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HomeMy WebLinkAbout2022 App-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth siio.00 Lodging License Number: BOHL-22-4337 Issue Date: 05/12/2022 Mailing Address: Location Address: YARMOUTH SUNBIRD I CORP 226 ROUTE 28 SUNBIRD ANNEX RESORT WEST YARMOUTH, MA 02673 226 ROUTE 28 WEST 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 BACK MOTEL: 44 UNITS; 44 BEDROOMS. EAST SIDE OF MOTEL: 13 UNITS; 13 BEDROOMS. Board Hillard Boskey, M.D.,Chairman Mary Craig,Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 17/)) Bruce G. Murphy, MP R.S., O/James G. Gardiner Health Director/Assistant Health Director 0 TOWN OF YARMOUTH BOARD OF HEALTH if4) APPLICATION FOR LICENSE/PERMIT-2022 *Please complete form and attach all necessarydocuments byDecember 18,2021. Failure to do so will result in the return f your applicatin packet. ESTABLISHMENT NAME:.SUNBI eD A,u.UE-(.e4..s 2 r TAX ID:B 7" S1S-LlS79O LOCATION ADDRESS: ZZ,6 ROc/re Zuf',. Sc y.9e-Afean/ /+m TEL.#:-508 6'L7- f`.970 MAILING ADDRESS: 2.2-6 /7-OvrE, ZB 1. ��YA92/oft n.. ', 4199 es6 Z7 3 E-MAIL ADDRESS: /4/.CO6).S'c/y8//LOC9PE'op.r-d502rCia41 OWNER NAME: Y42/170ait/ SU4./y/2O Go2/p CORPORATION NAME(IF APPLICABLE : ` oteMOCIT# ScY/1.6/.4O-IL G4ie". MANAGER'S NAME: U/RGq/E/Z C//4'/ i u/.a TEL.#: .5- /- 9 MAILING ADDRESS: Zoo Rt.Y/ G Zg/ /er657-V411"fOr/rY// A,,/ OZ673 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. te)96.te-- ' 7/A4wm/-4#A? 2, A/f/.475i 5/y/9 G7fE.(C/JZg2.L- 9 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. et2AG/!/6/2, ri/1/}'ANiAi/A 2. /79/ ,'/' /) -Z GOL/y9 3. 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. (,O*/12- 9O'/4/09 t%IHW 2. A f/Ars T/95/7.Q G//E' �92e.d4 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. ti.)4 &2 tu'/ A74r//lit4` 2. /jfr 9 /1/�ALCie44.i 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,165 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. d(/4647 ceiw.ex-oo A Y.t9 2. %/Y.9S Y'ASi y'/4 C/1'Lr.(---479iee l"y 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. /149c26,2- <///16'14/Y//L<fg 2. A/i/AS 717 S/Y# e ifc.M/1z•eeiiiit 3. eLE.2-A 1444 of A-/JG/-f 4. gen'/S6 a9 /04,1 CO•Cy7 RESTAURANT SEATING: TOTAL# /r1 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 —>100 SEATS $200 1�_COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 J.:-FROZEN DESSERT $40 TOBACCO tlit. $110 NAME CHANGE: $15 AMOUNT DUE = $ k 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 m the suspension or revocation of your Frozen Dessert Peewit 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 APPROVED BY THE BOARD OF LTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ A SIT DATE: Q /O2,/2C?< SIGNATURE: PRINT NAME&TITLE: GU Gft/ey2 707 44;9-G A- 'At ti14I 4 CrE Rev.10/15/19 I 1 CPO CERTIFIED POOL &SPA OPERATOR Certified Pool & Spa Operator Certification for Wagner Quintanilha as an Operator of Aquatic Facilities issued by the Pool & Hot Tub Alliance on Certification Date: 4/8/2022 Expiration Date: 4/30/2027 Certification Number: 15654596 Instructor Name(s) Achatd--- Steve Donohoe Sabeena Hickman,CAE President & CEO POOL Pool& Hot Tub Alliance -Milk HOT TUB ALLIANCE For venfication,telephone PHTA at 719-540-9119 or email serviceaphta.org Wagner Quintanilha Certified Pool&Spa Operator(CPO) Certified: 4/8/2022 Program,s the most recognized operator training prow:, and includes 14.16 hours of instruction in pool and spa Certification Number: 15654596 r.hemistry,testing,treatment,filtration,maintenance, Instructor Name: Steve Donohoe automatic feeding equipment.and government Expires:4/30/2027 requirernenr_s.CPO Certification is valid for 5 years. 