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App-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: C' /o ' Ste„ds 2//74. TAX ID: LOCATION ADDRESS: j19 /77,;, S/,-ee{ TEL.#: S"OS-775'-32.2.5- MAILING 8?SMAILING ADDRESS:14 9 54-et, des/ yv i ' /1/4 672 a-73 E-MAIL ADDRESS: /rcs`ies,•ro9Ai ,'/, / car,, OWNER NAME: / as # c/ a.s 4A, CORPORATION NAME(IF APPLICAB E): MANAGER'S NAME: Ai a-v5 , /C S { TEL.#: 'Ratty MAILING ADDRESS: 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. Leona,-c►/ �1'Gtrt f, 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. Leon eonG� N/ 6i'�ro 2. "tyke, ke, /'f fare 3. 4/o c.cs 4 , a f 4�/ .., 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 IA past years" records. You must provide new copies and maintain a file at your establishment. MAR 10 2022 1. 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. 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# CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 Z SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 / WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSEREQ.UIRED FE LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 Z`ONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 — ---- 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 = $ j1Q 0?c J *i . ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** V . 1q . 7_3,6)- lcf Z3414f L.15.239Z Ij Z (e `1' 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: 3 / k/Z 2- SIGNATURE: PRINT NAME & TITLE: ` N b V/ - A Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2349-03 Issue Date: 1/1/2022 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 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 WHIRLPOO./VAPOR BATH Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston _AA-9\ Bruce G.Mu ( y,MPH,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00Swimming Pool Operations License Number: BOHSP-19-2346-03 Issue Date: 1/1/2022 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 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 2.L Bruce G.Murphy, PH, - . .,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-19-2344-03 Issue Date: 1/1/2022 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 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 11/ Bruce G.Murphy,I PH,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-19-2342-03 Issue Date: 1/1/2022 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 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 *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 /04c— C25/ Bruce G.Mtirphy,MP R.1 , Health Director/ AC RD /DD/YYYY) ® CERTIFICATE OF LIABILITY INSURANCE DATE 02/09/2022(M 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 Wiliam Rohr NAME: Morse Insurance Agency,Inc. PHONE (508)238-0056 FAX (508)230-8367 (A/C,No,Ext): (A/C,No): 285 Washington Street E-MAIL billrohr@morseins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N North Easton MA 02356 • INSURERA: Vermont Mutual Insurance Co. 26018 INSUREDINSURER B: Associated Employers Ins.Company TWO FAMILIES INC DBA CAPE SANDS INN INSURER C: 149 RTE 28 INSURER D: INSURER E: WEST YARMOUTH MA 02673-4653 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 Master 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. NOTWITHSTANDINGANY 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 SUER- POLICY EFF POLICY EXP LTR I • TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS , -! 1,:,MERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ . i DAMAGE TO 1 CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A BP11058627 01/27/2022 01/27/2023 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ __ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY — AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE CU11005271 01/27/2022 01/27/2023 AGGREGATE $ 2,000,000 DED RETENTION $ $ WORKERS COMPENSATION I — X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? N N/A WCC-500-5026341-2022A 01/27/2022 01/27/2023 (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 $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RECEIVED MAR 10 2022 HEALTH DEPT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN EVIDENCE OF COVERAGE ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �,�s. ,YY.a.�! •4.--)--Tot--kw,,,..----4..-1,.--,44.,x1-n,;,,,,,,,, �' ' -' �-+�, .s,. .{`iltk* .�ft•;.„.„,.., ;Z'ri'r°"„-", �r\„/""3,,t":"--L- _ '''; 41.-•"""..3-•.;;�*.'78�_ . s.ve S_�t'"s'aAv �� '+1?.%:,t'fA .;fib .•.r.1srt-*�i�` �,:�' ''h '`t+'4` y-. t- _ n',(5 c. •`+."4, arg >"Sd4?.?" 4..x* 'V', Y'P°. 1 * �`J`: witteriarf rxt A2016513 r CPR/AED: Adult, Child, Infant Instructor Signature + Standard First Aid(BLS) Holder's Signature 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/AED or First Aid training information Health Care Academy's curriculum. call 1488-277-7865 or visit cpraedcourse,com 03/02/2022 03/02/2024.__. _—_.... American Health Care Academy have o, a`"` Date -0 Renewal Recommended every 2 years ,Am icon A2015419 00 ` InstructorI Signature !# CPR/AED: Adult, Child, Infant y�, + Standard First Aid(BLS) Holder's Signature Monzur Khan 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/AED or First Aid training information Health Care Academy's curriculum, call 1-888-277-7865 or visit cpraedcnurte.eom 03/01/2022. _ .03/0.112024 .___.._.._ American Health Care Academy • issue Date Renewal Date ; Renewal Recommended every 2 years / - / ,,.MI A rtc ti,r. At ant 'op y A2015416 / gs Instructor Signature �._ im CPR/AED: Adult, Child, Infant + Standard First Aid(BLS) Holder's Signature Noushad Kashem Call H1 in case of a medical emergency Call i-&(?0-222-1222 in a poison emergency This card certifies that the above individual has successfully for l II-SW2 or first Aid emergency completed the requirements in accordance with American call 1488-277-7865I)orFi or visit training information I lealth Care Acadenxy"s curriculum. 03/01/2022 03/01/2024 American Health Care Academy l ue D.iin Renewal tate [tel Recommended every 2 years j i 1