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� TOWN nI+YARMOUTH BOARll OF HrALTI-1 ��V �2 Za 17
��3�� APPLICATION rOR LICENSE/PERMI't'-2018
\'"'' �I'lease complete form anci attach all necessary documents by December LS 2UI . ,
F'ailure to do so will resuit in the return of your applicat�on packet. �'�'��T� �EPT.
ES'IA�I,ISHMENT�NAML: or TAXT : — i
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OWNER NAMI:?: r�
CORPORATION NnME(lF APPC,ICABLE): '� L `��;�
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I?OOL CERTIFICA"1'IONS:
'I'he pool supervisor must be certi�ied as a Pool Operator,as required by St�te law. Please list the design<lted
Pool Operator(s)anii attach a copy oYtl�e certification to this ti>rrn. , r��r
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Pool aperators must list a minimum of two employees cui7�ently eertitied in standard First Aid and Communi�v
Cardiopulmonary Resuscitation(C'PR),having one certifiecl employee on premises at�all times. Please list the �
employees below and attach copies of their certificati�ns to this form.The Health llepaa-tment will nnt use past
ycx�•s' recards. Yau must nrovide new copies and maintaiu a file at your place of business.
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1�00D PP.O'I`I�C�'I'1C�N MAN�AGI;RS-CFR'I'II�ICf1`I'IONS:
All food service cstablisliments ace rec�uired to have at lezst one full-time emplc�yee whu is certified as a Food
Protection Manager,as detuied in the State Saniiary Code for Fqod Service Establishnaents, 105 CMR 590.000.
Ptease attach copics of certification to this application. The t�ealth Uepartment will not use past years'records.
You must pe•ovicte new copies and maintain a�le xt your establishmenk.
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PERSON IN CHARGE:
I;ach i�>od establishment must have at least one Persan In Charge(PIC:)on site during how•s o{'vp�raticm.
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�LLERG�N CERTIFICA"I'IUNS:
A(1 F�od service establishments are required to have at least one fiill-time employee who has Allergen certiticati<>n,
as defined in the State Sanitary Cade for Food Service Establis(�ments, 1 US CMR 590.009(G)(�)(a). Pleas�attach
copies of certification ta this appiication. The Health Department will not use past yexrs'records. You must
provide ne���copies and maintain a tile at your estazblishment.
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t-CE[MI,1CH CF;RTIFICATIONS:
Al( food service establishroents with 2� seats or rnore must have at least one employee trained in the Heinalich
Maneuver on the pmmises at all times. Please list your employecs trained in anti-choking proced�u•es below�md
attach cc�pies of einployee certificaYions to this i�orn�. The Health Department will not usc past years'reeortls.
Yau must provide new copies and maintxin a�le at yuur piace of bnsiness.
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RIiSTA[JKANT SE:AT[NG: TO`rAL#
� . OFFICE USE ONLY
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�IC E NSIi RI:QUIRE{I> f l,li Pi R��1'1'� 1,1<1 NSfi R[i(IUIIZI:D 1 l'Ii PI!:Rblll'ir LICP.�tit.I.I:(1l�Ihf:U FF.t. (I f',\-Il :? �}�'�s�.� `�
I3�X13 '6ij ( �(31N $55 1 bit)tf'i $I10 �'��
�nn $>� -_ __c.�,Mi> $�5 ------ �SUIM�1lNG>>c�oi.xiio� boo7 OcNSP-15�341"�3C�
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FOOD SGR�ICL:
1[(['.vS[;f i Q111kt::U 11;E NGI M'C: LICLVSG RLQUIRI:iD 1 t li Plif b111'6' I.IC.'f?N11 kl Ql�litl D t[?I PI'iR�tll'iP 60�.P��S�S���3��
. �0-1005I�IS SI?� �� �CON1'INLtiI':�L ��5 �1�� NOiv PROPIC `�30
100 SI:ATJ 42t)0 ---. � C.UR1Mt)14 41C'. �,GU �.(�b� __btlit)I I 5\I F �so ---- �ot�F'►5�6857-�$
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RI'TAIL St R�ICl
IICt:NSt;RLQI�IREi? fltP: PERMI�I'� LlC[RSERCQUIREf) I I F. PE3RM1"frl l.l(.k?M[:It[:(,>t'IELI;I) FEI. PLILMfI i�
�50 sqJ�. ��0 � �S.QO(I ay It �38:i VF,�IDI;JG-I Ol)D �2i --
2�,U00 sy.li. �ISo -_k CiU7f:N UESSE;R7' :6JQ �_`f013�1CCt.7 91 l�l
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ADMINISTRATION
Under Chapter 152,Section 25C,Subsectian 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACEIEU STATE WURKER'S CU1�4P�NSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE A'I'1'ACHED V
OR
WnRKER'S COMP.AFFIDAVIT SIGNED AND A'i"I'ACHED
Town of Y�umouth taxes and liens must be paid prior to renewal or issuance of your pez�nits. PLEASL CH�CK
APPROPRIATELY IF PAID:
YES�_ NO _
MOTELS ANll 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 customaiily associated with motel and hotel use.
Tr•ansient occupants must have and be ab(e to deinonstrate that they maintain a principal place of residence
elsewhere."fransient occupancy shall�enerally reter to continuous occupancy of not more than thirty(3U)days,and ,
an aggregate of not more than ninety(90)days within 1ny siY(6)month pei•iod. 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 64U,as amended,shall generally be considered T'ransient.
POOLS
PO(}L OPrNING:All swimming,wading and whiripools whicl�have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department ta schedule the inspection three(3}
days prior to opening.PLEASE NOTE:People are NO"I'allowed to sit in the pool auea until the pool has been
inspected and opened.
POOL WAT�R TESTING: The water must be tested Ibr pseudomonas,total calif��nn and standard plate count
by a State certified lab, and submitted to the Healch Department tliree(3) days prior to opening, and quarterly
thereafler.
POOL CLOSING:F,very outdoor in�round swimmin�pool must be drained or covered within seven(7)days of
closing.
FOOD SCRVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prim�to opening. Please contact the
Iieaith Depa��tment to schedule the ins}�ection three(3)days prior to opening.
CAT�RING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depa►Kment by filing the
required Temporaiy Food Service Application forni 72 hours prior to the catered evenL These forn�s can be
obtained at the Health Department,or trom the'1'own's website at www.varmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN llESSLRTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly therealter,with sanlple results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Peiniit u�7til the above terms have been met.
OUTSIllE CAI+�:S:
Outside cafes(i.e.,outdoor seating with waiter/waitress seivice),nu�st have prior approval from the Board of Heahh.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any foad product by a retail or food seivice establishment is prohibited.
NOTICE:Permits rtm annually from:�anuary l to December 3 t. IT IS YOUR RESPONSIBILITY'I'O 1�,"I'tJRN
7'1 iE COMPLE'CED R�NEWAL APPL1CATlON(S)AND REQUtREU FEE(S)BY llL;CEMBER I5,2017.
AI.I, RENOVA"I'IUNS TO ANY FOOD ES`lABL1SHMENT, MOT�i. OR POOL (i.e., PAINTING. NEVv
EQUIYM�N"1',E'1'C,),MUST BE RF,PURTFD TO AND APYROVED BY'I'HE BOARD OF HEAL1'fi PRIOR
TO COMMENCEMEN"C. RENUVAT(QNS MAY RE UIRE A SI"I'E I'I.AN.
DATE: I��Z��(�" SICiNATURL:
PRINT NAME&T'I"I'LE: n-0D S�OC-Z"FNS IG1 C!.I�•
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 26158
POLICY NO. ` �MZ-800-8003721-2017A
PRIOR NO. WMZ-800-8003721-2016A
ITEM
1. The Insured: Travis Hospitaliry I�c
DBA: Bayside Resort Hotel
Mailing address: Rt 28 FEIN:"-`*'
225 Main Street
West Yarmouth, MA 02673
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 04/01/2017 to 04/01/2018 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 work in each state listed in item 3.A.
The limits of liabiliry 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: Coverage Repiaced by Endorsement WC 20 03 06 B
D. This Policy inciudes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 362922
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $292 Total Estimated Annual Premium $15,432
GOV GOV Deposit Premium $4,093
STATE CLASS
MA 9052 State Assessments/Surcharges
$16,775.00 x 5.6000% $939
This policy,including all endorsements, is hereby countersigned by ����1�� 03/13/2017
Authorized Signature Date
Service Office: Rogers&Gray Insurance Agency
290 Donald J. Lynch Boulevard 434 Route 134
Marlborough MA 01752 South Dennis, MA 02660
WC 00 00 01 A(7-11)
�includes copyrighted material of the Nationai Council on Compensatfon Insurance,
used with its permission.