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HomeMy WebLinkAbout2023 Licensing The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-17-1309-06 Issue Date: 1/1/2023 Mailing Address: Location Address: S & H HOTEL YARMOUTH LLC 476 ROUTE 28 AIDEN BY BEST WESTERN WEST YARMOUTH. MA 02673 476 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2023 LICENSE TO OPERATE: Motel This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2023 unless sooner suspended or revoked and is not transferable. Conditions 116 Units; 122 Bedrooms (Includes 6 suites), 40 seat restaurant. 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 ames G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-17-1312-06 Issue Date: 1/1/2023 Mailing Address: Location Address: S & H HOTEL YARMOUTH LLC 476 ROUTE 28 AIDEN BY BEST WESTERN WEST YARMOUTH. MA 02673 476 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2023 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2023 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 Bruce G.Murphy, H,R.S./ O/James G. Gardiner Health Director/A• istant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-17-1323-06 Issue Date: 1/1/2023 Mailing Address: Location Address: S & H HOTEL YARMOUTH LLC 476 ROUTE 28 AIDEN BY BEST WESTERN WEST YARMOUTH. MA 02673 476 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2023 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2023 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 40 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy,MPH, .S., C O/James G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $i io.00 Swimming Pool Operations License Number: BOHSP-18-1320-05 Issue Date: 1/1/2023 Mailing Address: Location Address: S & H HOTEL YARMOUTH LLC 476 ROUTE 28 AIDEN BY BEST WESTERN WEST YARMOUTH. MA 02673 476 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2023 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2023 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 2ruceG. Murphy . R.S..&sG. Gardiner Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH tt.. • ; APPLICATION FOR LICENSE/PERMIT -2023 * Please complete form and attach all necessary documents by December 18, 2022. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: /�/�i�v bc 1, sf wcs��.zw TAX ID: Z- /9a3 776 LOCATION ADDRESS: '/?. j2c 4 fzS TEL.#:sue. 773.- /5oc, MAILING ADDRESS: ,Stli/c/1 E-MAIL ADDRESS: G/4/Q,q,,/,-",yor,Ne..,SA OWNER NAME: idles, /q ( CORPORATION NAME (IF APPLICABLE):_c h1 /�o>� Y/Ixrw J-A 1-G MANAGER'S NAME: /t1,/,s'A, l TEL.#:3-op - - MAILING ADDRESS: -11‘, g u,. 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. Avic/ Sid ue 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. L3.2,t,�ll 540 i 2. DeAmit A. I 3. /41l1nk 1n6;` 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. gZetitia 2. JAN 1 U Z023 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site n. 1. /-32 , , ✓/14c414.-i, 2. Risk// L.ahayv' 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. P,-a.,t v 4,i e kc. 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. &t -ls4 sycr/r)-7 2. l )/ /7/4-4_( 3. frj/bvK i3-n/, 4. RESTAURANT SEATING: TOTAL # 'AU OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT,# B&B $55$ —CHIP $55 7 MOTEL $110 / ! C� INN $55 'SWIMMING POOL$110ea,4.22.4.;> LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE pEamix# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# >-100 100 SEATSS $200$125 ` CONTINENTAL $35 NON-PROFIT $30 COMMON VIC. $60 (A, WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sqq.