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HomeMy WebLinkAboutApp-Licenses-Certs-Inspections The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-22-4079-01 Issue Date: 1/1/2023 Mailing Address: Location Address: BLUE BIRD HOSPITALITY 793 ROUTE 28 CAPE SHORE INN SOUTH YARMOUTH, MA 02664 793 ROUTE 28 SOUTH YARMOUTH, MA 02664 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. 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 /James G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-22-4080-01 Issue Date: 1/1/2023 Mailing Address: Location Address: BLUE BIRD HOSPITATLITY CORP 793 ROUTE 28 CAPE SHORE INN SOUTH YARMOUTH, MA 02664 793 ROUTE 28 SOUTH YARMOUTH, MA 02664 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. Board Hillard Boskey, M.D.,Chairman Mary Craig,Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy,Tv1PH, R.S ,CHO/ mes G. Gardiner Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH 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: c- ?e St-to Re s ij(\) TAX ID: % 5 a? , ct c 5% 0 3 LOCATION ADDRESS: 4.?;) ¶JoS-C H ItA R'MOJTN- TEL.#: (QV( 0131-(1 MAILING ADDRESS: SHnle E-MAIL ADDRESS:CAQC SriO(teS IV) PrvA Q., G M fiI 1 • CO M OWNER NAME: (k'Pc Le_s go RTr1A4e ( Te,k, CORPORATION NAME (IF APPLICABLE): c5 e)t k 0 \-k Qs BPS T 'A )z V \/ MANAGER'S NAME: 'kt rJ e N .PA- C 1- R IR 5H fATe L TEL.#: 50$3. (og{( q(:)g MAILING ADDRESS: -1Q3 14k0V'T it) cortN yeftrfv\OUIT1+ (D 43(04 1Y1 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. RSN4 QAce 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. ( 11\ Pc 2. 3. .S+-4 f\ Q AT t 4. NOV 2 9 2022 FOOD PROTECTION MANAGERS - CERTIFICATIONS: _ HEALTH DEPT. 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. t\3 Pc 2. N I ()- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. IN Pt 2. 'N) 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. 1\il 2. N1A 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. IR-- 2. '(VI Pc 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 I MOTEL $110 INN $55 CAMP $55 L SWIMMING POOL$110ea. BADGE $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 = $ *****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 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. 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 commencement. Renovations may require a MA engineer site plan. DATE: I / /Z Z 1 ? 0 2 2 SIGNATURE.: !') .. ,/2/,e'_71719 PRINT NAME&TITLE: R z,R C')e eftTe k_ p 11J Rev. 10/11/2022 w, The Commonwealth of Massachusetts Print Form Department of Industrial Accidents H ._} Office of Investigations ,� 1 Congress Street, Suite 100 -";",N: ,� Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �'A Q e. S}{o(ke_ I Address: 'A ' 3 e_o, T 2 0/t Ou v ti yO¼YT1- City/State/Zip: 5. t i AR Moo 4- ww\R 40a(06I Phone #: (00.6 ( {f 09-- 1 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. ❑ Restaurant/Bar/Eating Establishment 2.figl I am a sole proprietor or partnership and have no 7. ❑ 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. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.IllWe are a non-profit organization, staffed by volunteers, 11.0 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 corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#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: i NOV 2 9 2022 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. Signature: /7 /2• g* / 'I Date: / / / 2 7 / 2 J 2 2 Phone#: (Q.C),3 (o { a aJ \°t( 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 • + American Red Cross • Certificate of Completion Rina Patel has successfully completed requirements for Adult Child and Baby First Aid/CPR/AED Online Only • conducted by American Red Cross Date Completed: 06/05/2021 Valid Period: 2 Years • Certificate ID: OOLDI4C • To verify, scan code or visit: https://www.redcross.org/take-a-class/grcode?certnumber=00LD14C • NOV 29 2022 HEALTH DEPT https:/Iwww,redcross.orgitake-a-classigrcode?email=rinap0000%40gmail.com&selectedCerts=i d-OOLDI4C%2C&size=1185 l 1 t merican Real Cross •R Certificate of Completion. Shyam Patel---- has successfully completed requirements for Adult Child and Baby First Aid/CPR/AED Online Only conducted by • American Red Cross • Date Completed:06/07/2021 Valid Period:2 Years T�LZ Ofi� Certificate ID:OOLGOHJ To verify, scan code or visit:https://www.redcross.org/take-a-class/grcode?certnumber=OOLGOHJ NOV 2 g 20�2 HEALTH 1-) C -T Training nin, Services Certificate of Completion Rina Patel has successfully completed requirements for Adult, Child and Baby First Aid/CPR/AED Online Only Date Completed: 6/5/2021 Validity Period: 2 - Years Conducted by: American Red Cross E*;E:i.• IS -74 To verify certificate, scan code or visit redcross.org/digitalcertificate and enter ID. - ��� 4"' Learn and be inspired at LifesavingAwards.org c•/Ce OOLDI4C Cross, rf ra. nin Service --; Certificate of Completion Shyam Patel has successfully completed requirements for Adult, Child and Baby First Aid/CPR/AED Online Only Date Completed: 6/7/2021 Validity Period: 2 - Years Conducted by: American Red Cross DLD 4 To verify certificate, scan code or visit redcross.org/digitalcertificate and enter ID. 7/.1-' • It -•' ' NA 5 Learn and be inspired at LifesavingAwards.org OOLGOHJ Tetiric nRe -` Trainin ervices CEU Shyam Patel has succesfully completed requirements for Adult, Child and Baby First Aid/CPR/AED Online Date Completed: 6/7/2021 Conducted by: American Red Cross Contact Hours: 3.0 CEUs Awarded: 0.3 coo To verify certificate, scan code or visit redcross.org/digitalcertificate and enter ID. Learn and be inspired at LifesavingAwards.org , erica - ross I raining Services CEU Rina Patel has succesfully completed requirements for Adult, Child and Baby First Aid/CPR/AED Online Date Completed: 6/5/2021 Conducted by: American Red Cross Contact Hours: 3.0 CEUs Awarded: 0.3 0. 00 To verify certificate, scan code or visit redcross.org/digitalcertificate and enter ID. .0 0 Learn and be inspired at LifesavingAwards.org Certificate of Completion American Red Cross t'ra ning Ser ii':s Rina Patel has completed the reqirements for 0 it'. .❑ 1 Adult,Child and BabyFirst Aid/CPR/AED Online Only r c.f' i. conducted by ..r.":13 31 • American Red Cross ri t • •Date Completed:6/5/21 rCI Validity Period:2 Years MI=E `i`iti Certificate ID:OOLDI4C THE CTIMA NQFALTH OF WSSACHl1SErrS TON OF YARMOUTH HEALTH DEPARIAIENT z POOL INSPECTION REPORT NAME C_C- � TIZPS� - 1-.r� • DATE i//,//cQ S ADDRESS / lQ 3' RC •P `�S�-%Q TELEPHONE NUMBER c_c C ct OPERATOR L_ �; 1.�:.�'>1 >« 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. C—(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. air 3. Ctx1IFIED POOL OPERATORS: Must staff at least two (2) certified operators in First Aid, Water Safety, C.P.R., and have one available on the premises during pool hours. .. /f� � / 4 4. '4 c . SAFETY: One shepards"E"rook and one ring b17"owith adequate rope for each 2,000 sq. ft. water surface. One pool divider for shallow end with floatation buoys. ( 5. FIRST AID: First aid kit (see back), emergency telephone numbers posted, local police, state police, fire department, and several available G/- /'L/physicians. Telephone available or other means of communication (no+ pay station). Rap l71 ,1 �' / 1,LY /�' S k� Lf <=015S 6. RECORDS: Written records available of daily operation of the pool, including attendance, water tests, chemicals used, hours of operation, aclishing ard�otherzigfon tion�grequired�l S T 14C"+" �"-.-, ` 'C. cY- / �"T. 7. RECIRGt1ATION - 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 meters and pressure gauges are required. •11 c 4/ /i3 p si , 6 g I"— v,1air �G�`=. 