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Home My WebLink About2022 App-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-16-10458-04 Issue Date: 1/1/2022 Mailing Address: Location Address: HARI HOSPITALITY INC. 135 ROUTE 28 TIDEWATER INN WEST YARMOUTH. MA 02673 135 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 *101 UNITS; 101 BEDROOMS. INCLUDES 2 MANAGER UNITS. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MP ,R.S., CHO/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-16-10464-05 Issue Date: 1/1/2022 Mailing Address: Location Address: HARI HOSPITALITY INC. 135 ROUTE 28 TIDEWATER INN WEST YARMOUTH. MA 02673 135 ROUTE 28 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: 90 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. rphy, M H, R.S., CHO/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth siio.00 Swimming Pool Operations License Number: BOHSP-16-10460-05 Issue Date: 1/1/2022 Mailing Address: Location Address: HARI HOSPITALITY INC. 135 ROUTE 28 TIDEWATER INN WEST YARMOUTH, MA 02673 135 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 INDOOR SWIMMING POOL Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 7 Bruce G.Murphy, M H, R.S., CHO/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-16-10462-05 Issue Date: 1/1/2022 Mailing Address: Location Address: HARI HOSPITALITY INC. 135 ROUTE 28 TIDEWATER INN WEST YARMOUTH. MA 02673 135 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions OUTDOOR SWIMMING POOL Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH 1 . CHO/James G. Gardiner Health Director/Assistant Health Director teTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 1 t(1 UQ' C TAX ID:`6t - 1'SC'i V`a(r: LOCATION ADDRESS: 135 R 0b ..2Fr w•Armev ,rrA -0267.3 _ TEL.#:So$•-775--63 4, MAILING ADDRESS: /3S Ro u f-c .25r, r(4). Arnipufito MA..0 267 3 . E-MAIL ADDRES S 70 ( f-I ,'s 1 Al do f-2 L . OWNER NAME: ,--l-h �4 fi et CORPORATION NAME(IF APPLICABLE): Hew, /-1'osp; ,"f y /Alt, . MANAGER'S NAME: `, q t $,,,i ng±v n, d TEL.#: MAILING ADDRESS: f35 i' u e a67 Zs•eso.,ar'rn3C-1-1.t . i'-+A- 026,73 . 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. C/f4Rt,&s o Z 4)A-f 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. -ReFtr►t ► TE.., 2. Li,scc t. .DaStu'n560-el 3.77.4p{/ of .:ngon . 4. C4ar/� dclu�- Ple a'1&v'PIILA14"s ii d 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 Establishrient- 143 i,'I.000. Please attach copies of certification to this application. The Health Department will Ili usi it years records. You must provide new copies and maintain a file at your establishment. APR 2 q 2022 1. tRTH 37dL 2. NEAALI:H DFPT — PERSON IN CHARGE: Eac establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Ali �it Tee.._ • 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 'TF�_ 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 copi s and maintain a file at your place of business. ,�, 1. � �oa n I' 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIc.ENSE 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: L ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 7 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 _WHOLESALE $80 _ —RESID.KITCHEN $80 RETAIL SERVICE: e LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED' FEE PERMIT# LICENSE-REQUIRED TEE ' PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 —<25,000sq.ft. $150 =FROZEN D$SSER.T,$'10 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 5 *****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 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 MAYS,• A SITE PLAN. DATE: it /orq . 2/ i SIGNATURE• �_ 4111 PRINT NAME & TITL '71.4 / jg....(. Rev. 10/15/19 NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727-4900 — http://www.ma.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: Hartford Casualty Insurance Company NAME OF INSURANCE COMPANY One Park Place, 300 South State St, 7th Floor Syracuse NY 13202 ADDRESS OF INSURANCE COMPANY 08 WEC AK8XPJ 03/12/22 - 03/12/23 POLICY NUMBER EFFECTIVE DATES PO BOX 9011 CORCORAN & HAVLIN INSURANCE GROUP WELLESLEY MA 02482 (800)-304-8242 NAME OF INSURANCE AGENT ADDRESS PHONE Hari Hospitality Inc 135 ROUTE 28 WEST YARMOUTH MA 02673-4653 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 E Printed in U.S.A. ,j441 „, '41 H EAR it V E R • ''*-1 American Hear •:v - Ht. -trt r ,1 As -,latica. vsfo Parth Patel has silcces,,,,ft.illy completed the cognitive and skillsev7:fl in aCCOI"CAclC;,)ul with the curriculum of the American Heart Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Renew 5;1312.321 05/20 •Training Ceritor Name Instructnr Survival Group, LLe Marjorie A Instructor ID Trainint:i Center ID cluty-J.46 eCarri 'c Training Ccnter City, State 21601217'1.•• • North Haven, CT QR Co, Training Center Phone Number 1-6326 i46, • • or/mycards. Toview or verify Quote liployers stioulo boa]i OR code with Moir mobile device or go t 0 2021 American Heart Association.AUtic)bts reserved. 