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HomeMy WebLinkAbout2022 App-Permit-Certifications 0APPL...."►, TOWN OF YARMOUTH BOARD OF HEALTH E ►\ ICATION 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: VS-11,126 G/1--e-� ' TAX /?- LOCATION LOCATION ADDRESS: 3 3 3 7 S e QS,rd,z V LCee y e Pc), TEL.#: MAILING ADDRESS: Sv4-u-'C- E-MAIL ADDRESS: ,.l k y,9G.>r`,r,21 *y, @ aj s .e-m-,,. OWNER NAME: -Ph-.9/ c-S': /''M9W-4,44-1•=4„ .i �A-G k Z ate, CORPORATION NAME(IF APPLICABLE): -.. nLa y,1.G /°/Lej ' €5 61--C--- MANAGER'S NAME: Z 4 1c- 1-1749eS TEL.#: GSA-- 73944.Y , MAILING ADDRESS: PP, /.3o or 7 alS. yAlL-e-e-e4-4a0> old- 694- ,c, f POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list t gejiglfVC t�D Pool Operator(s) and attach a copy of the certification to this form. �.. o 1. (P44 & 14,474. 2. i'iAY 0 6 2022 Pool operators must list a minimum of two employees currently certified in standard First Aid and i11.411* Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Q 1 tftt 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. £' l r-u.) i-j•,-' ' 2. ! fl-C.h-ct 4_9,.,---r-k“, 3. LI ,e-4'k vriv)." uSc0Y-�,% ) 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 use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. 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 4 LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 ZSWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE SEEQUIRED FEEATS PERMIT# LI ENSE$1REQUIRED EQ IR D FEE $3PERMIT# LICENSE OQ IT IRED FEE PERMIT# 0-100>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 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 = $ .2 55 *****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 f 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 RE► e ' A SITE PLAN. DATE: j � �� SIGNATURE: PRINT NAME & TITLE: , Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-22-4254 Issue Date: 05/06/2022 Mailing Address: Location Address: SHORESIDE PROPERTIES LLC 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH. MA 02664 33-37 SEASIDE VILLAGE ROAD 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. Conditions UNITS-46; BEDROOMS- 46 Board Hillard Boskey, M.D.. Chairman Mary Craig,Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston elP Bruce G. Murphy,MPH,R.S., CHO aures G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-22-4257 Issue Date: 05/06/2022 Mailing Address: Location Address: SHORESIDE PROPERTIES LLC 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH. MA 02664 33-37 SEASIDE VILLAGE ROAD 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. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston Br ce G. Murphy, -PH, R.S., ames G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee /...°' Town of Yarmouth $35.00 Food Establishment License Number: BOHF-22-4259 Issue Date: 05/06/2022 Mailing Address: Location Address: SHORESIDE PROPERTIES LLC 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH. MA 02664 33-37 SEASIDE VILLAGE ROAD SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast; 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 II oz - Bruce G. Murphy.MPH, R.S., CHO/James G. Gardiner Health Director/Assistant Health Director o u /� � CD C `� AIIr+ Xi O ruil NMI71 Z CD 3 Mill 0. oIVO L 5; O -< 0 rt 0 ut, ^♦ — rt- co n X C. O W }0 RI rt� =: O A) p -c" 2 m D rt rtithQ `D z O .13 D 0 O Ort iz• so a , ,,t,„.„0„, �a) m rt rt rt C �1•"'� amu: 71 N !D fD _ >iv :i.e.. . . g g Cr D 0 moo= r O NN r+ c z , l0 > O Na N Yl o Cl: ..1 r � (D to Ziv m 3 mvm.pg O - OP Z. ID T o' 0 IY on (( J i' N a 1 I o vea m € N= C 0Crt D n Qrn p z O n n > CD m nsc NSC First Aid CPR LEARNING & AED Course Includes Adult/Child/Infant CPR/AED Choking, First Aid, Epi Pen • Name:Yacha Watkis Security Control No. Address:The Yarmouth Resort 858851 Address:343 Route 28 City, State, Zip:West Yarmouth,MA 02673 • Course Completion Date: 0312212022 Training Center: Cape Cod Safety Training Expiration Date: 0312212024 Instructor Name: Rick Todd Instructor Number: 1040918 Yacha Watkis has successfully completed the NSC First Aid,CPR&AED Course. The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining • THIS DOCUMENT IS VOID IF REPRODUCED ■.nsc Security Control No. nsc LEARNING 858851 LEARNING Yacha Watkis • has completed the • We wantyour feedback! - NSC First Aid,CPR&AED Course Training Center: Cape Cod Safety Training Completion Date: 0312212022 Please visit nsc.org/firstaidevaluation to Expires: 0312212024 InstructionalHours: take a brief survey and share your opinions #1040918 • about the NSC course you completed. Instructor Signature Instructor No. J Keep this card for your records.Void if reproduced. 79178-0100 100M03092021 543401©2020 National Safety Council _ _ • • nSC NSC_ Firs !cJRCPI w -w.ca ecoa i. LEARNINGr. 