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HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-2171-06 Issue Date: 1/1/2021 Mailing Address: Location Address: AUM CORP. 41 ROUTE 28 SUPER 8 MOTEL WEST YARMOUTH. MA 02673 3 ALGONQUIN DRIVE BURLINGTON, MA 01803 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 11/ Bruce G. Mu shy, MPH, R.'/, *CHiclory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee /.* Town of Yarmouth $35.00 Food Establishment License Number: BOHF-17-2279-04 Issue Date: 1/1/2021 Mailing Address: Location Address: AUM CORP. 41 ROUTE 28 SUPER 8 MOTEL WEST YARMOUTH, MA 02673 3 ALGONQUIN DRIVE BURLINGTON, MA 01803 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Continental Breakfast; 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. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston / • / i Bruce G. Murphy, MPH,R.S`, r 0/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-2170-06 Issue Date: 1/1/2021 Mailing Address: Location Address: AUM CORP. 41 ROUTE 28 SUPER 8 MOTEL WEST YARMOUTH. MA 02673 3 ALGONQUIN DRIVE BURLINGTON, MA 01803 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 *40 Units; 40 Bedrooms. 1 Manager's Unit; 1 Bedroom. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . ruce G. Murphy, MPH, R.S., C /1 /11ory R. Langler, R.S. Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH t+ ;' APPLICATION FOR LiCENSE/PERMIT - 2021 i = * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 5u TAX ID: LOCATION ADDRESS: `-f 1 e 2-g e),(A• old TEL.#: MAILING ADDRESS: tGr)N6X)(nl 'fJ°elvc U12L, ioaG( ovi3 E-MAIL ADDRESS: AukA �P®`F' t-tc C) Gebt4 — -- — — — OWNER NAME: ch S't1 aF- Phrr—'— CORPORATION NAME (iF APPLICABLE): 41-uM MANAGER'S NAME: . .A c TEL.#: I £ c---/L-i1 21/L44 MAILING ADDRESS: 3 ALG-c*16c)c & j3)/2 r krc. ,NuptiNterroc.4 ofylA nF'0-3 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 form. 1. OCC-N1 p�L- 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 ° 5 u PQ 1f-� 2. C 1. �i 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one gull-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 pastye rs' records. You must provide new copies and maintain a file at your establishment. MAY ZOZ1 1. HEALTH Cil=lfi: PERSON IN CHARGE: " Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. I. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The i-Iealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. • 1. • 3 4. RESTAURANT SEATING: TOTAL # • OFFICE USE ONLY LODGING: .t cri n1:12Mi'i'11 LI('PNSI?RI.QIIIRP.I) FEE PERMIT II LICENSE REQUIRED FEE i'IiRMI" II . ��ArYrL� 4.1 IIi ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required tb 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 t--/- 01? /01? 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 ofMotel or I lotcl 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 lcalth Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening. PLIASIi NOTE: People arc NOT 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) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) clays of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must he inspected by the Ilcalth Department prior to opening. Please contact the 1 lea Ith Department to schedule the inspection three(3) days prior to opening. CATERING POLICY: Anyone who caters within the 'Town of Yarmouth must notify the Yarmouth I lealth Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.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 lcalth 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 l'rom 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 R FNFUUA r ACCPREI DATE(MM/DDM'YY) '� CERTIFICATE OF LIABILITY INSURANCE 05/11/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: DOWLING &O'NEIL INSURANCE AGENCY 973 Iyannough RoadNE _ {A+c,No): P.O. Box 1990 ADDRESS: Hyannis, MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NorGUARD Insurance Company _ 31470 INSURED INSURER s: Super 8 Motel Super 8 Motel INSURER C: 3 Algonquin Dr INSURER D: Burlington, MA 01803-3601 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW:-LAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER I POLICY EFF POLICY EXP LIMITS LTR 1NSD WVD POLICY NUMBER ,(MM/DD/YYYYI IMM+DD/YYYY1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 CLAIMS-MADE OCCUR DAMAGE TO RENTED _____ -___ -PREMISES LEa occurrence), $ 0 • MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED r-- SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE II 1 AUTOS ONLY AUTOS ONLY mer accident) J$ UMBRELLA UAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE I ERH Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICER/MEMBEREXCLUDED? N N/A AUWC259573 03/24/2021 03/24/2022 --- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under l DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Employees: Full Time: 2; Part Time: 3 Governing Class Description: HOTEL- ALL OTHER EMPLOYEES CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MA 28 South Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE: > ,,1r// �«a ;s ©1988-2015 ACORD CORPORATION. All rights resew ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1ti