20-3002 1/21 HEARTSAVkil ,,,,,4---;_-_, .7tr '3, :4•r* est . ri fi American Hertrt r',11--, 1 i ,j, r ii I, 7,, - Lr% , , - Association., • Mark Hutchinson has successfully completed the cognitive and skills eyall..., t;ons in accordance with the curriculum of the American Heart Ar...-.cciation • Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Renew By 5/9/2021 05/2023 Training Center Name Instructor , :flit ye Su,vrial Group, LLC Marjorie Art'old Instructor ID Training Center ID 07150349032 CT05943 eCard Cr,do Training C(.1)ter City, State 216012287''..5 North tiaveii, CT OR Co,:. , Trainirrj Center P:lone liqlsillibiar Pifer] r. .14.. (203) 2.34-6326 •Zt4L4Z4g i gg.t.t1.0441.8 To view or verify authe,ito,o students 4.1'.•:employers shoulo seal tlw,013 code with their mobile device or go to ww .r rt.org/cpr/mycwds. J 20'11 American Heart Ab3uclaticn All rights reserved. 20-3002 1/21 HEART AVER Ole Heartsaver® American Iul ' R Heart Association. Nicole Milley has successfully completed the cognitive and skills in accordance with the curriculum o the American Heart A• - o:i>v iation Heal°tsaver Fia✓t ,id cpn AED Program. Optional rnodtruis completed: Child CPR AED, Infant CPR Issue Date Renew l'"y 5/9/2021 05/2023 Training Center Name Instructor +eta Survival G:uu; , t.t"G Marjorie Arr, id Instructor ID Training Center ID 071503490",2 CT05948 eCard c°>rale Training Center City, State 216oualr,'c,.' North Haven, CT OR Cr Training center Phone Number (203)234-6326 � >` To view or verify autnenticey students and employers should:scan this OR code with their mobile device or go to v rrq!cpr/mycards. 2021 American Heart Awejclation.All rights reserved. 20-3002 1/21 HEARTSAVER late • H r er 0 First pia CPR AM , Violet Roach has successfully completed the cognitive and skills e; in accordance with the curriculum of th2. American Hr art Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Rnnev 5. 2021 DE/ Training Center Name sist Survival Group, Li.0 Marion Training Center ID Instrut:. 07150'el _ C n5948 eCard r- . Training Center City, State t North Haven, CT C'R Training Center Phone Number .. (203)234-6326 ,+ ro To view or verify authentic st H,.It; naployers should scan this OR code with their mob,' ,rr, 2C21 American Heart Association.All right's r:ae ved. 20 '`-.1 HEART AVER hi flOt Heat-7:saver® „. tra• First dd CPR , ' • - Sapna Patel has successfully completed the cognitive and skills ev- . in accordance with the curriculum of the American Heart t: Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR ISStge• Date Renev. F, .1 202 05/2- Training ..-enter Name Instruc; Survivri• oun 1.LC Marjorie •• Instruc'e, Trainiao Center ID 07150?-1 • eCarr; Training eci,der t;ity, State 216012 • North I laven, CT OR Training Center Phone Number (203,234-6326 kow , • To view or verify autheouc odems and employers should scan this OR code with their mobile device or go • , • . 1Ris. 2021 American Heart Association.AN rights reserved. 20-3002 1/21 4111• 4 4 -0 HEARTSAVER 0110 Heartsaver® American ', id CPR AEL) t Timothy Hutchinson has successfully completed the cognitive and skills in accordance with the curriculum of the American Heat Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Rene.. 5/9/2021 05/c Training Center Name Instruc; Survive, Group, LLC Marlon, Instrlictr- Training Center ID 07150' ° C105948 eCat CI e Training Center City, State 216o47- Not North Haven, CT OP (: Training Center Phone Number (203)234-6326 To view or verify authentic', students and employers should scan this OR code with their mobile device nr r' I, • • ^ -ive.ards. 0 2021 American Heart Association.All rights reserved. 20-3002 1/21 - ihil��i�i�VIIG HEARTSAVER Heartsaver® ir„,,r American First Aid CPR AE;al AssoHeaciation. Devon Adams has successfully completed the cognitive and skills evaluitions 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 By 5/9/2021 05/2023 Training Center Name Instructor tl nrre Survival Group, LLC Marjorie Arnold Instructor ID Training Center ID 07150349032 CT05948 eCard Code Training Center City, State 216012280739 North Haven, CT QR Cot-lo Training Center Phone Number �.aR` ,,�i6 i -4.! (203)234-6326 '''•~ To view or verify auti ienticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. if)2021 American Heart Association.All rights reserved. 20-3002 1/21 1Ju111 ,101 411111# l oI:° ;: HEARTSAVER :r American w r , w r1 1 Heart �� As,;cciationa Lisa Washington has successfully completed the cognitive and skills evaluiliions in accordance with the curriculum of the American Heart As.1.riciation Heartsaver First Aid CPR AED Program. Optional modules completed: Child CPR AED. Infant CPR Issue Date Renew By 5'9/202 1 05/2023 Training Center Name Instructor Name Survival Group. LLC Marjorie Arnold Instructor ID Training Center ID 07150349032 C T05948 eCard Code Training Center City, State 216012287:53 North Haven, CT QR Corp Training Center Phone Number (203; 234-6326 1 or verify authenticity,students and employers should scan this off code with their mobile device or go to www.l,o-;rt.org/cpr/mycards. 2021 A,nerican F a,;,Association.All rights reserved. 20-3002 i/21