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HomeMy WebLinkAboutApp-License-Certifications .... TOWN OF YARMOUTH BOARD OF HEALTH ti`' !11 ' APPLICATION FOR LICENSE/PERMIT -2022 II * 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: kkcirrkerS Green M O-vpA TAX LOCATION ADDRESS:S5S RT,ltt48•' Gv. ocnhLI 14.4-04,6 73 TEL.#5' -775-5'400 , MAILING ADDRESS: 3 #T'. .21', W . otrgt, HA^4.26'73'- E-MAIL ADDRES l c�ql' G j.q�p - •Co KA , OWNER NAME r-I� 'ei • CORPORATION NAME (IF APPLICABLE):S k(41 M Mn c MANAGER'S NAME: A}Qtoo @ t IIe,J • TEL.#5G5'775--S#pts , MAILING ADDRESS .vt_ L• A ,r L :rD • POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool0191 Op�erator(s) and attach a copy of the certification to this form. 1. C� 9tN 'VS 641 uti 4 • 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.or�IYou must provide new copies and maintain a file at your place of business. 1.T it (7 Mit-44(2. Plv1i rySo n • 3. /Tie of e t4 11ey . 4. Starves b r 1 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 n. . • •ars'records. You must provide new copies and maintain a file at your establishment. ;L; 1. 2. APR 9 r PERSON IN CHARGE: HEALTH DEPT. 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 # LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# IM0TEL NSE REQUIRED FEE PERMIT# —B&B $55 CABIN — $55 — $55 $110 LODGE $35 —TRAILER PARK $105 CAMP $55 WIMMING POOL$110ea. HIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 100 SEATS $200 _CONTINENTAL $35 NON-PROFIT $30 — —COMMON VIC. $60 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN.$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 LICENSE REQUIRED'FEE PERMIT# <25,000 sq.ft. $150 __FROZEN DESSERT $40 —VENDING-FOOD $25 _TOBACCO . $110 NAME CHANGE: $15 AMOUNT DUE _ $ 2-,Q *****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 • 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 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 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 A 'PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE le E PLAN. REN`7 /-Ly " . • SIGNATURE: Li n A �1 PRINT NAME & TITLE: fir' 4 Pe) Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth siio.00 Lodging License Number: BOHL-16-7819-06 Issue Date: 1/1/2022 Mailing Address: Location Address: SHRIM INC. 553 ROUTE 28 HUNTERS GREEN MOTEL WEST YARMOUTH. MA 02673 553 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 UNITS- 74; BEDROOMS-74 1 MANAGER'S UNIT Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston ./4 Bruce G. Murphy, MPH, R. , C d /James G Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth siio.00 Swimming Pool Operations License Number: BOHSP-16-7820-06 Issue Date: 1/1/2022 Mailing Address: Location Address: SHRIM INC. 553 ROUTE 28 HUNTERS GREEN MOTEL WEST YARMOUTH. MA 02673 553 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, MPH,R.S , CH e/ James G Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-16-7821-06 Issue Date: 1/1/2022 Mailing Address: Location Address: SHRIM INC. 553 ROUTE 28 HUNTERS GREEN MOTEL WEST YARMOUTH. MA 02673 553 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 WHIRLPOOL/VAPOR BATH Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, R.S., ' HO/ ames G. Gardiner Health Director/Assistant Health Director SHRIINC-01 DDONOHUE .�coRo.. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `-�-� 3/28/2022 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 Denise M. Donohue The Corcoran&Havlin Insurance Group PHONE FAX 287 Linden Street (A/C,No,Ext):(781)235-3100 271 (AIC,Ne):(781)235-1622 Wellesley,MA 02482 E-MAIL ADDRS:DDonohue@chinsurance.com INSURE (IS)AFFORDING COVERAGE NAIC# INSURER A:Technology Insurance Company,Inc 42376 INSURED INSURER B: Shrim Inc dba Hunters Green Motel INSURER C: 553 Main St,Route 28 INSURER D: West Yarmouth,MA 02673 — INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY1 (MM/DDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED 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: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ UNON-OWNED (Peaccident)AMAGEATOS ONLY UUTS Y $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ I $ A WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ERH TWC4078441 2/8/2022 2/8/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Parth Patel ACCORDANCE WITH THE POLICY PROVISIONS. 553 Main St Route 28 West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HEARTSAVER Heartsaver® American • z HecIrt AE:7) i s +e PR A- ,',wtCi,.• u . e.y+'I't Perth Pawl has successfully completed the cognitive and skills ev•- v in accordoo,co with the curriculum of the American Heart 1,, �<Jtioaa Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR l&=,a.ae Date Renew x'2.)2 i 05/20' Training :,.„'at oir Name lnstructnr , ,j e Survival Group, LLC Marjorie Artr an Training Center ll) Instructor ID C'105�48 07150^4r'r" eCaral Training Center City, State 216012.7. North Haven, CT Training Center Phone OR "t. Number (::C • "?4 432 • • yW ' To view or verify aunt..• ;; .c nployers shoulu scan snit,On code with their mobile device or go tc t ;•t<:nr/mycards. -,2021 American Heart Association.All rights reserved. 20-3002 1/21 ler l� IIIIIII� �IV I�III �I'IIIq�} •- li % Ir IN�I�h���l.l,,%II II w I I tl� j III% ml� I� ISI�4 III hNII I�'rf .�. � .a s� saw � suv n �YMN.i M'. r 9 ♦ a� III ppIII .lIP14101,' ° 41i Gfi %r'rir llIlllllI u � � e . ( �Rp _ %Ilp American ;3j, Li 2 tri2. Mark Hutchinson has successfully completed the cognitive and skills evalt,i ons in accordance with the curriculum of the American Heart Ac;-:eciation • Herr •tsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR issue Date Renew Cy 519;2021 05/2022 Training Center Name Instructor 111hie Su,vival Group,LLC Marjorie Art ic d Instructor ID Training Center ID 07150349032 CT05943 eCard Cr•cio Training Center City, State 21601223' North haven, CT QR Coo: Training Center Phone W ti m leer pr.0-4e +� (203)2341-6326 Si, To vow or verify authentioR; students tc'.0 employers should scai this OH code with their mobile device or go to ww,-",%ert.org/cpr/mycarde 20;'l American Heart Association.Ail rights reserved. 20-3002 1/21 a t 8r r i e a � �Gi h - n fid,� ��IiIVI I I 1 I hull I lw�' � plh Iii�I I III ILII I Illi ill mlu 9�'I II,'lllll�I s ".. IW�`"ham+u. '.#. �I�t�I I� IN I IIuV� iIV N I pl i ryiV x I II i III VIII u m�r� � a I IVIi�II H IL�. IwVl1II ydtl a 11�p if,,f olli f k ',µ mlxld t tN � �' IV p9r eltt I Io° 1W 4 .I a V VIII - ', v lNt II %I u l uu r, I� SII, p �Ip�I'�' ,.II III III%k ! I tl', 1 III III iIVI l i 11, 1���u l tl iul .y . tit IIJI1Jll 4i;.m I I Ili J I% ya -d !III, 11 I11 V: I ® `�• Illllq�, Anlerican u 1.1 tv Nicole id7iDey has suc c.,e i fully completed the cognitive and skcills evr.ll in accordance with the curriculum the American Heart Ae - ;;:dation F-lei.tsaver Fig-6.1 Aid CPf AED Program. Optional rnodulvs completed: Child CPR AEU, Infant CPR Issue Date Renew Sy 5;9/2021 05/2023 Training Center Name Instructor i id3 Survival G.UUP I.LC Marjorie A,r Id Instructor ID Training Center ID 071503490:"'2 CT05943 eCarc17 de Training Center City, State 2160122tr" ' North 1-lavon, CT Training `:enter Phone (203)2:)4-6326 1_0. ii To view or verify autnenttcry students and employers shoulu scan this Ori code with their mobile device or go to v ^+"" ry"t'cpr/mycards, 2021 American Heart Association.All rights reserved. 