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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-1937-07 Issue Date: 1/1/2022 Mailing Address: Location Address: OCEAN MIST, LLC 97 SOUTH SHORE DR OCEAN MIST BEACH HOTEL & SUITES SOUTH YARMOUTH. MA 02664 28 JACOME WAY MIDDLETOWN, RI 02842 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions `UNITS- 63; BEDROOMS- 63; PLUS 1 MANAGER UNIT. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Mu by. H, R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1939-07 Issue Date: 1/1/2022 Mailing Address: Location Address: OCEAN MIST, LLC 97 SOUTH SHORE DR OCEAN MIST BEACH HOTEL & SUITES SOUTH YARMOUTH, MA 02664 28 JACOME WAY MIDDLETOWN, RI 02842 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 Bruce G. Murp.'y, ,R.S., CHO Hea th Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1940-07 Issue Date: 1/1/2022 Mailing Address: Location Address: OCEAN MIST, LLC 97 SOUTH SHORE DR OCEAN MIST BEACH HOTEL & SUITES SOUTH YARMOUTH, MA 02664 28 JACOME WAY MIDDLETOWN, RI 02842 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 frA )Bruce G. Murphy, MPI R. ., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1941-07 Issue Date: 1/1/2022 Mailing Address: Location Address: OCEAN MIST, LLC 97 SOUTH SHORE DR OCEAN MIST BEACH HOTEL & SUITES SOUTH YARMOUTH, MA 02664 28 JACOME WAY MIDDLETOWN, RI 02842 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions WHIRLPOOL/VAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy P '.S., CHO Health Director E % TOWN OF YARMOUTH BOARD OF HEALTH E % APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Ocean Mist Beach Hotel & Suites TAX ID: LOCATION ADDRESS: 97 So. Shore Drive TEL.#: 508-398-2633 MAILING ADDRESS: 28 Jacome Way Middletown, RI 02842 E-MAIL ADDRESS: susanpl@newporthotelgroup.com OWNER NAME: Ocean Mist LLC CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Scott Alemany, Director of Operations TEL 401-258-3089 MAILING ADDRESS: 28 Jacome Way Middletown, RI 02842 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 Randy Russell, Chief Engineer' 2. H T1-1 DEPT. Pool operators must list a minimum of two employees currently certified in-utandii'EI-First-l id-7 nd 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. Randy Russell 2. Heather Powers 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. 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. 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. 2 1913 �r ,.f5.,fCi S? • 15. 1 d RLE/ ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of 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 X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel 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 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 Health Department prior to opening. Contact the Health 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 Health 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)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 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 Health 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 bacco-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. The Commonwealth of Massachusetts Department of Industrial Accidents M z .L!11 Office of Investigations 0.'4 1 Congress Street, Suite 100 �.w• Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Ocean Mist Beach Hotel &Suites Address: 97 So. Shore Drive City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-398-2633 Are you an employer? Check the appropriate box: Business Type(required): 1.0 J lam a employer with 15 employees(full and/ 5. 0 Retail ❑ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2 ! am a sole proprietor or partnership and have no 7. 0 Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9, 0 Entertainment their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]* 10.❑ Manufacturing 4.❑ We are a non-profit organization,staffed by volunteers, l 1.0 Health Care with no employees. [No workers' comp. insurance req.] 12.121 Other hospitality *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'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Genatt V Insurer's Address: 3333 New Hyde Park Rd Suite 400 City/State/Zip: New Hyde Park, NY 11042 Policy#or Self-ins. Lie. # 239126613 Expiration Date: 11/15/22 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year impriso;tns nt, 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, under the in nd penalties of perjury that the information provided above is true and correct. Signature: Phone#: 401-845-090 112 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 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/22/2021 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 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 NAMEAcT PHILIP GINEXI JR. GENATT V PHONE FAX 3333 NEW HYDE PARK RD (A/C.No.Ext): 516-387-3069 (A/C, SUITE 400 ADDRESS: pginexi@genattspecialty.com NEW HYDE PARK NY 11042 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich North America INSURED NEWPHOTE INSURER B Newport Hotel Group LLC, ETAL 28 Jacome Way INSURER C: Don McCall INSURER D: Middletown RI 02842 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:239126613 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 I 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 VNSURANCE 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 I POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER I(MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC014008007 11/15/2021 11/15/2022 PER X 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) LOCATIONS: 1) 1 WAVE AVENUE,MIDDLETOWN, RI 02842 2)213 OCEAN STREET, HYANNIS,MA 02601 3) 178-180 THAMES STREET, NEWPORT, RI 02840 4) 13-15 KILBURN CT.,NEWPORT,RI 02840 5)82 MT.HOPE STREET, NORTH ATTLEBORO,MA 02760 6)20 WAVE AVENUE,MIDDLETOWN, RI 02842 7)40 N.MAIN STREET,FALMOUTH,MA 02540 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EVIDENCE OF INSURANCE AUTHORIZED REPRESENTATIVE ,// �10/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: NEWPHOTE LOC#: ACOREP ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED GENATT V Newport Hotel Group LLC, ETAL 28 Jacome Way POLICY NUMBER Don McCall Middletown RI 02842 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 8)28 JACOME WAY, MIDDLETOWN, RI 02842 9)84 SEA STREET, HYANNIS,MA 02601 10)385 JONES RD., FALMOUTH, MA 02540 11)97 S. SHORE RD., SOUTH YARMOUTH, MA 02664 12)7710 GRANITE LOOP RD.,TETON VILLAGE,WY 83025 13)3285 MCCOLLISTER DR.,TETON,WY 83025 14)73 S.SHORE RD.,SOUTH YARMOUTH,MA 02664 15)390 N. GLENWOOD STREET, JACKSON,WY 83001 16)259,251,267 THAMES ST& 1 STATE STREET, BRISTOL, RI 02809 17)368 OLD POST RD., NORTH ATTLEBORO, MA 02760 18) 38 PURGATORY RD., MIDDLETOWN, RI 02842 19) 157 HOLLY RIDGE LANE,CONWAY, NH 03818 20)235 OCEAN STREET, HYANNIS, MA 0260 21) 120 PALMER AVE., FALMOUTH, MA 02540 22) 107 ATLANTIC RD., GLOUCESTER, MA 01930 23) 108 ATLANTIC RD., GLOUCESTER, MA 01930 24)43&45 HULL SHORE DRIVE, HULL, MA 02045 25) 132 PROSPECT AVE., MIDDLETOWN, RI 02842 26) 116 PROSPECT AVE., MIDDLETOWN, RI 02842 27) 131 OCEAN STREET, HYANNIS,MA 02601 28) 149 OCEAN STREET, HYANNIS, MA 02601 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD w C U cO Ili QR C a. E cat3 .Id u C a Iw _ o U " .- x I, 0Da ..M 15 Ca L . Qi If La(///] n u p zv 03 MI a11.1.11— U 0 11121 _ E.. 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