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HomeMy WebLinkAbout 2022 App-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1803-07 Issue Date: 1/1/2022 Mailing Address: Location Address: MAPLEWOOD AT MAYFLOWER PLACE SNF, LLC 579 BUCK ISLAND RD MAPLEWOOD AT MAYFLOWER PLACE WEST YARMOUTH, MA 02673 579 BUCK ISLAND RD 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.,CHO/James G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1802-07 Issue Date: 1/1/2022 Mailing Address: Location Address: MAPLEWOOD AT MAYFLOWER PLACE SNF, LLC 579 BUCK ISLAND RD MAPLEWOOD AT MAYFLOWER PLACE WEST YARMOUTH. MA 02673 579 BUCK ISLAND RD WEST 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 INDOOR SWIMMING POOL Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston I / truce G. Murphy, MPH, R.S./ Hite James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-1.5-1805-07 Issue Date: 1/1/2022 Mailing Address: Location Address: MAPLEWOOD AT MAYFLOWER PLACE ALF,LLC 579 BUCK ISLAND RD MAPLEWOOD AT MAYFLOWER PLACE WEST YARMOUTH. MA 02673 579 BUCK ISLAND RD WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 235 Board Hillard Boskey,M.D.,Chairman Mary Craig,Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston I • Bruce G. Murphy,MPH,R.S., H fi ames G.Gardiner Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2022 *Please complete form and attach all necessary documents by December 18,2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME:_ }�(lp1 y�1 �,�- r"(� {y�''6 TAX ID: -••:•.-•1A, LOCATION ADDRESS: ,. 7 ic4 .=SIGr lel) r ali►aTEL.#: ,O$-,0-0.24c MAILING ADDRESS: . &ril) C� 4.6\rP E-MAIL ADDRESS: IvLcANy, joJe-rQ 0 on_ap(rLAMoc S`. 001.1 OWNER NAME: Si Q Ile CORPORATION NAME(IF APPLICABLE): , . , •OA. ,4y • • • • LF L(J MANAGER'S NAME: _pas ke,l G vzee. -e TEL.#: co, ?'?O Q.36 d MAILING ADDRESS: e gurK. z,Lajell (d t ) Yair � ,A', ��7 POOL CERTIFICATIONS: f/ The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool�O`perator(s)fand attachI_a copy of the certification to this form. I. Flil'k c 4 i22ck4O 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. RClA0 k PIL2a..-t-6 2. LiA8.0( l-tzorci "3 (. � 3.C. \-al m0�- i'Z • 4. J 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 mu rovide new copies _i and maintain F�Q c maintain a file at your establishment. I Mac'` I. C) O2� an`-�?4 l "' 2. � }\-1-i S(' PERSON IN CHARGE: Each food establishment must have at least one `J Person In Charge(PIC)on site during hours of operation. I. l��??0, r ' (-S 2. le', Sciwz c t IN , 0 3 2022 ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, ' ,-!.I n"SPT 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.% e bte T0. If,4 2. 717a/,-/a-444-11V) L1/�.fd - 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. mOt .�je-LA 7-,,,,,9e,--r ( e CreAC) 2. 'b2/r 7 3. ,2 .4----/ � /d l' 7 l J 4. ',1/ Gula-{Z0 RESTAURANT SEATING: TOTAL# /r2 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS —INN $55 CAMP— $55 MOTEL $110 LODGE $55 TRAILER— PARK $105 55 CABIN $55 ,,SWIMMING POOL$I IOea. �WIIIRLPOOL $1IOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS /0-I00 SEATS CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS (..2...23 ,0 COMMON VIC. $60 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS <50 sq.ft. $50=<25,000 sq.R. $150 >25,000 sq.R. $285 —VENDING-FOOD $25 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ ^__ i *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** l IIJw� S. 15 , A55'°J 1 (602_ i%0 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 n 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 MG,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 = IRE A SITE PLAN. DATE: I (.;W ( SIGNATURE:_ cajtj PRINT NAME&TITLE: 110A - .,o' ,CI, . JI r, Rev.10/15/19 The Commonwealth of Massachusetts . Department of Industrial Accidents . Office of Investigations . 