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 = $ *****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 & VIOLATION ASSESSMENT A tobacco-permit-holder who hasfailed-to-renews-his or her-permit_within_tlurty_(3U)-days_of the previous 's permit expiration date is considered an expired license, and the tobacco license cap is reduced. Violations of 105 CMR 665.000, State minimum standards for retail sale tobacco,shall be assessed as follows: 1st Violation a fine of$1,000.00 shall be imposed,2nd Violation within 36 months of 1st violation,a fine of$2,000.00 shall be imposed and a prohibition on sale of tobacco products may be imposed for at least 1 day and up to 7 days, 3rd Violation within 36 months of 1st violation or additional violations during that time period,a fine of$5,000.00 shall be imposed, and a prohibition on the sale of tobacco products may be imposed for at least 7 consecutive business days and up to 30 consecutive business days. 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, 2022. All renovations to any food establishment,motel or pool (i.e.,painting,new equipment,ect.),Must be reported to and approved by the Board of Health to commenceme . ovat require a MA engineer site plan. DATE: /?//54/2.,, SIGNATURE• A/ PRINT NAME&TITLE: 0eA'.A/ t el___ Rev. 10/11/2022 i--..,N JAMSHOT-01 FQUISPE ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �� 11/16/2022 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 Francis Quispe NAME: Boyd&Boufford Insurance Agency,LLC PHONE FAX 167 S River Road Unit 10 (A/C,No,Ext): (A/C,No):Bedford,NH 03110 - E-MAIL Francis Bouffordins.com ADDRESS: @ INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Technology Insurance Con±Tany _ 42376 INSURED INSURER B: S&H Hotel Yarmouth LLC Jamsan Hotel Management Inc. INSURER c_: 83 Hartwell Ave. INSURER D Lexington,MA 02421 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 H POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBRI POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ l:':"-V J `JI MED EXP(Any one person) $ _. PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: «'A�. ! f r ; Y GENERAL AGGREGATE $ POLICY PRO-JECT LOC ~i 3 4 ` , PRODUCTS-COMP/OP AGG $ OTHER: r $ .,,.,,,�,,, COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO _ BODILY INJURY(Per person) $ OWNED SCHEDULED ._ _ AUTOS ONLY AUTOS �'I BODILY INJURY(Per accident) $ HIRED NON-OWNED ""- ! PROPERTY DAMAGE AUTOS ONLY ____ AUTOS ONLY _ (Per accident) $ JAN 10 2023 $ UMBRELLA LIAB L_. ' OCCUR EACH OCCURRENCE $ DEDESSLIARETENTION$ CLAIMS-MADE, HEALTH DEPT. AGGREGATE $ DEPT. $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN TWC4147543 8/1/2022 8/1/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A E.L.EACH ACCIDENT , $_ OFFICER/MEMBER EXCLUDED? -- -- (Mandatory in NH) 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ' $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) reference location:476 MA-28 West Yarmouth,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of Yam ACCORDANCE WITH THE POLICY PROVISIONS. 1146 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD f • ServSa' fe cz.,--3 a National Restaurant Association ! • x ServSafe® . CERTIFICATION ,, ,, ,eM PRANAV AMBEKARi1I ' ., 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). 10749 , : ER EXAM FORM NUMBER 2/8/2021 2/8/2026 DATE OF EX : DATE OF EXPIRATION Local laws apply.Che cy for recertification requirements. ANSI : : / i ACCREDITED PROGRAM '� American National Standards Institute F and the Conference for:Food Protection ® #0655 Sher,0 t_ * �..a. ' -�. F �....'