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HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH E��►'\ ` 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: 1 '-'`-•�l -1-1(4-4.--'?-.- TAX ID: ' LOCATION ADDRESS: 4 ?, \ �.Pcc� TEL.#: SbY 17 C ac,--/ MAILING ADDRESS: W d'� \ 0`2 —c E-MAIL ADDRESS: ej�('C ` l �'Z ).-t, ` ' \f\CO , C.V.---- OWNER NAME: A.fL— C vs J '' CORPORATION NAME (IF APPLIC- BLE • MANAGER'S NAME: \3 `5 C 't ' TEL.#: MAILING ADDRESS: �A\ 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. I. I, L4 C U L�►S 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 yearsrecords. You must provide new copie and maintain a file at our place of business. i\ A 011 1. C )4\-(\c 3. NE ► i _ - 4''N q11111aW=ahli 1111=1.- . ► ► r-- 7 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 Sani y Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this appl ica F •n. The Health Department will not use past years' reiords. You must provide new c o i ies and maintain a e at your establishment. 1. A 2 _ JAN 0 3 nu H=(1' SEPT. PERSON IN CHA' 1 Each food establish ave a'; east one '- A) rson In C'ari' (PIC) o site during hops of operation. 1. /. ALLERGEN CER FIC ' TIO : All food service estslis ents a req ed to ha - at least o - I1-tim; ploy: who has Allergen certification, as defined in the St.i - S. itary Cs e fo ood Se ice Establ h ent 05 CMR '0.009(G)(3)(a). Please attach copies of certificatio to is appli io The He th Depa nt will not use p• years' records. You must provide new copies I aintain • Il at your .tablishm 1. HEIMLICH CERTIFIC.1 ONS: All food service establish -nts with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises 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 4 B&B $55 _CABIN $55 /MOTEL $110 INN $55 CAMP $55 aSWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 - WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 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 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 <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 = $ (+40 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** L '5.1 2 s I) 1, 100 1n 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 eovered within seven(7)days of closing. 0 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 APPROVED BY THE B•ARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA RES UIR. - S " . P ',1\1.1 '► SIGNATURE. DATE: .A.7A �.�latirk4111111jtatfilia . *" PRINT NAME& TITLE: w.•f�t;"'Vt— IN����►�_;-�:�>_ Rev. 10/15/19 6 • 7� The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00Swimming Pool Operations License Number: BOHSP-15-1014-07 Issue Date: 1/1/2022 Mailing Address: Location Address: HOLLY TREE CONDOMINIUM TRUST 412 ROUTE 28 HOLLY TREE RESORT WEST YARMOUTH. MA 02673 31 FLINTLOCK WAY YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 ICENSE 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. urphy, 'H,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1015-07 Issue Date: 1/1/2022 Mailing Address: Location Address: HOLLY TREE CONDOMINIUM TRUST 412 ROUTE 28 HOLLY TREE RESORT WEST YARMOUTH, MA 02673 31 FLINTLOCK WAY YARMOUTHPORT, MA 02675 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 WHIRLPOOLNAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston LdJ_ Bruce G. Murphy, MPI,R.S., • Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-1012-07 Issue Date: 1/1/2022 Mailing Address: Location Address: HOLLY TREE CONDOMINIUM TRUST 412 ROUTE 28 HOLLY TREE RESORT WEST YARMOUTH, MA 02673 31 FLINTLOCK WAY YARMOUTHPORT, MA 02675 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 BUILDING A - 76 UNITS BUILDING B - 8 UNITS Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston f . Bruce G.Murphy,MPH,R. ., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00Swimming Pool Operations License Number: BOHSP-15-1013-07 Issue Date: 1/1/2022 Mailing Address: Location Address: HOLLY TREE CONDOMINIUM TRUST 412 ROUTE 28 HOLLY TREE RESORT WEST YARMOUTH, MA 02673 31 FLINTLOCK WAY YARMOUTHPORT, MA 02675 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 11111 Bruce G. Murphy,MP ,R.S., CHO Health Director The Commonwealth of Massachusetts �,== Department of industrial Accidents Y Office of Investigations M _ I}' 1 Congress Street, Suite 100 o nr -�- 1.t�^ Boston, MA 02114-2017 `t. - www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: liti L_ ' Address: N\ -a -- City/State/Zip: \ >\`, Phone #: � 7 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' coma. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby ce t'y, nd•r t • ,,, p n ies of perjury that the information provided above is true and co rect. or ` ► Signature: i Date: k L.