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HomeMy WebLinkAboutApp, License & Certifications A//ii d7`�7 �Io tL TOWN OF YARMOUTH BOARD OF HEALTH lir AA APPLICATION FOR LICENSE/PERMIT - 2021 * 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: Cc1 C cUndr1 fi TAX ID: 16- r 13 ct Oct LOCATION ADDRESS: I 15- FLOit C , i t Lvc(4Ye rnlorUJI— /KKA TEL.#: *R411- QI a MAILING ADDRESS: Sc-ril,G E-MAIL ADDRESS: c_01 04 el 'i c OWNER NAME: �� �� CORPORATION NAME (IF APPLICABLE):: "" Qtk li ft,'ilafdTAral MANAGER'S NAME: 4_ 1k-ej L a.,/4 T L.#: . / 4� MAILING ADDRESS: , , C'an e_ / litre y ii; 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 fonii. 1. 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. 1. 2. 3. 4. Th FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one hull-time employee who is certitied 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.�as _ You must provide new copies and maintain a file at your establishment. 1. APR302021 PERSON IN CHARGE: HEALTH DEPT. 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 lull-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. 1. 2. 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 Health 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: LICENSE REQUIRED FEE PERMIT!! LICENSE RI QIIIRFD FEE PERMIT it I ICENSE REQUIRED FEE PERMIT B&B $55 ('AKIN 4;55 j .A(VFL I IP I I It ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town ot'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 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 —TRANSIENT OCCUPANCY: For purposes of'the limitations of Motel 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.E. c. 64G or 83Q 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 he inspected by the I Iealth Department prior to opening. Contact the I Iealth Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People are 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 in-spec-ted by--1h; I leah1t-Departincra }n for to opening. Please contact the Health 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 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"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 Ilealth 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 31. IT IS YOUR RESPONSIBILITY TO RETURN m��r ,,flk A nr rTml r" n 17/, 17II/A I A nm it A fJf'KUC\ A TNF' I)L:ni bio rr rrric\ RV nrOr.NARRR I R 'NM The Commonwealth of Massachusetts Fee i°6°' Town of Yarmouth $110.00 Lodging License Number: BOHL-21-3576 Issue Date: 1/1/2021 Mailing Address: Location Address: WINDRIFT MOTEL 115 ROUTE 28 CAPE WINDRIFT MOTEL, INC. WEST YARMOUTH, MA 02673 88 CONSTANCE AVENEUE WEST YARMOUTH, MA 02673 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 EAST MOTEL: 18 Units; 18 Bedrooms WEST MOTEL: 18 Units; 18 Bedrooms Cottages 1 through 8- Separate rental permits. Existing house, 29 Baxter Avenue, is housing rental. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston IP4 Bruce G. Murphy, MP , R.S., CHI / -'•ry 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-21-3578 Issue Date: 1/1/2021 Mailing Address: Location Address: WINDRIFT MOTEL 115 ROUTE 28 CAPE WINDRIFT MOTEL INC WEST YARMOUTH. MA 02673 88 CONSTANCE AVE WEST 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 Bruce . Murphy, M'I , R.S., CH Il/Mal,:- R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents p• t ./. _%�l� vOffice of Investigations t =; ,, 1 Congress Street, Suite 100 �,^= = Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: V CA- €. W i (2Wr "'lel Address: f /SOU' g y< City/State/Zip: W es r yfrRmv urN 0.37.3 Phone #: 179— d6Tc-- 9 I O3 Are you an employer? Check the appropriate box: Business Type (required): 1.X I am a employer with '2— employees (full and/ 5. E Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required) 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing E..] no employees. [No workers' comp. insurance required]* . 11.7 Health Care 4.LJ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.11 Other A 9 SQ i rot i rf `. _y applicant that checks box n l must also fill out the section below showing their workers' compensation policy information. "If the corporate officers have exempted themselves,but the corporation has other employees,a workers' compensation policy is required and such an organization should check box€l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: I) Tt, rtlu7t'F 'i -vdva.4rvLt_ turyrrP l Insurer's Address: City/State/Zip: Policy or Self-ins. Lic. r 5('j i etcx cladat 1 Expiration Date: 03 /4 is t,20&-Z Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains//// and penalties of perjury that the information provided above is true and correct. Signature: / 2cctr�-1L k 4 Date: 7[ '7. 