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Home My WebLink About2022 Licensing The Commonwealth of Massachusetts Fee (--.1°' Town of Yarmouth $30.00 Food Establishment License Number: BOHF-15-4457-05 Issue Date: 1/1/2022 Mailing Address: Location Address: BASS RIVER YACHT CLUB, INC. 22 FROTHINGHAM WAY BASS RIVER YACHT CLUB SOUTH YARMOUTH. MA 02664 P.O. BOX 182 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Non-Profit; 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 rz...-) Bruce G. Murphy, MPH, .S., O/James 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: BAS Ruler' Vct J± 601-) TAX ID: LOCATION ADDRESS: c Tab iruih,u-n tea/ ott)tia.mt TEL.#: ,SDI'' an- 17DI MAILING ADDRESS: An krA V�1Dt>t�7 YM mei-tf92 r ✓h/2 4}&&: 1 E-MAIL ADDRESS: OWNER NAME: gtk-Sc I,i L y kafrr a-ug CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: n14 irc, Fitzziminerzs TEL.#: 5-019"27.-9O7V MAILING ADDRESS: po• 601� 182, 96--Vre y matind- intet e2,&64( POOL CERTIFICATIONS: gi The pool supervisor must be cert.k 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. UV Q 3 2022 1. 2. itrH DEPT. 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 tines. _ employees below and attach copies of their certifications to this form. The Health Department ho€i1ic.� st years records. You must provide new copies and maintain a file at your place of business. JUL 2 1 2022 1. 2. 3. 4. HEALTH DEPT. 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. k1Vf1Jd 2. !"DUI PP)(eiit( PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ih,mmc) 2. /Y6 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. n 1. N P J 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# 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# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _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 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ "f, *****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 Ni 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 -stablisinnents must be inspected by the_ lth 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 • ' ' • •L (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED :Y THE BO ' P : HEALTH PRIOR TO.COMMENCEM NT. RENOVATIONS MAY REQUIRE A SITE P ,► / DATE: 2074, SIGNATURE: .4, ` PRINT NAME& TITLE: N1;��/,;,, / d �'� lid') Rev. 10/15/19 62 Ov'�f/J/J6 06b iiti ServSafe Certificate of Achievement ANSI Gar-rett mr- Shinet ongratt,ilationst You nave completed Awl•CCSEDITIO PONIMM ServSafe• Food Handier CHO Mall WOKS; Employee Food Safety Online Course and Exam _ - . - Achievement Certi i cate o This certificate is awarded to NOAH PELLETIER Congratulations! You have completed a►ccREDrr® ARM E2654 ServSafe® Food Handler Certificate Number 4670478 Date 711/2020 National Restaurant Association �+?e._: i 233 S. Wacker Drive, Suite 3600 Expiration Date 7/1�2023 �` :r„.. Chicago, 4L 60606.6383 17:1 `' 800.765.2122 in Chicago area 312.715.1010 Restaurant.org i ServSafe.com ,r r?• a 't�9Y4 a s ti ; k'L ,„gm, .,p .. 4,4. ada x'''M �. :;?b L�' ..'4. !ro"fa`3 .. 4 ,' ., sF' r ,. A� F fro,.. — , :, W �° t , - a t �' 4 ,P A� F 'r� r fr' ‘Nnb V tr k T f A r < ) • ' : �V ' ► Ae%j`'',ti , ti n II e w , �! A d r :if' ,�_ , h 4 iT Y tt Cam`-9'e'� � •P VC ` :e' ".3"C 9•�5ve,—.9' Pt i.. i'l _, C:.sE RT I F I CAT E OF ; ,„. , v ,, 'r am ''. C,.= ALLERGEN AWARENESS TRAINING ,,.. '. c,,_. Name of Recipient: NOAH PELLETIER , ,y.,e,.. ,7:,,„,,.-,. j ` �4 t.xA ' Certificate Number: 4687738 ' w 7/18/2020 ,n Date of Completion: 4(1 . �c •*'4 ; Date of Expiration: 7/18/2025 t , o c, 1:4,• %•-•• .....%).P••• 1 0.. +�?n Issued By: e , ; The above-named person is h.ereby issued this certificate � NATk�NAL • ,' or completingan allergen awareness training program ..�.� .- RESTAURANT t9. ' 1. ASSOCIATION. recognized by the Massachusetts Department of'Public Health """"' V in accordance with 105 CMR 590.009(G)(3)(a0. Dlassachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 wsa�.restaurant.org C.1` r '-��j Southborough,MA 01772 i. Dais certificate will he zaliafor•five(S)Ye'ars,f ropm elate�f'comp e'tion. 508-303-9905 ww r1/4� tiv.marestaurantassoc.org y . :,,.. • purwrinrwirmnrawirinrainnnuirorrunonri 1 tizk ii. $6 — A - a s.).:i ' 4 ' • ''',.4'' ' ;1 , -p;_4_,;. . l'i 1-(..,...—. es . ..)) ,. 14 ‘, A , ff 1,-A-40 I I A The Commonwealth of Massachusetts Print Form Departmersp of Industrial Accidents li Office of Investigations 1 Congress Street,Suite 100 TC "� Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. El I;estaurant/Bar!E,r;„g Est^blisl,mert 2.El i am a sore proprietor or partners'nersi ip and have no ' 7 0 Office,and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers'comp. insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, MD Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. "If the crrnorate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is retired and an organization should Ai3 k'n,x#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 MGL 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. &nature: Date: Phone#: 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 NOTICE a Wig: NOTICE TO r '_ err lrr�r � MINIM TO _rr1II ZINN EMPLOYEES EMPLOYEES _[.�rn C cs mum, U Nor {M gN0 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727-4900 — www.mass.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: Federal Insurance Company NAME OF INSURANCE COMPANY 555 LONG WHARF DRIVE NEW HAVEN, CT 06511-6107 ADDRESS OF INSURANCE COMPANY (23) 7173-93-18 06/25/22 TO 06/25/23 POLICY NUMBER EFFECTIVE DATES 70 ESSEX ROAD GOWRIE GROUP INC WESTBROOK, 06498-0970 (860) 399-5945 NAME OF INSURANCE AGENT ADDRESS PHONE# PO BOX 182 BASS RIVER YACHT CLUB SOUTH YARMOUTH, MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKER'S 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 Worker's 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 trie 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 WC 99 97 20D(9/19)