20-3002 1/21 # " J1111V,11,1111171 , HEARTSAVER T-111,11 f — H Violet Roach has successfully completed the cognitive and skills e‘,, - in accordance with the curriculum of the American Ho,art lieartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Isscw Date Pnew 5, 2021 05/2 : Training eel'ter Name 'Hs! Survival Group, LLC Marjon Instruci Training Center ID C i.)5948 er-lre Training Center City, State North Haven, CT CAI Training Center Phone Number (203)234-6326 To view or verify authentic', st,do its ao,-.employers should scan this OR code with their mot d- 2621 Arne'!can Heart Association.All rights tJsetved. 20. '2 1 '11`1114,1 111 ° " I 1,1111 4,1 11111 ^ let RI E Aft 1: " .)111 : I, 11111 4 9,1 4,4,Dit 11?ii:44 11114 Hill II 111111 H 'Fr® p ,,rican Firspr,„19 t Li _1 Sapna Patel has successfully completed the cognitive and skills cv ' . in accordance with the curriculum of the American Heart Ileartsaver First Aid CPA AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Rene,- t 5'3202': 0512- Training Center Name Instruc;.- Survivh. (31'oup L.LC Marjorie lnstruc Training Center ID 07150?-1- ' eCar, Training CL-utter City, State 21601'2 • North Haven, CT ("IR Training Center Phone Number (203,234-6326 • To view or verify at.ithent c, r cud employers should scan till:,CSR code with their rnobite device or go 1,, 2021 American Heart Associatioi.All rights reaerved. 20-3002 1/21 111 2E70 e '4440 HEARTSAVER vr ;114I f.. Ir lit llil,llil"hell l l • i ® hIIIV°i r1` Atnerir_nn Heap , .ever h ,; c' SPR AE[ .,t i- �lll I,II t:; t Timothy Hutchinson has suc.:essfully completed the cognitive and skill. �. in accordance with the curriculum o* the American Hea-t Heartsaver First Aid CPfi AED Program. Optional modules completed: Child CPR AED. Infant CPR Issue Date Rene*,. ., 5/9/2021 05/`. Training Center Name Instri.rri• Surviv.,Group, LLC Marjorie Instr+�,r, Training Center ID 07150" ,, C105948 eCar-C`1 ._ s Training Center City, State 21Pr, .. .. North Haven, CT Cx Training Center Phone Number (203)234-6326 .; ';k2". lir To view or verify authentichy,students and employers should scan this OF code with their mobile device or r -rpsards. uJ 2021 American Heart Association.All rights reserved. 20-3002 1/21 HEARTSAVER fie Heartsaver® American First Aid CPR AE:... = Association. Devon Adams has successfully completed the cognitive and skills evalu-itions in accordance with the curriculum of the American Heart As.; ciation Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED. Infant CPR Issue Date Renew Ey 5/9/2021 05/2023 Training Center Name Instructor Name Survival Group, LLC Marjorie Arnold Instructor ID Training Center ID 07150349032 CT05948 eCard Code Training Center City, State 216012280789 North Haven, CT OR Code Training Center Phone Number gra "c (2 03) 234-6326 To view or verify authenticity,students and employers snuudd scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. 0 2021 American Heart Association.All rights reserved. 20-3002 1/21 HEARTSAVER ,„.....no 1,He h luuNu a iu, 1111111 y`.}4 rt aV r® American Heart .i :4— Aid .._;P r Association, Lisa Washington 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: Child CPR AED, Infant CPR Issue Date Renew Ey 519/2021 05/2023 Training Center Name Instructor NNNme Survival Group, LLC Marjorie Arnold Instructor ID Training Center ID 07150349032 C r05948 eCard Code Training Center City, State 216012287350 North Haven, CT Training Center Phone OR Cod:, Number (203; 234-6326 T.)view or verify authenticity,students and e,,iployers should aeon this CR code with their mobile device or go to www.hc^rt.org/cpr/mycards. te)2021 A.norican he,[ Association.All rights reserved. 20-3002 1/21