..t �' : tla zciation Solutions 0 • .0" f "z . 41. . a.i In accordance wi r it t ' r I e ServSafe logo ore trademarks of the NRAEF.Notional Restaurant Associations and the arc design Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or ServSafe@restaurant.org. m, V 4 IVY 4 -V:.,.-i-c• 41-23' -3N, 4 N 4 IVY ;NV, }' '0,• `,� n J�G��9: J`�C '')nQj�G��9= J'G _9: tjvG -9= "Yt 9: J�G 9 .-.'4:„1k..' .3> V CERTIFICATE OF 4i-2c-v . '76ArIV ALLERGEN AWARENESS TRAINING . .� Y '-ramM, (acttk- -,/ , ' •,iY Name of Recipient: PRANAV S AMBEKAR `\ r (°Ot /, v o :��,y� Date of Completion: October 7, 2022 ,�,,, z ^Vi , f V4 N.. 'nlHam ; �� ',. c • . rft Date of Expiration: October 7, 2027 , YY "7 N., RCN Issued By: ft�C,. II The above-named person is hereby issued this certificate }� 44 for completing an allergen awareness training program ) recognized by the Massachusetts Department of Public Health a.' Berkshire Al: in accordance with 105 CMR 590.009 G 3 a . �. F3.,• � ����� AHEC (7 Area Health Education Center vC �£�' Pittsfield,Massachusetts �> \ This certificate will be valid for five(5)years from date of completion. \ wwwmafbodaflergytraining.org ‘tv Ye U � { vl'i %%- ) � 5 � { V!'i!lI' ) S U � { Vl'a ,fr ) _ u I� 1 v�i-1;ems i � U Yi { V,`�!//- ) -K U ii { V\`�"'/v , � U � { lt�lv ) -4 77 , rj��c. �7 'i �7 s�`j}r �((/a tt7 a-� �c 7 i"r�c 7. r �c 7 rues;c Heart Saver Institute %': V ,,, t tr fit ' Upon the recommendation of the Faculty, American Heart Saver Institute does hereby confer upon , mil Brencüt Smith ,...t, .., i.,,,,,,, the completion of 'ta kg' ..tot iti CPR 42D & first Aid t %{ AHA & ECC guidelines to tthJ + with all the rights, honors and privileges thereunto appertaining. ftwit IN 5 CEUs 14 Pediatrics&Adult '' November 10,2022 t tA �, I a Expires on 2 Z November 10,2024 O C� Ln Adult "'� M..,1 y Hands on Completed ""�� _ I �e d4 e Iaaue fiuxh Paize flnersanFACombo-4794763726051d035e , ❑'_ r❑ t1 �� I i i ir eji D sR i'� ►� it i'*-- kt iY �� it ee r i` i'` ►ly '1;7 i` -- i it- i in01 i;"r i"' k ► HEART SAVER Heart Saver eri- Heart Saver Institute „iiss First Aid CPR AED Brenda Smith The above individual has successfully completed the cognitive skills evaluations in accordance with the guidelines of the Heart Saver curriculum. 11/10/22 11/10/24 fir_..•r • Issue Date Recommended Renewal Date 4,., ; r To view or verify authenticity,students and employers •44 01. should scan this OR code with their mobile device or ❑� .'.o go to www.heart-saverinstitute.com Adult Hands on Completed L—" Training Center Name AHS PO BOX 173272 TAMPA,FL 33672 Training Center Info 877-970-9009 Course Location 700 Myles Standish Blvd Taunton,MA 02780 Instructor Name Joao Amaral#5626262725 Holder's Signature c 2020 Hear,$aver Institute Tampering with this card will alter its appearance.77-19g6 0 ,� A� ,.n'.,AM n'LL' '1A� �: ,(�s ♦f}/�A � �`) -+S���r,��'���g� JY•�Y!Y7•~•�I I i �i •'4>r `1� �rT Ir� R A K��4��i�1+'-J^�F.�9lu Ar,Y y '�� L J 0 � x Certified Pool / Spa Operator'' Certification ' for lJ g(. 'e er e 1WI tjo 2 Oas an Operator of Aquatic Facilities Issued by the ENC NATIONAL SWIMMING POOL FOUNDATION Ci on May 02, 2021 CPO®Certification No.02-326428 Expires: May 02, 2026 o,,t.�sn,4, 00 hit �c (3„,, ,V /giled Ct �iFo4�¢' omas M. Lachacki IVSPF 1: Instructor itr tltl y 144i,l eallth livrGr,. Chief Executive Ottic;, �rAY7t+r 9,11r lcv *frillt1 9MIY]tr.0`.t lfrIt'rf:9./11(kv Q vfr vi f.4 2virytcv(.:.vtM+P`.c v HEART SAVER Heart Saver Heart Saver Institute First Aid CPR AED Mark Bardi The above individual has successfully completed the cognitive skills evaluations in accordance with the guidelines of the Heart Saver curriculum. 