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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2349-02 Issue Date: 1/1/2021 Mailing Address: Location Address: TWO FAMILIES INC. 151 ROUTE 28 CAPE SANDS INN WEST YARMOUTH. MA 02673 149 ROUTE 28 WEST YARMOUTH, MA 02673 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 WHIRLPOOL.NAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • Bruce G. Murphy, MPH, '.S., CHO/ a .ry R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-19-2340-02 Issue Date: 1/1/2021 Mailing Address: Location Address: TWO FAMILIES INC. 151 ROUTE 28 CAPE SANDS INN WEST YARMOUTH. MA 02673 149 ROUTE 28 WEST YARMOUTH, MA 02673 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 Bruce G. Murphy, MPH, R.S., CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-19-2342-02 Issue Date: 1/1/2021 Mailing Address: Location Address: TWO FAMILIES INC. 151 ROUTE 28 CAPE SANDS INN WEST YARMOUTH, MA 02673 149 ROUTE 28 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 *67 UNITS; 67 ROOMS, PLUS 1 MANAGER'S UNIT Standby generator required for septic system, per septic installation of April 2019. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston .4, Bruce G. Murphy, MPH, R.S. HO 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-19-2344-02 Issue Date: 1/1/2021 Mailing Address: Location Address: TWO FAMILIES INC. 151 ROUTE 28 CAPE SANDS INN WEST YARMOUTH. MA 02673 149 ROUTE 28 WEST YARMOUTH, MA 02673 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 INDOOR SWIMMING POOL Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston . ruce G. Murphy, MPH, .5., CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee igu Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2346-02 Issue Date: 1/1/2021 Mailing Address: Location Address: TWO FAMILIES INC. 151 ROUTE 28 CAPE SANDS INN WEST YARMOUTH, MA 02673 149 ROUTE 28 WEST YARMOUTH, MA 02673 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 ' .40 Bruce G. Murphy, MPH, R.S , CH' Mallory R. Langler, R.S. Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2021 fl 2 2020 * Please complete form and attach all necessary documents by December 8, 2020. Failure to do so will result in the return of your application packet. HEALTH DEPT ESTABLISHMENT NAME: e 717 TAX ID: 7 7- bC 0 6 2 3 LOCATION ADDRESS: TEL.#: 2 /Z - 8 S 8 y 7¢3 MAILING ADDRESS: / 517 /`7 ti:, S75 114:5/ 7 -#M o,,� //,9 U2 673 E-MAIL ADDRESS: Aat sn o (19("' � . co OWNER NAME: /1 ri 1 dea r✓ /(c S ,lea? CORPORATION NAME (IF APPLICABLE): T o -* s MANAGER'S NAME: Ze n II, l n o TEL.#: SO, - ?7,1: 3 82.6-- MAILING 2SMAILING ADDRESS: /1-7 /3 , Sf IVV. oz__‘ 73 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) andattacha copy of the certification to this form. 1. Le am ar d „Z":451,. /.10 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�leat your place of business. 1. Leah Gyp 4' /4-4! • cn p 2. / " d a /i CIM/ 3. "a y A.r "%gilt 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 IN CHARGE: 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' records. You must provide new copies and maintain a file at your establishment. 1. 2. HE1MLICH 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. NOV 9,-o LY 2. 2 }t.t, 3. 4. Pmu,-i iq ,)231-1-7 • 0-2— - t q•23 '+ f' P is tG 73149 (wP)'' ACC0R0 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/21/2020 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 Boynton Insurance NAME: Boynton Insurance Agency PHONE (781)449-6786 FAX No): (781)449-4269 (A/C,No,Ext): (A/C, 72 River Park Street E-MAIL certificates©boyntonins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Needham MA 02494 INSURER A: Vermont Mutual Insurance Company INSUREDINSURER B: Technology Insurance Company,Inc. Two Families Inc. INSURER C: American Bankers Insurance DBA Cape Sands Inn INSURER D: 149 Route 28 INSURER E: West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1811912875 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence)DAMAGE RENTE $ 50, 000 MED EXP(Any one person) $ 5,000 A BP11050289 01/27/2020 01/27/2021pERSONAL8ADV INJURY $ 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Included (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BP11050289 01/27/2020 01/27/2021 BODILYINJURY(Peraccident) $ AUTOS ONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY /� AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE CU11003952 01/27/2020 01/27/2021 AGGREGATE $ 3,000,000 DEO X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE 0TH AND EMPLOYERS'LIABILITYER Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N W OFFICER/MEMBER EXCLUDED? N/A TC3684816 01/05/2020 01/05/2021 E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 _DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Flood Each Building $350,000 C Building#1&#2 See below 04/09/2020 04/09/2021 Each Contents $50,000 $1,250 deductibles DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 41191Xrie-. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD srkSrs'1, .1 LLC VV/IL LLLVLL rvGLLLLLL UJ 1r1U3)UI.RL43GLL3 Department of Industrial Accidents 1 Office of Investigations 4 1" 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: (.7��e Address: /¢ � / �.. $7c t / /2 - gsdr'- `j �¢.3 City/State/Zip:17 resvc/ , C /)/ 024?J Phone#: T 'f- 9,25" - 3 eZS Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12,,® Other /to 7/e *Any applicant that checks box#1 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#1. I am an employer that is providing workers'compensationinsurancefor my employees. Below is the policy information. Insurance Company Name: ,4/rt 7/1"..,tr c; e-WCt.F Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# The 3 6 8 ¢ 8/ Expiration Date: 6'.f/Df/..2/ 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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,u der t pains and pe alties of perjury that the information provided above is true and correct. Signature: Date: ef /2/0//2- Phone Phone#: 2/2 — I - 9 7¢j 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#: www.mass.gov/dia • ',� < `+ uP -'.� •a'�i 6` '^.`` ''j�' ':t.'....1C"-'1•,z xt,4 1',.... 44•411;,.. s''.. ' 4.41 a.A r,-----,_6,,,- •,.' 9-a. 'aY�' ? ••• t. r. t ' �S,.-,f.1 'efa"9�7See2ro";hw�•. >ls ?t,`p: rAitri`tr`"r. r'r'.M fs Y •ej'.. �, #.4tfys�, �r r-r,y[, r t -:,,,,,-1.,:......:.,.:.;.4), yyrZ f tR yC -- abs t•. A �'{ r'd�il� u;: °.•'�df14�'�*# , S <#°4 '"' 1�,`9 �r#a°si,°!t,,`�tiS`$$laS i''dO.fY+*-``.�'`,•if`y a '♦±'rr r,j••5 °r :.pp���yr#M':°s•• ;3Y}:044.144,.....•.1 ,�..f , 4 .. .. I47 , h df�Vit.- °A'*, r g �¢ yd i+##r-�. 7e f +, fr y e 1if ytfik.fes A{ Vit." -:...C.*f t� f of `. .; Y/4 .: f- .y+l d-T.. A $ f c ,' T a, f . 1 'P. 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' "' �"�e�'y'^�'�«`�..�Y,,. ,%,;, if• a.� airec n A1550787 CPR/AED: Adult, Child, Infant Instructor Signature bgp— + Standard First Aid (BLS) Holder's Sip t :41if Leonard Fabiano Call 911 in case of a medical emergency This card certifies that the above individual has successfully Call 1-800-222-1222 in a poison emergency completed the requirements in accordance with American For CPR/AEI)or First Aid training information Health Care Academy's curriculum. call 1-888-277-7865 or visit cpraedcourse.com 02/08/2020 02/08/2022 American Health Care Academy tssuea .,E�a1 Date , Renewal Recommended every 2 years : or' Arn,pricarf A1551)720 CPR/AE.13; Adult, Child; Infant Instructor Signature • . 0. 44,22„,_., , '----------') + Standard First Aid (BLS) Hottier's Signature Monzur Khan 9h in case of a rneimeal eniorgency 'Has raid certilies that the above individual has successfully Call 1400-2224222 in a poison emergency completed the requirements in accodasice with American For(TR/AEI)or First Aid traimag infbnnation Health Care Academy's can-tritium. call 14388-277-7865 or visit eprocricutirse,corn 02/08/2020 02/08/2022 American Health Care Academy isss,..Dale Kenewal Date erSArrierictic A1548619 I 4 1 i CPRIAED: Adult, Child, Infant Instructor Signature , + Standard First Aid (BLS) Holder's Signature 1' ,4V Noushad Kashem Call 911 in case of a medical emergency This card certifies that the above individual has successfully Cali I 400-222-1222 in a poison emergency completed the requirements in accordance with American For CPRIAED or First Aid training information Health Care Academy's curriculum. call 1-888-277-7865 or visit cpraedcourse.com 02/04/2020 02/04/2022 American Health Care Academy Issue Date Renewal Date Renewal Recommended every 2 years