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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-14-0424-08 Issue Date: 1/1/2022 Mailing Address: Location Address: RJ RESORTS GREEN HARBOR VILLLAGE OWER LLC 182 BAXTER AVE GREEN HARBOR VILLAGE WEST YARMOUTH. MA 02673 20 NORTH MAIN STREET 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 Bruce d. Murph M•,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00Lodging License Number: BOHL-14-0423-08 Issue Date: 1/1/2022 Mailing Address: Location Address: RJ RESORTS GREEN HARBOR VILLAGE OWNER LLC 182 BAXTER AVE GREEN HARBOR VILLAGE WEST YARMOUTH, MA 02673 20 NORTH MAIN STREET 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. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston I • Bru e G. Murphy, PH, '.S.,CHO Health IP irector TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2022 4J *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: ( —N '�.• ri Ni.E 0,01/4,c TAX ID: 874931477 LOCATION ADDRESS: 182 Baxter Ave,W Yarmouth,MA 02673- TEL.#: 508)771-1126 MAILING ADDRESS:65 E 55th Street,Floor 33 New York,NY 10022 E-MAIL ADDRESS:jwang@eosinvestors.com OWNER NAME: Jonathan Wang, _ - CORPORATION NAME(IF APPLICABLE): RJ Resorts Green Harbor Village Resort Owner LLC _ MANAGER'S NAME: EOS Hospitality LLC TEL.#: 212 630-5028 MAILING ADDRESS:65 E 55th Street,Floor 33 New 'or ` ' 1022 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. Nate Cruiser 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. I.Nate Cruiser 2. Ryan O'Loughlin 3. Janice Copley 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 590.11 Please attach copies of certification to this application. The Health Department will not use past years'reco •s. _ JJ�_ You must provide new copies and maintain a file at your establishment. I N/A-No food establishments j jly 6201 PERSON IN CHARGE: HEALTH DEPT. Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I N/A-No food establishments 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(GX3)(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. I. N/A-No food establishments 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. N/A-No food establishments 2. 3. — 4. RESTAURANT SEATING: TOTAL# N/A-No food establishments OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LIC NOTE REQUIRED EL FEE PER B&B S55 CABIN S55 1 10 —INN $55 —CAMP S55 SWIMMING POOL S110ea. —LODGE S55 _TRAILER PARK $105 WHIRLPOOL S11Dee FOOD SERVICE: LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# LICENSERNON.PRREQUIRED SFIT 30 PERMIT# 0-100 SEATS $125 _CONTINENTAL S35 __WHOLESALE S30 _>I00 SEATS $200 _COMMON VIC. S60 =RESID.KrrcHEN S80 RETAIL SERVICE: IRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE VEND NG UFOOD 125 <50 sq.aE.. 550 >25,000 N 5285 —TOBACCO SI10 —<25,000 Ny.11. 5150 =FROZEN DESSERT S40 _ NAME CHANGE: S15 AMOUNT DUE = Ste.? PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM 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 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 he considered transient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 640.as amended,shall generally he 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 een 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 he 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 I lealth Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by tiling 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 stehsite at%s v.varmouth_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 to the suspension or revocation of your 7rozen 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 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 Ito December 31.IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FF.E(S)BY DECEMBER 18.202(1. ALI. RENOVATIONS TO ANY FOOD ESTABLISHMENT. MOTEL OR POOL (i.e.. PAINTING. NEW EQUIPMENT.ETC.).MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTII PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUI 'A SITE PLAN. DATE: i241413-I.M.) SIGNATURE: PRINT NAME&TITLE: Jonath Titir ani President Rev P1'15,15 (10 ACG CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/10/2021 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 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 NAME: Doug Jones PHONE 480 FAX 480 951-4266 c/o Artex Risk Solutions,Inc. /Arc.No Extl: (480)951-4177 (A/c,No): (480) P.O.Box 13838 nDDRESS: SDL.BSD.Certificates@artexrisk.com Scottsdale,AZ 85267 INSURER(S)AFFORDING COVERAGE NAIC INSURER A: American Zurich Insurance Company 40142 INSURED INSURER B Oasis,a Paychex Company 2054 Vista Parkway Suite 300 INSURER C: West Palm Beach,FL 33411 INSURER D: INSURER E: _ INSURER F COVERAGES CERTIFICATE NUMBER:21FL1751086835 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. 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 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 ADDL SUBR I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER I(MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ JECT 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY Y/N STATUTE ER A OF I ER/MEMBERE CLU ED?ECUTIVE N N/A WC 16-85-800-00 10/01/2021 06/01/2022 E.L.EACH ACCIDENT $ 2,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 Location Coverage Period: 11/01/2021 06/01/2022 Client# 23975-1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage is provided for EOS HOSPITALITY LLC only those co-employees 182 BAXTER AVE of,but not subcontractors WEST YARMOUTH,MA 02673 to: CERTIFICATE HOLDER CANCELLATION EOS HOSPITALITY LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 182 BAXTER AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WEST YARMOUTH,MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE !©1988-2015 ACORD CORPORATION. All rights reserved. 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