl�e Ya�uth Hea�ith b��g t3� '
reqvired T Foad Sarviae�p licati�finm T2 I�urs prci�ir to the cnt�od cvmt 'I'�C�c�n be
abtaianesd a#tbeHf�th Dqmr�az,ar i�mn t�e'Tuwra's v�t�te at uader Hai2th De�p�.
DawNoadeble Farms.
FROZElY DESSERTS:
Fmxen desserix mu�t l�e testeci tsy a State eert�f"xed lab�to : and m�thty ther�after,with sample results
Des�t Pa�mi ta�l��have been mtz. �It ra�lt ui suspe¢�aion or r+evocatia�a�your Fro�n
4UT3ID�CAF�S:
Outaide c�fes(i.e..oe�tdaor a�ting with vunik,rhvaitreas savme}>a�t have priar'+�'�al from the Bo�d of I�.
I OUTDOpR COOI�TG:
I �°O��P�����1SY��Y�P�63'�r�il or€aod seiwloe ea�b�t is p�r�ed.
;
�' NOTICE:Peamits r+m aaauaUy&om Ja�susry I�c D�cnbec 31.iT IS YU[1RRE5Y'DlaiSiiBIL11'Y TU RET't}RN
. 'hIE COMPI�ETED R�T+IEWAI,APPi.ICATIt?N(S)AND REQtJiRSD FEE(3;BY DEGEMBSR IG,20iG. i
' ALL RENOVATIONS TU AItiiY FOOD EST �;t��NT, MUTEL OR F�DQL (ix.. FAdNTxt+IG, NEW (
( EQUIPMENT.ETC.�MU3T 8E REFORTED AFP O B T[iE BQARI?OF HEALTH FRICIR I
TO COI��EMENT. RENOVATION� ,
pA�: May 22, 2017 g3�p,�: '
p�Np�y{E��; Andrew Witter, Manager
a�.imivis
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� The Co�nro�wu�JY ofMtrss�u�t�`s'
laeepartn��nfl�rdr�lAc�ents
O,�ce ofl�es�i�s
1 Catg�ess,�ee�;S�tt IOU
Barta►u,MA P211�#-Z017.
www.mas��vld�tar
Workers' Compcm�t�n Ia�ar�se�A�'Idari� Genera!B�es�
.�otica�t Iaform�tion Pl�e Pariu�t L�eali�iv
BU31riCS3/Oi�;B�iZ&�1pII�AtqC: Buck Island Village Condominiums
A�; C/O First Property Management 1046 Main St. Suite 11
City/StateJZip: Osterville pb�#; 508-420-0299
Are yon An empbyer?c�oClc the�tppropriats baz: Bosint�T�pe{required).
1:'�' I�a�� 0 ���� 3. :❑R+�4ui
�'P�'t-�)•� 6. ❑Reatauraa�'Barl�sog EstelaU�actrt
2-❑ I am a sole proprietor or�ip and have no 7. ❑t�'ice andfor Salea(imel.real�,�Ga,�c.)
anployee�working for me in any cagecity.
[No workers'comp.insurerlce reqturedj 8. ❑Non-pmfit '
3.❑ Wc are a cflrporation and i1s offic�s l�ave� 9. ❑Etit�tai�tunenct �
tfieir right of exemption pe��. 152,�1(4},atd we have I O.n Mamuf�turit� ;
no en�loyees,[Tto warke�s'ts�tnp.it�u�race r�ed}*
4.❑ We are a non-profit arga�i�s�,�ffed by vah�tae$a� X i.[]Heah�C�ne
with�na angloyo�,[No vrctrkcxs'comp.insur,�re�q:J i2,�t�
•Mq�plicent d�t cbeda�bar A�1�ut aba P�f1 a�t tLa sactiao betaw��ar+��eir�vcrlcros' ` p�tic��infaemrtiae.
ssIf the oarpa�abe oi�a hs►ne oa�empmd t�vp�,�tla uarpontioa laM other amployaes,s w�ae�mes• paiiay is e�+ed and wc��
ar�dan s6ould�bmc�!1.
I a��t e�doys tb�� w�'rr� �e je�r niry�y+oe� Bes�la�po�'�'b�r.
In���y N�• Norfolk and Dedham Mutual Fire
Insur��s pddnss; 222 Ames St.
Cjty/S�p; Dedham, Ma. 02026
Policy#a Sel#=ins.Lic.# wE145637A �����: November 8,2017
A�a co�r oi't�e'w�nrlt�rs'ca�tg�a�tt�a p�c�*�ae�trE1l�aa p�eti{sitt�tlr�ptr�ey aturber��irstloa dtie�.
Failure to s�au+�t:c►vNge ss tbquired�Secti�n 25A af M�"r�.�. �52 c�pn�d to t1�e i�positio�af ari�l pan�ltiea�ofa
fiae up to�1,500.00 aad/or one-year imprisvnmen�a�s well as civil penalties in t�e form of a as'11C)P WOR��J►Rt�ER and e fin�e
of�r ta 5250.00 a da�r a�,ainst t�violator. Iie advi�d th�t a c�y sf th'ss may be fon�var�ed w the Qffioe of
Inves�igat'rc�as tbe DIA for instttance coverage veea�ific�a�i�.
I do A�,by , F��jP�:�►��e�'� �b�+r 3itr�re�rad car�ct
May 22,2017
��. 508-494-6456
D,�9cfirt rrae oul}s. D�o�eo,t wr6ot i��tikis+a�ras,��e�a�ed�g c�'o�'�Q,,(�
City ct�Towa• Pet�oaitJl.�es�Oee#
Ie�ai�Aatirority(dircle o�}:
�.�of Healt� 2.��p�� 3.Ciutyli�Clecic 4.T�i�HosM S.�e�'s 418oe
Cost�et Person: p���
vr�vrir.n�a.�av/�s
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F���t �'�� �rt
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I'4+t A N �i E � E IV T
1046 Main Street Suite 11 Telephone 508.420.0299
Ostenrille, Ma. 02655 Facsimile 508.420.0789
www.fpmcapecod.com
October 27, 2016
Pooltection
PO Box 496
East Dennis MA 02641
Dear Dave,
Attached is the 2017 pool permit application for Buck Island Village. Could you please complete and return it
to me with the appropriate certificates of insurance and CPO licenses.
Sincerely,
Andrew Witter, Praperty Manager ���
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