11/10/22 11/10/24 1:1,',#,r o Issue Date Recommended Renewal Date `Ly: To view or verify authenticity,students and employers should scan this OR code with their mobile device or L 1 i s. • go to www.heart-saverinstitute.com Adult Hands on Completed Training Center Name AHS , yr PO BOX 173272 TAMPA,FL 33672 % Training t>>� q Center Info 877-970-9009 .yam Course Location 700 Myles Standish Blvd Taunton,MA 02780 Instructor Name Joao Amaral#5626262725 Holder's Signature c 2020 Hean Saver Institute Tampering with this card will alter its appearance.77-1986 - , Heart Saver Institutet. �� `. it Amenea 114 agi LN Upon the recommendation of the Faculty, ta {" American Heart Saver Institute does hereby confer upon 74 rA i J'lark Bari NA the completion of t. , CPR .tiD & First Aid L ao O , AHA & ECC guidelines to i y ti l with all the rights, honors and privileges thereunto appertaining. ` .5 CEUs Pediatrics&Adult 0 November 10,2022 m Expires on � ' November 10,2024 � . Adult tilt kiplia Hands on Completed r ,_ Jamie Husrh cfs.d*butt.etet Paige Eiae<<mn,de....ni 6.re.'"t FACombo-5018763bc8122555dd E '"O 4yyy .' 4 g:F i.G0 + _ r r _ r _ r _ _ a 4�''�'�'" +�"�e '�4Tt►"-'�_ o►'.'+ffr'' �'`�.,,��i)�i�'�#1�� ,l�i�*4�L� �"`' art �* " _4r I �-. 0 . _ p Heart Saver Institute `" ,t Amens_ Foggy ... �,, N. Upon the recommendation of the Faculty, American Heart Saver Institute does hereby confer upon fDIvva Tate C- ) the completion of 1 NI CPR A D & First Aid 70 AHA&ECC guidelines tilk 10, with all the rights, honors and privileges thereunto appertaining. ta , ' .5 CEUs tr. Pediatrics&Adult NI November 10,2022 P,I, Expires on h November 10,2024 01, Adult Hands on Completed Jamie Hutch,ofe.rv. .ems ?+ige Emer:cq d^ 1?6,5-'-"' (21 FACombo-5015163bc3f7d93341 } HEART SAN/ R Heart Saver w Heart Saver Institute FrstAidCr # ED Divya Patel The above individual has successfully completed the cognitive skills evaluations in accordance with the guidelines of the Heart Saver curriculum. I I/10/22 11/10/24 Issue Date Recommended Renewal Date ks4.,34.1:77,•14 To view or verify authenticity,students and employers t should scan this OR code with their mobile device or i-1S4tf go to www.her-saverinstitute.com Adult Hands on Completed Hear CPR AED & First Aid Training Center Name AHS PO BOX 173272 TAMPA,FL 33672 Training Center Info 877-970-9009 Course Location 700 Myles Standish Blvd Taunton,MA 02780 Instructor Name Joao Amaral#5626262725 Holder's Signature c 2020 Heart Saver Institute Tampering with this cant will alter its appearance.77-1986 THE (XII;4NNFALTH OF MiLTWIRSEITS TOWN OF YAIM U H HEALTH DEPARTMENT POOL INSPECTION REPORT NAME A vim,, G'-j. CG kdi/)+- DATE 5)c?5i 3 ADDRESS1"y'71., t�c�� o?R / G , TELEPHONE NUMBER OPERATOR Ce ` LDS PERMIT POSTED # r'?r-)n� Pc c 47.0, .\ C)- v r G/Ci +r cvN 5 Regulations of the Massachusetts Sanitary Code: Article VI, Minimum Standards for Pools; and Town Amendments to Article VI. 1. All items approved on the construction plan are of permanent nature and need not be checked at each inspection. 0_ 2. HEALTH: Shower and health signs posted which state that bathers take showers; no sick or infected bathers; no glass or dangerous objects; and children under the age of 16 must be accompanied by an adult swimmer within. 3. Ctx1IFIED POOL OPERATORS: Must staff at least two (2) certified operators in First Aid, ater Safety, C.P.R., and have one available on the premises during pool operating hours. 5771E c -�f� C4. SAFETY: One shepards crook and one ringoy with adequate rope for each 2,000 sq. ft. water surface. One pool divider .shallow end with floatation buoys. ckf 5. FIRST AID: First aid kit (see back), emergency telephone numbers posted, local police, state police, fire department, and several available physicians. Telephone available or other means of communication (no+ pay station). 91/ ,Lv,p `BPS '.,'" SJ" )Z (k 6. RECORDS: Written records available of daily operation of the pool, including attendance, water tests, chemicals used, hours of operation, backwashing and other information required. C7-c' 7. RECIRCULATION - FILTRATION: Purification system capable of maintaining maximum filtration rate 2-3gal. per min. quality of water, turnover every 8 hours, per sq. ft. filter. Disinfection equipment finely adjustable. Flow meters and pressure gauges are required. 1 Or<8. DEPTH MARKINGS: Must be clearly marked on deck and wall of pool. Markings must be displayed for every foot down to a depth of 5 feet, and then at appropriate places of not more than 25 foot intervals around the deep portion of the pool. Al/A 9. DIVING BOARDS: Rigidly constructed, properly anchored, braced for heaviest load, sound no splinters or cracks, non slip surface. Not over 10 feet above water level and at least 13 feet unobstructed head roam. (U_10. WATER SOURCE: Water used in any swimming pool shall be from a source approved by the Health Department. 0''11. BACTERIOLOGICAL QUALITY: Health Department shall cause water samples to be analyzed as considered necessary. Quality shall meet the USPHS drinking water standards. Untreated water not over 2,400 MPN Coliform. 12. CHEMICAL STANDARDS: Treated with chlorine or other effective method. Tests taken at least 4 times a day as required by Health Department. Free Chlorine 1.0 - 3.0, pH 7.2 7.8, Bromine 2.0 6.0, Total Alkalinity 50 - 150 p.p.m. and Combined Chlorine less than 2 p.p.m. are required once a day. SWIMMING POOL: Cl = 3, 0 7 y CDpH = T.A. _ �� Combined Cl = SWIMMING POOL: Cl = pH = T.A. _ Combined Cl = WHIRLPOOL: CI = pH = T.A. _ Combined CI = WADING POOL: CI = pH = T.A. = Combined CI = ( p13. TESTING EQUIPMENT: Testing equipmentprro—vided,�-in-good repair and complete with fresh reagents. �14. WATER CLARITY: A 6�inchdisc a� t bottom of deepest pe part of pool visable at 10 yards away. /015. WADING POOLS: Quality of the water shall be the same as swimming pools. Turnover 4 hours or less. "16. WHIRLPOOLS: Quality of the water shall be the same as swimming pools and shall be equipped with a thermometer and a time instrument for the use of bathers. 17. ENCLOSURE: A 6 foot high fence in accordance with M.G.L. c.140 with self-closing and self-latching gates or doors. Indoor pool must also be rest; 0 8 icted in a similar manner. Pool entrances and exits to be locked during non-operating hours. y' /f • CLOSURE: Operator to close/pool when water does not meet the requirements of this code. Operator understands their responsibilities in regards to operating a public/semi-public swimming pool. NOTES: vrc �-�j-f- C ry C ,i /:/;,>/,' ,, ,__ ,, / ,,, -- // ....-- _"7--d-c ,-- P YAWED POOL INSPECTION dr ! "� .