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Home My WebLink AboutApp-License-Certification 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: 6k,?it')t r J )14 c, i 2✓. 1`Iv J TAX ID: LOCATION ADDRESS: .9"61 dL% 3.-q So: YfIA/140 r/l'j..L TEL.#(,S150 _c?-1(1 Z- MAILING ADDRESS: 4/.4 E-MAIL ADDRESS: J nt(,.)c}0 c=eapc r rf C cm OWNER NAME: e. Te-a< • CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: V9.4ict }-kit/7A TEL.#(6,10 792 -2_2,27 MAILING ADDRESS: / /t�rl reit/ 4h d,;i/v iyA J j 7( 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. MAY 0 3 2022 1. ek--51eJ?1.cr 2. HEALTH DEPT. 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. i( C 4�4 1t.)7/7A 2. K, r /41),)fl Ac1 � / 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. 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. 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. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 /MOTEL $110 INN $55 CAMP $55 %SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 /WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >I00 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 = $ 510 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t 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 V Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES t- 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. j - 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 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 in het penult within thirty (30)days-of the previous ycar'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 BY T E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE SITE ).24 N. DATE: C - E.- 2Z- SIGNATURE: --1-) f_____ c' PRINT NAME &TITLE: ,. Ni it 4 #cr i,/� Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-14-0404-08 Issue Date: 1/1/2022 Mailing Address: Location Address: BRENTWOOD MOTOR INN 961 ROUTE 28 961 ROUTE 28 SOUTH YARMOUTH, MA 02664 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- 46; BEDROOMS- 46 ONE(1) MANAGER'S UNIT Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 1111 Bruce G. Murphy, MPH, R.S., CH O /James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee (11-11. Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-14-0405-08 Issue Date: 1/1/2022 Mailing Address: Location Address: HUYNH-KIEU FAMILY TRUST 961 ROUTE 28 BRENTWOOD MOTOR INN SOUTH YARMOUTH. MA 02664 961 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 Weston41, truce G. Murphy. MPH, R.S., fl, O/ times G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-14-0406-08 Issue Date: 1/1/2022 Mailing Address: Location Address: HUYNH-KIEU FAMILY TRUST 961 ROUTE 28 BRENTWOOD MOTOR INN SOUTH YARMOUTH. MA 02664 961 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 WHIRLPOOWAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston41111P Bruce G. Murphy, MPH, R.S., CHO Ja es G. Gardiner Health Director/Assistant Health Director A Berkshire Hathaway GUARD VA ,Berkshire Hathaway P.O. Box AH • 39 Public Square Wilkes-Barre, PA 18703-0020 GUARD Insurance 570-825-9900 (Toll-Free FAX 800-673-2465) Companiesm570-823-2059 www.guard.com June 28, 2021 Brentwood Motor Inn Inc Agent: DOWLING & O'NEIL INSURANCE AGENCY 961 Route 28 973 Iyannough Road S Yarmouth, MA 02664 P.O. Box 1990 Hyannis, MA 02601 Phone: 508-775-1620; Fax: 508-778-1218 Binder #: 000072144 Policy #: R2WC278941 Policy Period: 08/16/2021 - 08/16/2022 Customer #: 1150768 To Request Certificates of Insurance You can either fax us at 570-823-2059 or call our Customer Service Department at 800-673-2465. Either way, be prepared to provide the company name, address, fax number, and contact person of the entity requesting the certificate. Workers' Compensation Resources To obtain a copy of your state's Posting Notices as well as managed care and/or claims information that may need to be shared with your employees, visit: {OutputHeaderPostingNoticesAddress}. To Obtain Service from a Specific Discipline You can feel free to address your issue to the attention of the following individuals. Department Contact Name Email Adg/ress Extension Fax Number Claims Jason Volonakis GUARDClaimsTeam@guard.com 1300 570-825-0611 Billing Lori Decker ar@guard.com 1300 570-825-6211 Loss Control Marissa Page LossControl@guard.com 1300 570-825-2990 Audit Tami Hoover PrerniumAudit@guard.com 1300 570-829-4587 Underwriting Tami Hoover underwriting3@guard.com 1300 570-820-7968 We look forward to having this opportunity to serve your insurance needs. Please keep a copy of this letter with your policy for future reference. Thank you, Berkshire Hathaway GUARD Insurance Companies • CPCY Certification Name: Quoc-Christopher H. Kiev Date Certified: May 23, 2018 Certification Number: CPO-602572 Instructor Name: Robert R. 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""` `'"""'"'y A1768565 immummuumanimmikamminummimein CPR/AED: Adult, Child, Infant Instructor Signature Gin,- /"' + Standard First Aid (BLS) ' 1e Holder's Signature Minh-Nguyet Kieu CalThis card(vilifies that theabove individual has successfully Call Iical emergency l 800.222-1222 911 in case of in a poison emergency completed the requirements in accordance with American For C!'RIAEI)or First Aid training information [teaIth tare Academy~curriculum. 03/02/2021 call 1-888-277-7865 or visit cpraedcourse.com r,,2 Date 03/02/2023 ttrnettal Darr American Health Care Academy Renewal Recommended------ --- ....- - •----•------ every-Years rrirN Aaterican w rr.a...�. r HN Cert t em �.,..�, ,,. ,,.r A1768530 CPR/AED: Adult, Child, Infant ` Instructor Signature qtw,, + Standard First Aid (BLS) Holder's Signature Nghia Huu Huynh y __. _... Call')1! in case of medical emergency This card certifies that the above individual ha,successfully Call 1-800-222-1222 in apoison emergency completed the requirements in accordance with American For CPR/AED or First Aid training information I tealth('arr Academy's curriculum. call 1-888-277-7865 or visit cpraedcourse.com 03/02/2021 03/02/2023 twie.naw awli al nate American Health Care Academy -, Renewal Recommended every 2 years