9 C7' l Phone 4: 941/ 6 t- C/(9,3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: 1 ww .capecodsa..fetytrammg.Com �-°gyp` S� NSC First Ai a d Course ., 2 county` OSHA CPR 1910.151 Includes Epi-Pen Name: Sajendra B.Chitrakar Security Control No. Address: Windrift Motel 202032 Address: 115 Main Street, Route 28 City, State, Zip: West Yarmouth, MA 02673 - Course Completion Date: 0413012021 , Training Center: Cape Cod Safety Training Expiration Date: 04/30/2023 Instructor Name Rick Todd • Instructor Number:1 1040918 Sajendra B. Chitrakar has successfully completed the NSC First Aid Course. 7i The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED ,toz ,r>�,9 Security Control No. _©' 202022 �. _Q� °°44 `6 Sajendra B.Chitrakar �' has completed the (�av wS Irv'cO44���.s NSC First Aid Course We want your feedback! Please visit nsc.org/firstaidevaluation to Training Center: Cape Cod Safety Training Completion Date: 04/30/2021 take a brief survey and share your opinions Expires: 04/30/2023 Instructional Hours: about the NSC course you completed. *1040918 Instructor Signature Instructor No. \NSC-in it for life. nsc.org/fatrainin! Keep this card for your records.Void if reproduced. 30M04032019 1015 900008129 ©2016 National Safety Council 79173-0000 www_capecodsafetytraining.core NSC CPR Course a -4154, < OSHA CPR 1910.151 °°"`' © Adult, Child, Infant, FBAO & AED Name: Sajendra B.Chitrakar Security Control No. Address: Windrift Motel 873108 Address: 115 Main Street,Route 28 City, State, Zip: West Yarmouth,MA 02673 Course Completion Date: 0413012021 , Training Center: Cape Cod Safety Training Expiration Date: 04/30/2023 Instructor Name?. Rick Todd Instructor Number:* 1040918 Sajendra B. Chitrakar has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. ir The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining \ / THIS DOCUMENT IS VOID IF REPRODUCED o.•a,t<. Security Control No. o�.�s*, �0l Sajendra.B. Chitrakar 873108 �4NG mcor, has completed the NSC CPR Course We want your feedback! Adult,Child,Infant FBAO,CPR &AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 04130 12021 take a brief survey and share your opinions Expires: 04012028 Instructional Hours: about the NSC course you completed. ,e tca� !..1q #1040918 Instructor Signature Instructor No. ,NSC-in it for life® nsc.org/fatraining Keep this card for your records.Void if reproduced. 50M04012020 1015 900008130 ©2016 National Safety Council 79174-0000 www.capecodsafetytraining.COITI gyp` S NSC CPR Course a s < OSHA CPR 1910.151 °°"`' e Adult, Child, Infant, FBAO & AED Name: Bhadresh Patel Security Control No. Address: Windrift Motel 873176 Address: 115 Main Street,Route 28 City, State, Zip: West Yarmouth,MA 02673 Course Completion Date: 0413012021 Training Center: Cape Cod Safety Training Expiration Date: 04130/2023 Instructor Namer Rick Todd Instructor Number:4 1040918 Bhadresh Patel has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED , 4 Security Control No. oNa,s� :i4(>� Bhadresh Patel 8731 cO� has completed the NSC CPR Course We want your feedback! Adult,Child,infant FBAO,CPR BAER Training Center Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 04f301 take a brief survey and share your opinions Expires: 04f3012023 Instructional Hours: about the NSC course you completed. ccs i`a;Y7 #1040918 instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining Keep this card for your records.Void if reproduced. 50M04012020 1015 900008130 02016 National Safety Council 79174-0000 Wr arm { "" www.capecodsafetytraining.com S9� 0Z NSC First Aid Course < cvUNG OSHA CPR 1910.151 Includes Epi-Pen "P°* Name: Bhadresh Patel Security Control No. Address: windrift Motel 202031 Address: 115 Main Street, Route 28 City, State, Zip: West Yarmouth,MA 02673 Course Completion Date: 0413012021 , Training Center: Cape Cod Safety Training Expiration Date: 0413012023 Instructor Name.* Rick Todd Instructor Number: 1040918 Bhadresh Patel has successfully completed the NSC First Aid Course. The National Safety Council eliminates preventable deaths at work, in homes and communities,and on the road through leadership, research,education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining 's. T \ J THIS DOCUMENT IS VOID IF REPRODUCED It 1:tn. '� T o w.as - Security Control No. 31 �5V-' ,. S- Bhadresh Patel 2 0 ,�,,,{� o„.o•s has completed the NSC First Aid Course We want your feedback! Please visit nsc.org/firstaidevaluation to Training center: Cape Cod Safety Training take a brief survey and share your opinions Completion date: 04130/2021 about the NSC course you completed. Expires: Instructional Hours: f4�n #1040918 ra i&>,7 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining Keep this card for your records.Void if reproduced. 30M04032019 1015 900008129 02016 National Safety Council 79173-0000