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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-1807-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SHOOSHALOO INC. 1237 ROUTE 28 THE ESCAPE INN SOUTH YARMOUTH, MA 02664 P.O. BOX 1054 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 19 units; Manager unit upstairs (1 bedroom). Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston a Bruce G. Murphy, MPH,R.S. CHO , allory 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-15-1808-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SHOOSHALOO INC. 1237 ROUTE 28 THE ESCAPE INN SOUTH YARMOUTH, MA 02664 P.O. BOX 1054 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 Bruce G. Murphy, MPH, R.S. CH• 'Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-15-1809-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SHOOSHALOO INC. 1237 ROUTE 28 THE ESCAPE INN SOUTH YARMOUTH. MA 02664 P.O. BOX 1054 SOUTH YARMOUTH, MA 02664 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 41Health Eric Weston f Bruce G. Murphy, MPH, R.S , CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director _i ke c Cer•Q- s--.-� 14 ►., TOWN OF YARMOUTH BOARi) OF HEALTH \ 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: The Escape Inn TAX ID: LOCATION ADDRESS: 1237 MA 28, South Yamouth, MA 02664 TEL.#: 508.694.7153 MAILING ADDRESS:_ _23 Mann Ave Unit 3, Newport, RI 20840 E-MAIL ADDRESS: isidro.beccar©gmail.com OWNER NAME: Isidro Beccar Varela CORPORATION NAME (IF APPLICABLE): Go Dutch Colivinq LLC MANAGER'S NAME: Isidro Beccar Varela TEL.#: 401 855 5095 MAILING ADDRESS: 23 Mann Ave Unit 3, Newport, RI 20840 .: 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 torn. 1. Isidro Beccar Varela 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 Ilealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Isidro Beccar Varela _ 2. Carolina Maria Schilling FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments arc 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 ofcertification to this application. The Health Department will not use past ' ecords. You must provide new copies and maintain a file at your establishment. T. 1. Ftp 4.g 2021 --- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site dun lg hours oloperation. 1. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one frill-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. HEIMLICH CERTIFICATIONS: All food service establishments with 25 scats 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 tile at your place of business. 1. 3. 4. RESTAURANT SEATING: TOTAL I. 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. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one frill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code fi)r 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. PERSON IN CFIARGE: Each food establishment must have at least one Person In ('barge(PIC) on site during hours of operation. I. 1 ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one frill-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. 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 N OFFICE USE ONLY LODGING: LICENSE•REQUIRED FEL: PERMIT LICENSE REQUIRED FEE P RMI.1 It I ICENSE RI QIiIR!?I) Mai PERMI•rN B&B $55 CABIN $55 II MOTTE! $110 INN $55 CAMP $55 SWIMMING POOL$1 IOca - LODGE $55 TRAILER.PARK $I(IS WIIIRLPOOI. $11(lea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT It LICENSE REQUIRED FI-:1• PERMIT It LICENSE REQUIRED FEE PERMIT M 0-100 SEATS $125 C'ONTINENTAI. $35 NON-PROFIT $30 00 SEATS $200 COMMON VIC $60 WIIOLESAEL. $50 - RETAIL SERVICE: —RESID. KITCHEN 55(1 LICENSE REQUIRED FEE PERMIT II I.10ENSFF REQUIRED FEE PERMIT// LICENSE.REQI1IRED FE.I• PERMIT II '.50 sy.il. $50 -25.000 sq.0 $235 VENDING- FOOD 525 -,25.000 Nil $ISO FROZEN DESSFRI $•Jif TOBACCO $1 11) 00 NAME CHANGE: $15 AMOUNT DUE = $ a *****/'LEASE TURN OVER AND COMPLETE OTIiER SIDE OF FORM***** L i%oi c)3� l4sO F 1 \W7-1 ADMINISTRATION tinder Chapter 152, Section 25C, Subsection 6,the Town at 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 ATTAC I LED X OR WORKER'S COMP. AFFIDAVIT SIGNET) 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 i 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)days,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 he considered transient. Occupancy that is subject to the collection of Room Occupancy Nxcise, as defined in M.(LI.. c. 64G or 830 C'MR 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. ('unmet the I lcalth Department to schedule the inspection three (3) clays prior to opening. P1,EASE 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: !=.very outdoor in ground swimming pool must he drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the 1lealth Department to schedule the inspection three(3)clays prior to opening. CATERING POLICY: Anyone who caters within the I own of Yarmouth must notify the Yarmouth !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 wcbsnc at www.2.armoutll_ma.us under Health Department, Downloadable. Forms. FROZEN DESSERTS: Frozen desserts must he 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 CAFÉS: Outside cafes(i.e.. outdoor seating with .anter w litres,service), must have prior approval from the Hoard of 1 lealth. OUTDOOR COOKING: Outdoor cooking, prepaiatiun. or display of any food product by a :, .::1 or food service establishment is prohibited. TOBACCO PROI)I CI PERMIT CAP A tobacco €' :_: ::. :. e: .' i:;+ :las sailed to renew his or her permit •. _: in thirty (,t)) days of the previous year's perms: is considered an expired license, and the license cap is reduced. _ .. - 1 ran.