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HomeMy WebLinkAboutApp, WC, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-16-10888-05 Issue Date: 1/1/2021 Mailing Address: Location Address: SURFCOMBER INC. 107 SOUTH SHORE DR SURFCOMBER ON THE OCEAN SOUTH YARMOUTH, MA 02664 107 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Motel This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions MOTEL ROOMS- 33 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 411 / _ Bruce G. Murphy, PH, R.S., CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-16-10891-05 Issue Date: 1/1/2021 Mailing Address: Location Address: SURFCOMBER INC. 107 SOUTH SHORE DR SURFCOMBER ON THE OCEAN SOUTH YARMOUTH, MA 02664 107 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions OUTDOOR SWIMMING POOL Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . C Bruce G. Murphy, MPH, R.S., CHIP /Mallory R. Langler, R.S. Health Director/Assistant Health Director Sur`l-cc—e.. 02 OCP n pF.... TOWN OF YARMOUTH BOARD OF HEALTH E. .,,,) APPLICATION FOR LiCENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. \y.�a . Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Su, Fcor,ber .A N G TAX ID: () LOCATION ADDRESS: 10g 5ntn-irlll 5teto,be_ Dr..vt , 5. \PcMo,,,ih TEL.#: 508 3q4 $q3O MAILING ADDRESS: t I t , i. ,, ,. , E-MAIL ADDRESS: „\ .,, e Si,,i`CoM6cr 8& MAL ocean _�.o _ OWNER NAME: Kefri T to Gst.n CORPORATION NAME (iF APPLICABLE): SAr („,..0,.e..,- ,. nc , MANAGER'S NAME: j u5-e -- n3614 TEL.#: 508 3 94 8 ' 30 MAILING ADDRESS: \(a. 5. Sckr:l.. Dr. S • `fdsrlo.A-111 AA O2l0GL( POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a Copy of the certification to this foim. . 1. -Su e.)\- k Z43ol A 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. JVSk1 leNJ Oto 2. Ml�-szkP1/4 -r0��VR. 6VA 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. -PERSON 1N-'HARGi; Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years'.-i ecords. You must I provide new copies and maintain a file at your establishment. I. DEC 'I 5 2020 HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the I leimlich 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 toren. The 1-iealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 2. 3. 4. - RESTAURANT SEATING: TOTAL it OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT ll LICENSE RI Ql1IR1?.i) PEI: PERMIT 11 LICENSE REQUIRED FEE Pt RMII it o 0.0 a•cc CA RINI 4:55 I MOTH. S11i1 ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town o['Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED X OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or I lotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)clays, and an aggregate of not more than ninety(90)days within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the I lealth Department prior to opening. Contact the I lealth Department to schedule the inspection three (3) clays prior to opening. PLEASE NOTE: People are NO'!' allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, and submitted to the I lealth Department'three (3) clays prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the I lealth Department prior to opening. Please contact the Health Department to schedule the inspection three (3) clays prior to opening. CATERING POLICY: Anyone who caters within the "town of' Yarmouth must notify the Yarmouth health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department, or from the "t'own's website at www,y_lrmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the I lealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENFWAI APPI I ATI(IN/C1 ANn RFni IIRRn r.Pi:ic\ RV nrr►.nnncn is lnyn 4/9/2019 Saba American Red Cross Certificate of Completion Justin Ingold has successfully completed requirements for Adult and Pediatric First Aid/CPR/AED- valid 2 Years conducted by American Red Cross • 4' 4 • R • • Date Completed: 04/06/2019 tree: Instructors: Richard A.Stabile Certificate ID:15UYSB To verify,scan code or visit: redcross.org/confirm https://classes.redcross.org/Saba/Web/Main/goto/FullCertificate?t=15UYSB 1/2 Certificate of Completion 411. Maria Todorova has completed the requirements for American Adult and Pediatric First Aid/CPR/AED Red Crass conducted by Q" p American Red Cross Date completed:06/11/2019 Validity period: 2 Years am Certificate ID:16NDXT Scan code or visit: redcross.org/digitalcertificate https://classes.redcross.org/Saba/Web/Main/goto/WalletCertificate?certificate_n:ode=student&t=x000000071635025 7/12/19.8:25 AV Pagel of �•-. •.'•,P'� I'S �e • ��{ �; ,� --Az,• v4,• �� .. .•.4'4,',i''',.'h .l; -s,,,././.--...-1,- �ti�a J ;• y' 'x t i. 1 $9A 3 - t �y � �t^Sx ri Y JS r ,r• ;� x5' t1 •�� s s •r. •x..111 s°�` atz,.� t. 1 :1� r � i v >'�} ' � `_, ♦� _'". „ . ,, --e,, ,;;,-:„.-1, .... - — .! s s,.... ..... ,,,, t,„ 6titiLL9-L660E1 �„,, •. ® t i' ` _. -.>,moi. I— 0 - , sizz-`� Y � CZ {6s' ,:bo ei u s a iNwit, s"e e ° '� \ > • ,ate 4• el .c - •••••=-4_---- u -- fir- 6--i 4.o b . 1 .y�/: _ ° t� y 0 0 \ 0 U \r.\If”..;4e, J Ili Z --------,.-- 0 C-..\\\,-.> - iis' Cyd x, . "w ._ _ /Lw�, \\ � ,Y'. 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The Insured: Surfcomber Inc DBA: Mailing address: 107 South Shore Drive FEIN:**-***6310 South Yarmouth, MA 02664 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 01/01/2021 to 01/01/2022 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 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: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes 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 000120204 INTER SEE CLASS CODE SCHEDULE Minimum Premium $276 Total Estimated Annual Premium $2,903 GOV GOV Deposit Premium $748 STATE CLASS MA 9052 State Assessments/Surcharges $2,460.00 x 3.5100% $86 This policy, including all endorsements, is hereby countersigned by '� 11/20/2020 Authorized Signature Date Service Office: HUB International New England LLC 54 Third Avenue PO Box 696 Burlington MA 01803 Wilmington, MA 01887 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.