8. DEPTH MARKINGS: Must be'cralrly 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. 440,179. 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. 7j7/- 10. WATER SOURCE: Water used in any swimming pool shall be from a source approved by the Health Department. 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. 2. 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 = .� 8 pH = - T.A. _ 9 Combined Cl = SWIMMING POOL: Cl = pH = T.A. = Combined Cl = WHIRLPOOL: Cl = pH = T.A. = Combined Cl = WADING POOL: Cl = pH = T.A. = Combined Cl = clik_13. TESTING EQUIPMENT: Toting equipmegi pr ided, in o repair and complete with fresh reagents. C<14. WATER CLARITY: A 6 inch black disc at bottom of deepest part of pool visable at 10 yards away. 415. WADING POOLS: Quality of the water shall be the same as swimming pools. Turnover 4 hours or less. n//4 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. 0 u 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 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: /p oGrS c cXv R. p, roe] 6k4 PERSON INTERVIEWED PO L fN f XT 10/96 iAFEIY SIGNS AND ELJJIPMFINI 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 allowed to use the pool. * No bather shall wear a bathing suit that is unclean. * No person suffering from a cough, cold, inflamnation of the eyes. nasal or ear discharges, or any other 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 covering 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 dressing rooms. * No glass containers shall be permitted in the pool or on walkways within 8 feet of the pool. * No person shall bring or throw into the pool any abject that may in any way carry contamination or endanger the safety of the bathers. 2. Lifeguards and operators must enforce the rules noted on the above-signs. 3. A shepherds crook or reaching pole with a minimum handle length that extends greater than 15 feet ,,east be provided for each 2,000 sq. ft. of water surface area (MGL, c140, s206). 4. One Ring Buoy or Rescue Tube with a }" polyethelene rope attached, no less in length than 1} the width of the pool. If the pool has lifeguards, a rescue tube must be located at each station. 5. Emergency communication equipment mast be available for reaching emergency response persons. Appropriate telephone numbers and directions for the use of the equipment must be posted. 6. There must be an appropriately equipped first aid kit. Public pools mast have a roan designed and equipped t._ emergency care of sick and injured bathers. 7. Whirlpool - Must be drained every 30 days and scrubbed and disinfected. FIRST AID KIT 35 1" Band-Aids 10 3" x 3" sterile gauze pads 2 5" x 5" surgipads 1 8" x 10" surgipad 2" soft roller bandage 2 3" soft roller bandages I roll 1/2" hypoallergenic tape triangular bandage 1 scissors rescue blanket 12 antiseptic wipes 2 disposable instant ice packs 1 sterile isotonic buffered eye wash 2 pair one size-fits-all latex gloves 1 microshield or pocket mask with a one way valve POOL. LI)GS Logs must be kept each day the pool is in operation. Test for: Free Chlorine 4X/day Combined Chlorine 1X/day ph 4X/clay Total Alkalinity 1X/day Also note on the log: Clarity Good/Average/Poor Chlorinator Oni Off Chlorinator Setting Lev/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 POOL. OPERATOR TO CLOSE THE POOL. WHEN ANY OF THE CHEMICAL, PHYSICAL OR SAE'EIN SfANDARLX5 ARE NOT MET, OR FOR ANY DIHF1t REASON THAT MOLD MAKE POOL USE UNSAFE. USE r1(11) J D Nrl t l ERR ON THE SIDE OF SAFETY in compliance with MGL 140.206, when closing your outdoor inground swinrning pool for the season, pools must 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 whirlpool must he submitted for testing for coliform and pseudommonas by an independent lab. Lab results must be submitted prior to inspection and opening.