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Home My WebLink AboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH 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: Ahi 13A--SS ?6 R I i 3 k i SUI VE c TAX ID: LOCATION ADDRESS: 1 -2)/4) 121-;2. SO.yaLnutd-t4I'YI 2t��4 TEL.#: ( ccg) �,c1L i,clMAILING ADDRESS: ,'�-- S 'yr)r laoye -� E-MAIL ADDRESS: i4X2 C17✓1lex a od vr: 4,0.cc/.(IiGvL� OWNER NAME: ( GUL ttyi ( Gt , (Y 47 • CORPORATION NAME(APPLICABLE): CI ( c/ 1rLApt.L., rap • MANAGER'S NAME: `° --z PctieJ ::JJ`` TEL.#f 7 89 Lf-Lisom /f MAILING ADDRESS: syn r .-S --.1-476 ve_ --> 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. ply us frie 12-4_____- . 2. R 1 p& p/17Ei 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. qUrh,S 2. P1 S !' [ I' 3. pA—f 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 Est hlibrnents Ins CMD 590.000. Please attach copies of certification to this application. The Health Department will It se ears'records. You must provide new copies and maintain a file at your establishment. ULC "i 4 2021 1. /(//A-- 2. HEALTH DEPT. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. kVA-- 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. A)/A- 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 mainta' a file at your place of business. 1. / " 2. 3. 4. RESTAURANT SEATING: TOTAL OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LLCENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 /WHIRLPOOL $1 10ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 75----TD i$ oS3� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Iq �Iq � � ZSI1 r I9-26ZD 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t enewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES 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 mnst_be-.inspected_by the Health--Impartment 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 CAFÉS: 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 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 B THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A !► AN. WI DATE: /2 /� X02/ SIGNATURE: , C` / I I , f PRINT NAME & TITLE: / 411 / /r./LJ Rev. 10/15/19 • The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-19-2812-02 Issue Date: 1/1/2022 Mailing Address: Location Address: GAYATRIKRUPA CORP. 1314 ROUTE 28 AMBASSADOR INN & SUITES SOUTH YARMOUTH, MA 02664 1314 ROUTE 28 SOUTH YARMOUTH, MA 02664 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- 80; Bedrooms- 89 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • Bruce G. Murph , M , R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2816-02 Issue Date: 1/1/2022 Mailing Address: Location Address: GAYATRIKRUPA CORP. 1314 ROUTE 28 AMBASSADOR INN & SUITES SOUTH YARMOUTH. MA 02664 1314 ROUTE 28 SOUTH YARMOUTH, MA 02664 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 4 iv Bruce G. urphy, . 'H, '.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-20-0885-01 Issue Date: 1/1/2022 Mailing Address: Location Address: GKYATRI KRUPA CORP 1314 ROUTE 28 AMBASSADOR INN & SUITES SOUTH YARMOUTH, MA 02664 1314 ROUTE 28 SOUTH YARMOUTH, MA 02664 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. Murphy, M'H, R :., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2819-02 Issue Date: 1/1/2022 Mailing Address: Location Address: GAYATRIKRUPA CORP. 1314 ROUTE 28 AMBASSADOR INN & SUITES SOUTH YARMOUTH, MA 02664 1314 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 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, MP-', R. ., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-19-2820-02 Issue Date: 1/1/2022 Mailing Address: Location Address: GAYATRIKRUPA CORP. 1314 ROUTE 28 AMBASSADOR INN & SUITES SOUTH YARMOUTH. MA 02664 1314 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast; 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. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, ' , R.S., CHO Health Director 12/09/2004 02:16 5087593883 MARK PATEL PAGE 02 I • -.,! .., .. .� I i,.. ,,.I .. .. .. I,,.1i,.. 1,,..",..:-1., .. I __ Ii,. I I.., _. ..L .. .. __ .,I __. I,. ._,.II II ... I_ f i1, ., '8 \Y i x - 0 et- K. - o 00 pem < . v) n - N - ^ m .,0<c'i= 4 4 VI 0 *CI ell :; K.:,-, 1.: li,(„kb, ,_, u., $ e 8 ivi)4S 13(fift, ... -->- ,.-...,,,:.-:,1 v 13 t"--is 2 c<cr ).4`:' ; 1 ---- g . ',,' .'k':•:.r. "ri -I 4%... :1' - , k ,.. . _ „.,..,.. , ..„....,,„, „,,:, ,,...,..;44, „,‘ - <:'$), 4. S;;* 171 ° Pmil * 7'. 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't'l ---;'-'1TP• (:': S.Yarmouth,MA 02664 i • i Cape Cod Satety TrainingOM ! 1 1,1at juror Name: Rick Todd • Instructor Number: 1040918 1 tli • 0 2 I i Davie Dumas I , . 1 i! has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. 1 • l , S- `.:';‘ ‘,1,s,sulicil eliminates p'e,en,D.Us, deaths at weri-c, In la-.,ei:_- cornmJnities. and on the nod through i .: I,•. ,I.;; - i.--,--,,..,i, i; education are advocalr, For-more life-saving cuui ses :,-31 a NSC please visi+ nse.org/fatraining , j THIS DOCUMENT IS VOID IF REPRODUCED ---,„,, Security Control No. David Dumas c....e. 1 CI Mtn Oifin'' has completed the •.4.LA.,t,.., NSC CPR Course ! ' , ,Infant CPR, 1 1 " Wir: want your feedback! , AdultChild i Cape Cod Safety TrainiChoking &AEDng visii nsc.orolfirstaidevakiation t:.) - '-' ' 12/02/2020 , c°1. '1°'"-11 L'''t''' 12102/2022 i.ake a brief survey and share your poinicr 1 Instructional Hours: :ito,,,ui the :',:riSC course. you completed. #1040918 , 1--1,c.1.0 SicioL,tule instr.,clo, No. NIC:;C: —in it for life.' nsc org/fatria:i•ing / . ....,•,:.: ,,,11.-::,;',:;:::,::,w,-.„::::; --;:t.---, .-,,,-i,,f,-.,,..r',,` :',:,,-".;:',..!,•=10-`7.;4, ' ?...,IF!,3ft...-..`'4.-tr,y.• - -. ,;.-#...*;44:-.4.1.,,-;::::;.,„,,, ;.-4,. .--;..-• . -:- :.• ,,,,,---, .. '-:.-:::-.5:: ,:•:.!-.Y:t5,127tTti!:: :,:ir ik'ithIP.J.tttrilt *;?:.;r;' n:-:. ":1',0(:005',K, 1', s ..r1,31::',1..T` '-',)11r':1' 791 7 i • -- "410:7441-' ,fra, 00.4;.S/ !SC r ! 04. '41 '4, •4i1;:d' • !fir .1.!'34 4Ask." k:a5 Ccurse - , tt-tecurih,Conthtl Ne , .,:timbass,adw Inn&Suites t3 1:V.4r,- t Rt 28 026.64 1210212020 Cape Cod Safety Tr3ining 12/0212022 ' Rick Todd Instc:clor Nur-O:)er: 1040918 David Dumas has successfully completed the NSC First Aid Course. :.c., elui c c a 0/Ork. hccres and coarinrilitles. ,- rd oh the read thmugh arc.: Teasa\..ing co NSC nsc.org/fatraining . _ TFS. DOCUMENT IS VOID IF REPRODUCED dot"- • +i David Dumas 4;olia'Nev -*V NSC First Aid Course ou ;- fczydba yck! ,611 riscmrgistaideval.uation to Cape Cod Safety Training a. leI survey and sha.-e your opinions 1210212020 • • n NSC NSC yon comp!eted 41210212022 - r 104091S ;A a t4c7jr hie nsc ormatralninc 0.4.p*n NSC Frt Aid Course • Suites .3i4 Main Si,R 28 o u t!I Yarmouth, MA 02664 Cape Cd Sajraining „„. 116 Rick Todd J;;to! Nurl ILE;1: 1040918 • 71 A) PIVUSit atei has successfully completed the tSC First Aid Course, prey,s;ntah rrt hicu.S r unities and • HP road throrqi courses rr vease nsc.org/fatrainino THIS Is VOID IF REPRODUCED 101'W". r) Control No. Zi:CO" Piyush Patel cn,:pleten NSC First Aid Course 54 !1,411;,'J;'i iCie kid • Cape Cod Safety Training Co.m)le,tio : Li sliare your opinlons - 1210212020 ' ,st iuur fl \i3C course you completed. 