8( AED Course Includes Adult/Child/Infant CPR/AED Choking, First Aid, Epi Pen Name:Catherine Watson Security Control No. Address:The Yarmouth Resort 8 5 8 2 41 Address:343 Route 28 City, state, Zip:West Yarmouth, MA 02673 Course Completion Date: 0312212022 Training Center: Cape Cod Safety Training Expiration Date: 0312212024 Instructor Name: Rick Todd Instructor Number: 1040918 Catherine Watson has successfully completed the NSC First Aid,CPR&AED Course. ( The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED :.nsc Security Control N< t • '�nsc LEARNING 8 5 8 2 41 LEARNING Catherine Watson has completed the NSC First Aid,CPR&AED Course We want your feedback! Training center: Cape Cod Safety Training Completion Date: 0312212022 Please visit nsc.org/firstaidevaivation to Expires: 03171/2024 InstructionalHours: take a brief survey and share your opinions r, about the NSC course you completed. `-f �� #1040918 Instructor Signature Instructor No. • / Keep this card for your records.Void if reproduced. 7917&( 100M03092021 543401 02020 National Safety Council : : 11SCCPF NSC First Aid, LEARNING 8( AED Course Includes Adult/Child/Infant CPR/AED Choking, First Aid, Epi Pen Name:Eileen Byrne Hynes Security Control No. Address:The Yarmouth Resort 8 5 82 4 5 Address:343 Route 28 City, State, Zip:West Yarmouth, MA 02673 Course Completion Date: 0312212022 Training Center: Cape Cod Safety Training Expiration Date: 03122/2024 Instructor Name: Rick Todd Instructor Number: 1040918 Eileen Byrne Hynes has successfully completed the NSC First Aid, CPR&AED Course. The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED ■ .f SC .•::nsc Security Control No. LEARNING 8 5 8 2 4 5 LEARNING Eileen Byrne Hynes has completed the NSC First Aid,CPR&AED Course We want your feedback! .. Training Center: Cape Cod Safety Training Completion Date: 0312212022 Please visit nsc.org/firstaidevaivation to Expires: 0312212024 InstructionalHours: take a brief survey and share your opinions about the NSC course you completed. ltc -'4`L z"1 Instructor 08 Instructor Signature . Keep this card for your records.Void if reproduced. 79178-0 100M03092021 543401©2020 National Safety Council A ® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/04/2022 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 Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C.No.Ext): (A/C,No): 973 lyannough Road E-MAILDSS: treeves@doins.com INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601INSURER A: Lloyds of London XS0123 INSUREDINSURER B: Evanston Insurance Company Shoreside Properties,LLCINSURER C: Associated Employers Ins Co 11104 PO BOX 714 INSURER D: _INSURER E: _ South Yarmouth MA 02664 _INSURER F: COVERAGES CERTIFICATE NUMBER: CL225410487 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 SUNK POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD_WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)_ X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 CLAIMS-MADE [X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A XSZ191715 04/14/2022 04/14/2023 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X LOC PRODUCTS-COMP/OPAGG $ INCLUDED POLICY 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 LIAROCCUR EACH OCCURRENCE $ 1,000,000 _ B X EXCESS LIAB CLAIMS-MADE EZXS3076928 04/14/2022 04/14/2023 AGGREGATE $ 1,000,000 _ DED RETENTION$ $ WORKERS COMPENSATION x STATUTE EORH AND EMPLOYERS'LIABILITY Y/N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A TBD 05/04/2022 05/04/2023 E.L.EACH ACCIDENT $ C OFFICER/MEMBEREXCLUDED? 500,000 (Mandatory in NH)) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 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) ***Jack Hynes is excluded from workers compensation coverage. Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions 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 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664w.,.��" ��s G I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ( 4 ) TOWN OF YARMOUTH L ��b�Do °: HEALTH DEPARTMENT MAY .e ? 2022 Y-•.. 'x TH DEPT ,, PERMIT APPLICATION SIGN OFF TRANSMITTAL Su To he completed by Applicant: Building Site Location: - - 31 5 6',,, .- Ac V +;I\ ie - `') Proposed Improvement: r'1 ,,4,- ( c) 1 e,C _.r- i\,- ,, ,,) ,)(h)NJc .f;. LA, t,z,7 ,i5 ") 1/6 dee, .S Applicant: S h' : . A.,e,_. -i '.-t_c_ ....-14 -k 44-144,-,c,.7_, Tel. No.: c rf-)2 -2 :2 L)q zt Address: n f : .2, 7.-,r,, jJ,y t' n y.0�•fi L. a 4 a :.-4 % : Date Filed: ,_ ! ,, **/fyou would like e-mail notification of sign off,please provide e-mail address: Owner Name: -.- rk r /-i62 n._ Owner Address: = - 2 c;N. P . , {1. r. .4fd,Ld.v,1i, Owner Tel. No.: --:`,--,-c- 7 7 57-,-,/o RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) - Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: Q DATE: 5/' 2-A:2-- PLEASE NOTE COMMENTS/CONDITIONS: f--1- 'c, 1 171 -The--rt f-tisk- t j(-- fC_"�-