41%.. i.'19540-9119!service apntaorg Srgnoture CPO o 411116 HINgli T CUM!uawo, ALLIANCE •iM o.faA/W- phta.org CPO CERTIFIED POOL &SPA OPERATOR" Fe , Certified Pool & Spa Operator Certification for Anastasiya Chekmareva as an Operator of Aquatic Facilities issued by the Pool & Hot Tub Alliance on Certification Date: 4/8/2022 Expiration Date: 4/30/2027 Certification Number: 15654595 Instructor Name(s) AtkJ SSitl CL— Steve Donohoe Sabeena Hickman,CAE President& CEO POOL Pool& Hot Tub Alliance -., HOT TUB ALLIANCE For verification,telephone PHTA at 719-540 9119 or ernail service a phta.org Anastasiya Chekmareva 1-1 e CsrtilledPool&SpaOp.rator(CPO) Certifies' 4/8/2022 Program is the most recognized operator traiiu,)g 1)r .,,,_: anal includes 14 16 hours of instruction in pool and spa Certification Number: 15654595 hemistry.testing,treatment,fiitratron,maintenance, instructor Name: Steve Donohoe ,tr,rmatrr^feedingequipment and �1 government Expires:4/30/2027 •erqurements.CPO Certification is valid for 9 years. '19)b 0-9119!service aphta arg Signature CPO M!f7T TUB urrrrrreoww ALLIANCE *IPA°POPPT0*` phta.org BASIC LIFE SUPPORT BLSAmerican Provider HeartAssociation. Wagner Quintanilha has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 1/20/2021 01/2023 Training Center Name Instructor Name Safety Program Consultants edward gavin Instructor ID Training Center ID 09102045664 MA04688 Training Center City, State eCard Code 215418317244 Rehoboth, MA Training Center Phone QR Code Number o "'PIE (508)252-3049 :4 • spy-y�.�.'yy. 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. 20-3001 10/20 � 1 www.capecodsafetytraining.com gyp` s NSC CPR Course a t °""`SN' Adult, Child, Infant, FBAO & AED Name: Misha Malcolm Security Control No. Address: Quality Inn 874955 Address: 216 Main Street,Rt 28 City, State, Zip: West Yarmouth,MA 02673 Course Completion Date: 04120/2021 Training Center: Cape Cod Safety Training Expiration Date: 04/20/2023 Instructor Name: Rick Todd Instructor Number: 1040918 Misha Malcolm has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities,and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining 1 THIS DOCUMENT IS VOID IF REPRODUCED Security Control No. Misha Malcolm 874955 Q K °�u■o�• has completed the NSC CPR Course We want your feedback! Adult,Child,Infant FBAO,CPR &AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: take a brief survey and share your opinions 0412012021 Expires: 0412012023 Instructional Hours: about the NSC course you completed. J-r 1 %Cui• #1040918 Instructor Signature Instructor No. NSC-in it for life. nsc.org/fatraining.) Keep this card for your records.Void if reproduced. 50M04012020 1015 900008130 02016 National Safety Council 79174-0000 o. I j A ..i ua z o 1 w 4 oc1 1 z ci 1 ...... I N +u Le °19 Z g 74 U. c NJp . illeall ° i A _ts -11 ou ,,II) kil, Z "I tL! ,a r � � `.I.. 0 ,_...".„...,,,..,......: F- ,,,,,I..,,,,::...,',,, t MM.= Ct w -� .7,'"- 0 Cle Z ''''.--'::12,1'-':'-.. - . ' '' i• ,,,,,i;•.-• _UP) '-_,,,- , V # a . Q ��k ServSac National Restaurant Association TM S safe® ervSafe® CERTIFICATION ANASTASIYA CHEKMAREVA for successfully completing the standards set forth for the ServSafe° Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 2 10752 CERTIFIC - E NUMBER EXAM FORM NUMBER 12/7/2021 `' 12/7/2026 DATE OF EX (NATION DATE OF EXPIRATION Local laws apply. Che with your local regulatory cy for recertification requirements. ANSI ji ACCREDITED PROGRAM American National Standards Institute / !' and the Conference for Food Protection 1-,) - Sher n Brown #0655 EicMtive Vice President, National Restaurani As •ciation Solutions I ; • 0 et 0' O In accordance wi _ Resolution ' Laboarawention 2006,Rlution ADM N 068-2013(Regulation 3.2,; ' 0 ' rant Association Educational Foundation(NRAEF).All rights reserved.ServSa'' . . -ServSafe logo are trademarks of the NRAEF.National Restaurant Association®and the arc design ' National Restaurant Association. This document cannot be reproduced or altered. 