-% Phone#: I 1. l c.. % Q_ --:4--- -:. —----- Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia DATE(MM/DD/YYYY) ACIEi 1 CERTIFICATE OF LIABILITY INSURANCE 04/28/2021 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 Diane Carmain NAME: The Armstrong Company Insurance Consultants PHONE (310)530-0099 FAX (310)530-0098 (A/C,No,Eat): (A/C,No): 2780 Skypark Dr,Ste 440 E-MAIL dcarmain@armstronginsco.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Torrance CA 90505 INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Holly Tree Condominium Trust INSURER C: 412 Main Street,Route 28 INSURER D: INSURER E: West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 WC Only REVISION NUMBER: I 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED $ CLAIMS-MADE OCCUR PREM SESO(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _$ POLICY PRO 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A XWS57855775 04/01/2021 04/01/2022 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Health Department-Hazmat Ren AUTHORIZED REPRESENTATIVE 1146 Route 28 South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD HEARTSAVER Heartsaver R R American First Aid CPR AED HeAs orciation. Craig Murphy has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Optional modules completed: Exam,Child CPR AED, Infant CPR Issue Date Renew By 2/9/2021 02/2023 Training Center Name Instructor Name Sylvester Consultants, Inc. Andrew Kleamenakis Instructor ID Training Center ID 11070600905 MA20132 Training Center City, State eCard Code 206003945673 Hyannis, MA Training Center Phone OR Code Number (508)771-8700 6?; 11 To view or verify authenticity,students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3002 R3/20 HEARTSAVER HEARTSAVER Heartsaver° et Training Sylvester Consultants,Inc. First Aid CPR AED American Center Name Heart Association- Training MA20132 Craig Murphy Center ID has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association TC City,State Hyannis,MA Heartsaver First Aid CPR AED Program. TC Phone (508)771-8700 Optional modules completed: Exam,Child CPR AED,Infant CPR ID.;;u 4,.p Instructor Issue Date Renew By eCard Code Andrew Kleamenakis ' z ` ,.•:, Name 2/9/2021 02/2023 206003945673r*h Instructor ID 11070600905 �., To view or verity authenticity,students and employers should scan this 0, ' �, „'f3 OR code with their mobile device or go to www.heart.org/cpr/mycards. a 2020 American Heart Association 15-3002 53/20 Directions 1. Cut along dotted lines 2. Fold both halves together 3. Use adhesive to combine halves r r- , ZN i c C i W o E0 o cn ci tet- g m Q -. r-- o c .c .@ r ai 05 0 2 as n V L o w m m f-' z; '0 c0 c r/ v CC o ® c m mem CCS : CD in zi U U U O i a L U L P U 0 C .� cuto co Va o a) cc E T a U LII CC c m LL co o ' 0 �.. al 3 a O a a.) a, coel . > U m E Z L m w a o 2 N m 0 N N 0 U " 1 0 -o _� a7 H o >+ Z n 0 E CD co CO U 'a 0 L� o o a_ ++ c as ! E. ctirte O m N - v Q ❑ ❑ m ra m U O O E D. m 1 >,.� « >, . m .- O N >s, 0 u = 4 U EETY _ 0 cmO? yilb yc Q O Gfl Z m iri irQ U v fO N Z -0 GCt al mm 111/N ZQ¢ W m ai _c v} t U HEARTSAVER Heartsaver® American FiHeart r Association. Chris L_eaveII has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Optional modules completed: Exam,Child CPR AED, Infant CPR Issue Date Renew By 2/9/2021 02/2023 Training Center Name Instructor Name Sylvester Consultants, Inc. Andrew Kleamenakis Training Center ID Instructor ID 11070600905 MA20132 eCard Code Training Center City, State 206003945674 Hyannis, MA Training Center Phone OR Code Number (508)771-8700 To view or verify authenticity,students and employers should scan this OF node with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All right3 reserved. 15-3002 R3/20 HEARTSAVER Heartsaver® American First Aid CPR AED Heart Association. Jacob Nlourhess has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Optional modules completed: Exam, Child CPR AED, Infant CPR Issue Date Renew By 2/9/2021 02/2023 Training Center Name Instructor Name Sylvester Consultants, Inc. Andrew Kleamenakis Instructor ID Training Center ID 11070600905 MA20132 eCard Code Training Center City, State 206003945675 Hyannis, MA Training Center Phone QR Code Number o: ;. o (508)771 8700 E��'i. 1 To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All ri*its reserved. 15-3002 R3/20 LU a, Q U c o, Z3 o ESQ 4▪ •rU al COs _ 411) ami 2 °a ■■a CU d 6lim 1) o cn a L 410 Ci) o Q L a) a, 0 i cn O cu co _ a V in 11.1 E a411. Lem iiE 01 a CJ Rom I2 N -?i ` LI C‘I 00 .d I"`Z 6 CiO 00 �°° CL 4 atl/O OO .NU < � NN & 2 ✓ C ■ • C RC .. O 0:3 -C4-im in.:0 (3V Cr) L 4-4 -) IV C .Q ,-- 0�Q OOJ AiQ O a N .c.1CD 0 o o z - ia CC▪S c = U aO 0 143 O N cuQWas NC a)m V a 0 U ° O t� a a 110 co NMM Co w W CU x Gl ii▪ - C ■... z 8 /LECJ tl/ U E