--- 10/96 . _ i SAFEEY SIGNS AND BQUIPMENT 1. Signs to be posted at the pool include: " All persons are required to take a cleansing shower before entering the pool. • No person with a communicable disease is ailowed to use the pool. * No bather shall wear a bathing suit that is unclean. • No person suffering fran a cough, cold, inflammation of the eyes, nasal or ear c scharges, or any ether communicable disease shall be allowed to use the pool. • No person with sores or other evidence of skin disease, or who is wearing a bandage or medical coverieg of any kind, shall be allowed use of the pool. * No person shall spit or in any other way contaminate the pool. or its floors, walkways, aisles, or elceeeing rooms. * No glass containers shall be permitted in the pool or on walkways within & feet of the cool. • No person shall bring or throw into the pool any object that may in any way carry contamination or endanger the safety of the bathers. 2. Lifeguards and operators trust enforce the rules noted on the above-signs. 3. A shephards crook or reaching pole with a minimum handle length that extends greater than 15 feet east be provided t' each 2,000 sq. ft. of water surface area (NFL, c140, s20b)• 4. One Ring Buoy or Rescue Tube with a i" polyethelene rope attached, no less in length than 1} the width of the e: e . If the pool has lifeguards, a rescue tube rust be located at each station. 5. Emergency communication equipment must be available for reaching emergency response persons. Appropriate telepb.ie numbers and directions for the use of the equipment must be posted. b. There must be an appropriately equipped first aid kit. Public pools rust have a roam designed and equipper lee emergency care of sick and injured bathers. 7. Whirlpool - Must be drained every 30 days and scrubbed and disinfected. FlgSr AID KIT 35 1" Band-Aids 10 3" x 3" sterile gauze pads 2 5" x 5" surgipads 1 6" x 10' surgipad 2 soft roller bandage 2 3" so:t roller bandages I roll 1/2' hypoallergenic tape triangular bandage 1 scissors rescue blanket 12- antiseptic wipes 2 disposable instant ice packs sterile isotonic buffered eye wash 2 pair one size-tits--all latex gloves microshield or pocket mask with a one way valve POOL LOGS Logs trust be kept eacn day the pool is in operation. 'loot for: Free Chlorine 4X/day Combined Chlorine 1X/day pH 4X!day Total Alkalinity 1X/day Also note on the log: Clarity Good/Average/Poor Chlorinator OniOff Chlorinator Setting Low/Mediunihigh or 1/2/3, etc. Weather Sunny/Cloudy. etc. Air Temperature Bather Load Chemicals Added Any Other Actions Taken Initials of Tester ADMINISTRATION POOL CLOSURE 1T IS THE RESPONSIBILITY Of THE FOOL 0 ERA1UR TO CLOSE THE POOL WHEN ANY OF THE CHEMICAL, PHYSICAL OR SAFELY SCANOARlIh ARE NOT MET, OR FOR ANY OTHER RFA:X1 'ITIAT MOULD AWAKE POOL USE UNSAFE. 1 t'4` (al) J I&NI'l!! ERR (N 111E SIDE OF SAFETY in compliance with Mil 140.206, when closing your outdoor inground swimming peol for the season, pools Trust be drained and remain dry throughout closure time, or covered within seven (7) days of closing. P(X)L OPENING In the event that your pools have been closed for the season, all swimming, wading and whirlpools are to be inspected by the Health Department prior to opening. Prior to calling for an inspection appointment, a water sample from each pool and .vtiiripeol must be submittec ter teszini7 for coliform and pseudanonas by an independent lab. Lab results must be submitted prier to inspection and ,pu ing. THE (XMKINYE\LTH OF MASSATIS TOWN OF YARMOUIfi HEALTH DEPARTMENT POOL INSPECTION REPORT NAME G-t- Cope Pc, DATE */a"/,1 ADDRESS I/762 l2O"L/32 ag` IVY TELEPHONE NUMBER OPERATOR h ci 4''E' PERMIT POSTED # Regulations of the Massachusetts Sanitary Code: Article VI, Minimum Standards for Pools; and Town Amendments to Article VI. 1. All items approved on the construction plan are of permanent nature and need not be checked at each inspection. a: 2. HEALTH: Shower and health signs posted which state that bathers take showers; no sick or infected bathers; no glass or dangerous objects; and children under the age of 16 must be accompanied by an adult swimmer within. 