17110811 v.171 1 Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or ServSafe@restaurant.org. -1- r , •S r , r , rir , o ,ri, T r , 's r , T5 r , I. i. So -Thwei ire 1 .,. n SFFF�Fi a"'YKFtYisF..11.1iYii'i�#'iFi�afYc•ws..w....i.•.aliFFFiTFLTiav .w. ....� ._w.•a...w. 1 4. ///\\\jjj���'''`�jw- �±! ••SS�_.. ....4'1YF'�YiY'F'.'s"iFY'.i'Yii'FFTi"tea_ - ..... .�_.. w...� V t J n • 2"" CE RT I F I C AT E O F w �N 4. e +y V M r 4f , r cm " ALLERGEN AWARENESS TRAINING 4.1,�-.4..,,,, 1i .__, .. . , i . . ..• .. 1 t 4 C .ti I M rq?:,lN tt�()^ , < 1.4 Name of Recipient: WAGNER QUINTANILHA " a„ / cS � ; i \ 6 ' Certificate Number: 3762929 �.. Date of Completion: 2/7/2019 ;y c r 1r Date of Expiration: 217r2o24 ❑ �;r��. 11 /\ r fi yl Issued By: " ttti ^ , „s The above-named person is hereby issued this certificate 11� L for completing an allergen awareness training program NATIONAL . .�........ RESTAURANT ` \ � recognized by the Massachusetts Department of Public Health 4-67 ASSOCIATION in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 y• 30 333 Turnpike Road,Suite 102 www.restaurant.org y C * Southborough,MA 01772 This certificate will be valid for five(5)years from date of completion. 508-303 9905 r � �Z www marestauranrassoc.org /c' tY' , I. ....._a et.w.s:IL - -..._ ies.ICaxAstr +yLLs tts._fsta:... IM1151f.e_+tetaw*...uerz... .z-n z -rz. mzix 1 rcac.. • .1 ir IL I J li i 1 4 1° 'F(..tV:1' 4 l' '11P: 4 41 'l ..; 1° 'lir' J. 461, 4 IA Ir? Ci'-, i\7 riri VV '/ '/\7 ririVV��// YY '� ✓ 16. wi ilko fro • Ile vli cl. a , I I l _rx_i., z. _.. rrsss-rrasrrrrarecalr _. ..... -avx.1{11-- _.y.r..,II,- - --rc-r ____ -_. - - _. - __- - _.— - - - ....- .I .11114 il m - i CE RT I F I CATE OF N• ; Y ✓ '''f'r? . : ,c,,: , J,.... ALLERGEN AWARENESS TRAINING ., 40 , •& • : r 2 •i►. +.a y Name of Recipient: ANASTASIYA CHEKMAREVA H• 4„ � c4...1) i . Certificate Number: 5358930 4. I? '"1 : Date of Completion: 11/18/2021 �7'1 C� Date of Expiration: 11/18/2026 ' ( aQ . • -r• • .. y rq y,, Issued By: • / -) , ii „) The above-named person is hereby issued this certificate NATIONAL ' 4 .I for completing an allergen awareness training programIssernial RESTAURANT y �( tlif tip/ recognized by the Massachusetts Department of Public Health 'w ASSOCIATION, : �' 3 in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 h• a i 333 Turnpike Road,Suite 102 www.restaurant.org .41e..;, 1 Southborough,MA 01772 This certificate will be valid for five(5)years from date ofcompletion. 508-303-9905 ✓ "q www.marestaurantassoc.org + te'ti j�_ .• �•=..1111e/LMaaaLa tezTM*araz:s..s.erms cstaasxxa_aaaiCIrwsaes•----zxa:stye.- _.. _..uv:s_si_aIGAaaaa.:aesr...r ate ifeees...�e:.awia...��_:awataaeau.aus. ze. e..x. < rt-t-rzrt' ., .1110111 CUT EmergencyRespo se Training An Authorized AHA & A . ; Training Center Certificat 4 t*äining Wa8 ( iintanItha #40 Has Successiu ly Completed the 2.0 hour Choke Saver Course This class meets the training requirements of Mass DPH 105 CMR 590 and 105 CMR 605 November 11 , 2021 Certification valid for two years Joseph Boykin from the above date www.EmergencyResponseTraining.corn 877-378-2336 IERT •iir EmergencyRespo se Training An Authorized AHA & A ARV raining Center Certificate ii, . ining .a r Anast,0-, e k m v reti . _ Has SuccessTu ly Completed the 2.0 hour Choke Saver Course This class meets the training requirements of Mass DPH 105 CMR 590 and 105 CMR 605 November 11 , 2021 Certification valid for two years Joseph Boykin from the above date www.EmergencyResponseTraining.corn 877-378-2336