12/02/2022 41.°091.8_ - for iife nse.cri-gif-rtranng 1 ..„.,;14itfifitti°' • - ,, , . . ._. 1 0 NSC CPR Course I* 0 ....... :-.•.*14604,6" :„ Adult, Child, infant, Choking & AED . ... Secunty Co i Itro! No. , . ..-: t',mbassador inn&Suites 1314 Main St, gt 28 Yarmouth, MA C2664 Cape Cod Safety Training Instructor Number: 1040918 Piyush Pate has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. -.,, , ,,.;---; ir,:r,,,H-,1-1,:- 'i.'.:1-rh-13 at work in liome.,_z and communities, and on the road through . ' - • ,,,:r.:?.- ". cci!,:'::::ilin z.-cl :'-l'..ci 2.1, ''..;',' !TIC:17,?, Le,.-saving corses-lrom NSC please visit nsc.orgifatraining I THIS DOCUMENT IS VOID IF REPRODUCED , 0se.7..,1.t. 1,-,.'N ri ' 15, _. u , ...,, vsrt Patel ftmi) ' 0•00e, 1 ' , NSC CPR Course We want your feedback! 74. .., Adult,Child,infant CPR,Choking &AED Reuse visit nsc.orgifirstaidevaivation to ;!;=•,!1•,(..) . , Cape Cod Safety Training Co r -,3.i„-.4 [:Lif(• Like:-::!-_•:r;el Cu:yey and share your opinions rir12102/2020 F,:' --. 12/02/2022 }:Ist,uctiona;Hic:,r a L'Ou i.the NSC course you completed. fl91 1 -.-,t,' ....: :$•..--..,-,it. rsmJc.,tor Ni:: i'",,t:•:75,73t4; — it for fife l'isc.orc.lat.atmii,g , .,:.; ,•.::,.-.:- 7-1.Z.:.:'"',-,1;-.'3:= Ve,i0.14.4.it:Ti*I4t,f,'';;4=A',?,''''t..-•:-.:`'''-'.Z.""..''''-j.li"'-'f.4,}1.-g..' '''r--:::',.• -,--.=.'.--:'-':.:.,1-!.'7,-:.-':'.::;',14i.:44-14.1i:;:-‘Ui;.7.1:it.;SP::,.44.44t:--;443t:J::. ll 1 11,, Ad Course 4ith,ta.'. ;71 1 • Pitia; Pah.) Ambassador Inn&Suites 1314 Main Et,Rt 28 Soot',s! itritioutli, MA 026.64 ZiC212112.0 ',.;ape Cod Safety Training • Rick Todd litt,strocio! Nurnlpei: 1040918 Penal Patel has successfully completed the NSC First Aid Course. nryl ntrip roan ip nso.orn/fatraining THIS DOCUMENT IS VOID IF REPRODUCED Seu r,ty ol No • 1: Pinal Patel tH, NSC First Aid Course fedback7 Cape Cod Safety Training LyE-f s;...!vey and share your op!nions 1210212020 7..ourse you c:)mpleted. 1210212022 !!! —in t for life ,sc 0,C! NC CPR Course Ad!,14, ret7 Ufl. # flUfo.!o .faolt5 • C.:0 No fns&SitAtes St;Rt • Cape Cod Safety Training Mek Todd Instructor Number' 1040918 Pill al Patel has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. „1„-lc,1 : ea7ns ..ork, in r'onr m and communities, and on the road through ecl;ivation ai‘.d more iife,-say,ng coiirses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED SeoL.rity Control No. elv-i Puna I Patel has completed the NSC CPR Course • yoLq'feedback! Adult,Child,Infant CPR,Choking &AED c Cape Cod Safety Training psc„oifIrstaidevaltration • o(•:-Iri'ition Date. 12/0212020 • .Jr-vey and snare your opurnry 15 '-xPir et:: 12/02/2022 fsISC course you completed. , , #1040918 n)! 't:Tuto lnstruotot No 7i;ri It for life nsc _410744,, NSC • „.4 ce m0:4 Adult, Child, inial • it, Chokhj & AED !sin R,Suites Ail Seasoris Resort 1314 Main Sz.,Rt 28 1199 Main tit, Rt 28 ' • s Yarninotn, !VIA 02664, S.Yarmouth, MA 02664 nctor Number: 1040918 Ru.p.a 4, 4. 4,;.• • rue '-a-ed or the c.;irrert Guidelines for CPR and ECC. • H aid Uie :uaci 11 Nsc 'Please visii nsc.org!fatraining • ',Z71Ciiiki7E/41' IS .ifOlD IF REPRODUCED SerOrdiy Centroi No. 4,17' ktipal Patel NSC CPR Course teedbacKI, Adult,Child,Infant CPR,Choking &AED Cape.Cod Safety'Trainitig ; ; ,:sc.cniOirstaidekiaIuatioil to 1210212020 arid ;Mare your opinions 12102/2022 HO' ccu,se you completed. . #1040918 €51 it for !tieiisc.orgifatrainog , _