�iiI _ •_ transient occupancy shall _ _ irst ((t f not morem than ninety() U)days within n:. .,�, ,r n1;-. Use Ot a cae unit aS arL'S'deuce or dwelling unit shall not be considered transient. ':sc`etia r, of Room ()ccupancy l-'.erre, as defined in Iti.(i.l.. c. 64(i or 830 CMR 64(;, as amended.e ied_ , >.. tiered l r.art>rei1: POOLS Pot U C)PI I1(:: adult! and whirlpools which have been closed for the season must he inspected by the : _ ::_ Contact the Ileaith Department to schedule the inspection three (3) days prior to opcnin_. ( i i allowed to sit m the pool area until the pool has been inspected and opened. POOL \l A I LR I Ls FING: i he : :•-eudomonas. total colrtOrm and standard plate count by a State lie 7or to opening.and quarterly thereafter. POOL CLOSING: : - - •- -----, be drained of covered within seven(7)days of closing. FOOD SERVICE `!SEASONAL FOOT) SERVICE OPENING: All food service establishments must be-inspected by the Health Department prior to opening. Please contact the health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: An:.one w tens within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required I emporar} I-ood Sets tee :\pplication toi ni 72 hours prior to the catered event. These forms can be obtained at the Health Department. or from the Town's website at www_varmouth_ma.us under I lealth Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must he tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the 1 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 caks(i.e., outdoor seating with waiter waitress service), must have prior approval from the Board of llealth. 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 RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU RE A SITE PLAN. fAi DATE: 2/16/2021 SIGNATURE: PRINT NAME & TITLE: Isidro Beccar Varela - Manager _ • Ro 10 15 ty Name ISIDRO BECCAR VARELA Email address isidro.beccar@gmail.com Logon Id PH96614660 Company Birthdate 1/1/1900 I.Exam res: Test name CPO English Imperial Attempt# 1 Taken on 2/9/2021 11:39 PM Reference# 12222.3.1 Score 100% Required to pass 74% Recommended score 74% Outcome Passed Feedback on exam Congratulations on passing the exam and becoming a Certified Pool Operator!Your detailed results are below,you should expect to receive a link to your certificate within 2-4 weeks.The email will come from PHTA.org so please be sure to approve this sender and/or check your spam folder occasionally. If you have any questions please contact PHTA at 719-540-9119. Section scores Chemical Feed&Control 100% The score achieved on this section indicates a passing knowledge of the subject. Chemical Testing 100% The score achieved on this section indicates a passing knowledge of the subject. Disinfection 100% The score achieved on this section indicates a passing knowledge of the subject. Essential Calculations 100% The score achieved on this section indicates a passing knowledge of the subject. Facility Safety 100% The score achieved on this section indicates a passing knowledge of the subject. Heating and Air Circulation 100% The score achieved on this section indicates a passing knowledge of the subject. Keeping Records 100% The score achieved on this section indicates a passing knowledge of the subject. ; Maintenance Systems 100% The score achieved on this section indicates a passing knowledge of the subject. Pool&Spa Filtration 100% The score achieved on this section indicates a passing knowledge of the subject. • Pool&Spa Management 100% The score achieved on this section indicates a passing knowledge of the subject. Pool&Spa Water Problems 100% The score achieved on this section indicates a passing knowledge of the subject. Pot!Water Contamination 100% The score achieved on this section indicates a passing knowledge of the subject. Spa&Therapy Operations 100% The score achieved on this section indicates a passing knowledge of the subject. Troubleshooting 100% The score achieved on this section indicates a passing knowledge of the subject. Water Balance 100% The score achieved on this section indicates a passing knowledge of the subject. Water Circulation 100% The score achieved on this section indicates a passing knowledge of the subject. 014FE20939A323E011A10640A44049D6 n s 1 A 0 D 10 Q F • nIP- IIv O= CO Lrn II cr a Gm cin '_. CD CD 3 w Fi3 7-- a 3 0 — '�' y -.m D' . tD 3 o. — ivO,h �. 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The Insured: Go Dutch Coliving LLC DBA: The Escape Inn Mailing address: 23 Mann Ave Unit 3 FEIN:--***1171 Newport,RI 02840 Legal Entity Type: Limited Liability Company Other workplaces not shown above: See Location 2. The policy period is from 10/19/2020 to 10/19/2021 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 I Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA INTER 111111111 SEE CLASS CODE SCHEDULE Minimum Premium $276 Total Estimated Annual Premium $572 GOV GOV Deposit Premium $581 STATE CLASS MA 9052 1 State Assessments/Surcharges --- $266.00 x 3.5100% $9 This policy,including all endorsements,is hereby countersigned by ` ( 10/06/2020 Authorized Signature Date Service Office: Starkweather&Shepley Ins Brkg Inc 54 Third Avenue PO Box 549 Burlington MA 01803 Providence,RI 02901 WC000001 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission.