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Home My WebLink AboutApp-License-Certification . � _ TOWN OF YARMOUTH BOARD OF HEALTH Ems. !-� '' APPLICATION FOR LICENSE/PERMIT - 2022 * P ease complete form and attach all necessary documents by December 18, 2021. `.' 2 2 2021 Failure to do so will result in the return of your application packet. HEALTH DEPT. ESTABLISHMENT NAME: k(s td e17soc{- TAX ID: / - LOCATION ADDRESS: ZZ� fat,irre 2y TEL.#: 5O&r71S-5 9 MAILING ADDRESS: W • 'Jl rrtA 11/1..A. O2cai 3 E-MAIL ADDRESS: t?--t' CO 1 tiS t&e ot4- - C cam, OWNER NAME: Ocv 1 tS PDQ e-+16- t-L-C__ CORPORATION NAME (IF APPLICABLE): Mk L a f+tSP t i---1,-LI 1 N c . MANAGER'S NAME: 1224 c(4ocLe,tc Li TEL.#: 57 &( MAILING ADDRESS: S eum.e 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. r\AQ(ktO Z Pk c A I4— 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 at your place of business. 1.1 VLe(AlVS'e Nol2. 1GSI., R.eavtettsL 3. G t ►.eti ---CC, " Itt"{Z o✓lG(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. 1Je&�t',Gk rok C LOA 0'e V t 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. cc to TO Terriers 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. S1VtAo I1%t 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. 1—c5 t,. q(A.IS 2. 12.0 eA C 0.0 ea e.- s L, 3. 4. i S e-e d++,0,t4 I c.,-1-1r--64.4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# CENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 IMOTEL $110 110 $ INN $55 CAMP SWIMMING POOL$110ea. 2z c) LODGE $55 TRAILER PARK $105 LWHIRLPOOL $110ea. ice_ FOOD SERVICE: LI NSE REQUIRED FEE P NUT# LICENSE REQUIRED FEE PERM LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 i ONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 OMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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 = $ CSD *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** " 1 5 LIS. 5-3R ; sQ•lL .c,2,9 i so. 1c. s?. i • cl402, 5367 i 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 to renewal 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 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 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 BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I l '5 • 2t'z-i SIGNATURE: PRINT NAME &TITLE: jug D 4(ZO C-2- " I Rev.10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-5400-07 Issue Date: 1/1/2022 Mailing Address: Location Address: TRAVIS HOSPITALITY, INC. 225 ROUTE 28 BAYSIDE RESORT WEST YARMOUTH. MA 02673 225 ROUTE 28 WEST YARMOUTH, MA 02673 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 . Bruce G. Murphy, M , .5., CHO Health Director The Commonwealth of Massachusetts Fee (-1°' Town of Yarmouth $220.00 Food Establishment License Number: BOHF-15-5357-07 Issue Date: 1/1/2022 Mailing Address: Location Address: TRAVIS HOSPITALITY, INC. 225 ROUTE 28 BAYSIDE RESORT WEST YARMOUTH. MA 02673 225 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast; Food Service; Common Victualler 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 SEATING: 36 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murph MPH, R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-5391-07 Issue Date: 1/1/2022 Mailing Address: Location Address: TRAVIS HOSPITALITY, INC. 225 ROUTE 28 BAYSIDE RESORT WEST YARMOUTH, MA 02673 225 ROUTE 28 WEST YARMOUTH, MA 02673 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 Westonito J Bruce G. Murphy. MP , R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-5403-07 Issue Date: 1/1/2022 Mailing Address: Location Address: TRAVIS HOSPITALITY, INC. 225 ROUTE 28 BAYSIDE RESORT WEST YARMOUTH. MA 02673 225 ROUTE 28 WEST YARMOUTH, MA 02673 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 WHIRLPOONAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, PH �., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-5383-07 Issue Date: 1/1/2022 Mailing Address: Location Address: TRAVIS HOSPITALITY, INC. 225 ROUTE 28 BAYSIDE RESORT WEST YARMOUTH. MA 02673 225 ROUTE 28 WEST YARMOUTH, MA 02673 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 ROOMS: 128 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., HO Health Director WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. WMZ-800-8003721-2021A PRIOR NO. WMZ-800-8003721-2020A • ITEM 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotel Mailing address: Rt 28 FEIN:**-***7972 ` 225 Main Street West Yarmouth, MA 02673-0000 NOV 2 2 Zolr Legal Entity Type: Corporation HAL- 77.4 DEpT Other workplaces not shown above: See Location 2. The policy period is from 04/01/2021 to 04/01/2022 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 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000362922 INTER SEE CLASS CODE SCHEDU_E Minimum Premium $276 Total Estimated Annual Premium $13,361 GOV GOV Deposit Premium $3,465 STATE CLASS MA 9052 State Assessments/Surcharges $14,277.00 x 3.5100% $501 This policy, including all endorsements, is hereby countersigned bye 03/29/2021 Authorized Signature Date Service Office: Rogers&Gray Insurance Agency 54 Third Avenue 434 Route 134 Burlington MA 01803 South Dennis, MA 02660 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. Bayside Resort Employee Certifications 11/15/2021 CPR/FIRST AID Name Dept Epiration Beamish, Tashula MGR FD 7/9/2022 Green, Alyssa FD 7/20/2023 Gaylord, Nicolette FD 10/14/2023 Mulligan, Sean FD 6/22/2022 Nicholson, Carol FD 10/18/2023 Pacak, Mariusz MGR/BAR 12/2/2022 Pontz, Robert FD 8/16/2022 Sroczenski, Rod MGR 7/9/2022 Wright, Sonia FD 5/2/2023 TIPS Name _ Dept Expiration Beamish, Tashula MGR FD 6/6/2022 Campbell, AvrilBAR 6/9/2022 -- DeYesso, L. John _ _ BAR 5/10/2022 Mulligan, Sean FD 6/6/2022 Pacak, Mariusz ~ MGR/BAR 5/23/2022 Pontz, Robert FD 5/4/2022 Sroczenski, Rod MGR 4/16/2022 Green, Alyssa FD 6/14/2024 CPO Pacak, Mariusz MGR/BAR 12/10/2025 SERVSAFE Simonelli, Barbara MGR 12/9/2024 FOOD ALLERGENS Simonelli, Barbara MGR 12/10/2024 NOV k 2 202/ Hak,rH DEpr . , \„0.`,14), - ' ' '' ......;:‘,.::;`,, '',..,,:",s,,1."-'4',,N 4,Akcir .,14,.?",..:"*:,,,, '','....,',,,,,'t-Cc, 4 '41,6s,,,,,,,, -Art,,,;,"•:;„.,,',4-,,1-00,,tty*-4,,,,,v.,,,!,,,,- ;• - t-.'4 , , , w ' 1051-•••%,,,,,O, -- --'‘er,"krr....,..7z,,,,-- -,,,,z,:: .,—,,, --1,-1.-•-,,-'--,‘","—,L.,a. .e.;•..:_-,,,,,,,f., k .r•••••---i•-••••::',4%,„:„.-.7.„•,-,",,,•;.=-1",-"..--.;,/'•..›..)•,,,,=.,•:(,,,F.•—•' ,---.„,,..,,,,,,,,,,,,,, t.,=,-;.;.1- --,,,.=•,..... =:••.,,.,, -,..-.,--,,,,:-...,„,,,....,..,::,:r, _ 04 ,.... C•1,A. CIZ It • . ,,,,,. 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BAYSIDE RESORT HOTEL Security Control # SEAN MULLIGAN 876159 225 ROUTE 28 WEST YARMOUTH, MA 02673 3 I Completion Date: Jun-22-2020 Instructor Name: Sal Coppolino Expiration Date: Jun-22-2022 Instructor#: D1317S SEAN MULLIGAN Has successfully completed the Interntional CPR Institute's CPR/AED, First Aid Course Adult/Child/Infant The International CPR Institute's cognitive assessment of the 1 CPR/,AEDiFirst Aid Course based on the current standards for CPR, ECC, & OSHA. 3 T q THIS DOCUMENT IS VOID IF REPRODUCED y Cut out card below (i14---'1'''."4'A Vlore life-saving NOV 22 2021 courses from- International CPR Institute Inc. ~Srrrure"'� HEALTH DEPT, SEAN MULLIGAN www.icpri.com (` This certifies that the person named above has successfully New C R / AED completed the International CPR Institute's • f_ •....!”i E,.),/ mow.mprr.com CPR/AED, First Aid Course a CPR /AED Renewal Adult/Child/Infant Completion Date: Jun-22-2020 Security Control# a Healthcare Provider, B.L.S. 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