0y- 3. CERTIFIED POOL OPERATORS: Must staff at least two (2) certified operators in First AiSi, Water Safety, C.P.R., and have one available on the premises during pool operating hours. s-;4,,z' s .'47 64,7, Ll.6. SAFETY: One shepards crook and one ring buoy witk iAequate rope for each 2,000 sq. ft. water surface. One pool dividerll4Ar shallow end with floatation buoys. ae 5. FIRST AID: First aid kit (see back), emergency telephone numbers posted, local police, state police, fire department, and several available physicians. Telephone available or other means of communication (no,. pay station). !7, 17/i CA-:6• RECORDS: Written records available of daily operation of the pool, including attendance, water tests, chemicals '/ used, hours of operation, backwashing and other information required. Ovt 7. RECIRCULATION - FILTRATION: Purification system capable of maintaining quality of water, turnover every 8 hours, maximum filtration rate 2-3 gal. per min. per sq. ft. filter. Disinfection equipment finely adjustable. Flow Metes ad���pppressure gauges are required. U Af /C7 5. 7 f9--.i C 1 /err-- , S L. (.1,1X 8. DEPTH MARKINGS: Must be clearly marked on deck and wall of pool. Markings must be displayed for every foot down to a depth of 5 feet, and then at appropriate places of not more than 25 foot intervals around the deep portion of nn the pool. N//')9. DIVING BOARDS: Rigidly constructed, properly anchored, braced for heaviest load, sound no splinters or cracks, non slip surface. Not over 10 feet above water level and at least 13 feet unobstructed head roam. `TC/i�10. WATER SOURCE: Water used in any swimming pool shall be from a source approved by the Health Department. BACTERIOLOGICAL QUALITY: Health Department shall cause water samples to be analyzed as considered necessary. Quality shall meet the USPHS drinking water standards. Untreated water not over 2,400 MPN Coliform. i c_C12. CHEMICAL STANDARDS: Treated with chlorine or other effective method. Tests taken at least 4 times a day as required by Health Department. Free Chlorine 1.0 - 3.0, pH 7.2 - 7.8, Bromine 2.0 6.0, Total Alkalinity 50 - 150 p.p.m. and Combined Chlorine less than 2 p.p.m. are required once a day. SWIMMING POOL: CI = , ° pH = /x t7 T,A. = 7 2 Combined Cl = SWIMMING POOL: Cl = pH = T.A. = Combined Cl = WHIRLPOOL: Cl = pH = T.A. = Combined CI = WADING POOL: Cl = pH = T.A. = Combined Cl = 13. TESTING EQUIPMENT: Testing equipment provided, in good re air and complete with fresh reagents. 4(14. WATER CLARITY: A 6 inch black disc at bottom of deepest part of pool visable at 10 yards away. N/A 15. WADING POOLS: Quality of the water shall be the same as swimming pools. Turnover 4 hours or less. AILA16. WHIRLPOOLS: Quality of the water shall be the same as swimming pools and shall be equipped with a thermometer and a time instrument for the use of bathers. • ENCLOSURE: A 6 foot high fence in accordance with M.G.L. c.140 with self-closing and self-latching gates or doors. Indoor pool must also be restricted in a similar manner. Pool entrances and exits to be locked during non-operating hours. '18• CLOSURE: Operator to close pool when water does not meet the requirements of this code. Operator understands their responsibilities in regards to operating a public/semi-public swimming pool. NOTES: 1 20/c O --TC v _ PERSON INTERVIEWED ~ POOL INSPECTI 10/96