1 Congress Street,Suite 100 �_ Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Maplewood Mayflower Place ALF, LLC Address: 579 Buck Island Road City/State/Zip:West Yarmouth, MA 02673 Phone#: (508) • 790-0200 Are you an employer?Check the appropriate box: Business Type(required): 1 i✓I 1 am a employer with 99 employees(full and/ 5. ❑Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 7• 0 Office and/or Saks(incl.real estate,auto,etc.) [No workers'comp.insurance required] 8. Li Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance require31** 4.❑ We are a non-profit organization,staffed by voluntee-s, I lig Health Care with no employees.[No workers'comp.insurance req.] '2.❑Other *Any applicant that checks box#1 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:MEMIC Indemnity Company Insurer's Address:650 Elm St, Ste 401 City/state/zip:Manchester;NH 03101-2551 Policy#or Self-ins.Lic.#3102804908 _ Expiration Date:6/1/22 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 MOL.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 DIA for insurance coverage verification. • I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 12/9/21 Phone#: (1_,P3) 55 7— tf177 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 AC�® DATE(MM/DD/YYYY) 4.....----- CERTIFICATE OF LIABILITY INSURANCE 11/29/2021 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 Commercial Lines Service Team M&T Insurance Agency, Inc. PHONE FAX 285 Delaware Avenue, Ste 4000 (A/c.No.Ext):716-853-7960 (A/C,No):855-595-4605 Buffalo NY 14202 ADDRESS: CLServicing@mtb.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:TDC Specialty Ins Co 34487 INSURED MAPLE-5 INSURER B:StarStone Specialty Ins Co 44776 Maplewood Mayflower Place, LLC INSURER C:Federal Insurance Company 20281 C/o Maplewood Senior Living, LLC 1 Gorham Island INSURER D:National Fire&Marine Ins Co 20079 Westport CT 06880 INSURER E:American Empire Surplus Lines Ins 35351 INSURER F: COVERAGES CERTIFICATE NUMBER:1888916735 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. INSRRNSD TYPE OF INSURANCE IDDL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDD/YYYY) IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY LTP-01015-21-01 6/1/2021 6/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) _$100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JECT X LOC PRODUCTS-COMP/OP AGG $ X OTHER: Shared Aggregate Policy Aggregate $10,000,000 C AUTOMOBILE LIABILITY 73594041 6/1/2021 6/1/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) _ B UMBRELLA LIAB OCCUR 82176D210AHL 6/1/2021 6/1/2022 EACH OCCURRENCE $13,000,000 D E X EXCESS LIAB X FNSC100124 6/1/2021 6/1/2022 - - CLAIMS-MADE XS E717399 6/1/2021 6/1/2022 AGGREGATE $13,000,000 DED RETENTION$ $ WORKERS COMPENSATION I PEARTUTE I j I ETH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? n N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability LTP-01015-21-01 6/1/2021 6/1/2022 Per Incident 1,000,000 CLAIMS MADE Aggregate 3,000,000 retro 6/1/20 Policy Shared Aggr 10,000,000 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUT RIZED REPRESENTATIVE 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 ..._. .. ---- •' __-_-----:--M___'''''Ig"'", „...---7,--.----..., ,::::' -•.--...==-•\/_I---.-1--?..._\44e.,--s.-.„.:4--Tki•:;:•.-4. li:ii,:%•:c1.::::::;7;iirg;g:•:•:•;11 ----_,-_,__-, HIL,,,,op -_-:;_::::: „,.____„...:-,,,..„:,-,....,.\7_,..i...i„---..;. .',Tlii. ii,viiiii,..z.;1:::::-..-3.*:;;;;;;:,,.;:;•:::$.:,;,i?,n;;;;,,',,;v40,;,;„•ovx,,k•ir;?,.:i4 .7,4-, -..:.- .4?- z?-.\/-=t-.F----\/--z:::-‘4•4*:,7'-v$:':'''''''' ''s:;$'4'.'1":Agi'''..N04,.y4A,ve.,,10,4y,.1*Ir. 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