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Home My WebLink AboutApplications, WC, Licenses Prior to 2009, ' '. � �'`"(j'�S' uRu-r� )NN � �� Ypk� TOWN OF YARMOUTH BOARD OF HEALT� '; `, ��;i� �� s ' APPLICATION FOR LICENSE/PERMTT-20�5 ��/��jb 2 /� 2 �// 2 'C � S � . � � I� � LS �V' LS � l/ LS � * Please complete form and attach all necessary documenfs by December�?' 2007. Failure to do so will result in the retum of your application packet. D E C 1 3 2 D 07 NAME OF ESTABLISHMENT: � A�N TEL. # LOCATION ADDRESS: I MAILING ADDRESS: '�O t#f OWN�R NAME: 1'AX I (FFTN nr 4RN1- �-� —�« -- CORPORATION NAME (IF APPLICABLE): -��y,4�R��2UP� �'('JI�,P� MANAGER'S NAME: �� TEL. #��_�4.-L�j(� MAILING ADDRESS: �-- R,ev✓Y,ka �#,,,�/�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desienated Pool Operator(s) and attach a copy of the certification to this form. �. �-puNV�MtT�,A-I�_��C-f z. UP�M_ p�"C-� Pool operators must list a minimum of two employees currently cenified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee eertifications to this form. The �Iealth Department will not use past years' records. You must previde ne�• copies and maintain a fde at your place of business. 1. ��O�- �Tl��SC�7LI 2. p/ U`).S i� p� 3. 4. �- FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one ful]-time employee who is cenified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certiScafion to this applieation. 'i'he Health Department wi}I not nse p�st years'records. You must provide new copies and maintain a file at your estabGshment 1. 2. PERS9N�N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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 REQUIltED FEE PERYf17# LICENSE REQL'IltED FEE PERbi17 4 LICENSE REQL'IRED FEE PERbUT= _B&B S50 _CABIN S50 �MOTEL � S50 ��O�pt6��, Q3� _INN S50 CA1�iP S50 � 2 SR7�L�t[NG POOL S75ea. �4�^� �-e.d�_a _LODGE S50 _TRAILERPARK S(00 1��I-IIRLPOOL 575ea. _�(,�-�Ja� FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PER>4IT a LICEtiSE REQtiIRED FEE PER�ilT= _0.100 SEATS S75 LCONTINEN7'AL S30 �0�� _NON-PROFIT S25 >I00 SEATS 5150 _COYIl�ION V[C. S50 4l7-IOLESALE S7i RETAIL SERVICE: —RESID.KITCHEN S7i LICENSE REQUIRED FEE PERMIT= LiCENSE REQUIRED FEE PER�I17= LICENSE REQL7RED FEE PER�II'I= _<50 sq.R. S45 _>25.000 sq.d. 5200 �'ENDING-FOOD S20 QS,OOOsq.B. S75 _FROZENDESSERT S35 TOBACCO � S50 vn:He c�vcE: sio AMOUnT DUE = S 3p6.a6 � •wR�:pLEASE TL'R.Y O�'ER�\D CO3iPLETE OTf[ER SIDE OF FOR�f'"*** I 3 ADMI�STRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 STA'TE 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 pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motei 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 princapal place ofre�dence 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 wittun any s�(6)manth 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. a 64G or 830 CMR 64G, as amended, shall generally be considered Transiem. * NOTE: En��o�d Motel Census must be completed and returned wit�tbis apP��cation. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins � by the Health Department prior to openu►g. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 CATERING POLICY: Anyone who caters within the Town of Yazrnouth must notify the Yazmouth Heatth Departmcmt 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Hea(th Department. Failure to do so will result in the suspension or revocation of yow Frozen Dessert Permit urnil 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 ofHealth. OUTDOOR COOKING: Outdoor cooking prepazation, or display of any food product by a retail or food service establishmecrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER� 2007. ALL RENOVATIONS TO ANl' FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), M[JST BE REPORTED TO AND APPROVED B THE BOARD OF HEALTf� PRIOR TO COMMENCEME�IT. REVOVATIO.VS MAY REQUT A T P �i. DATE: � SIGNATURE: ` PRINT:VAME&TITLE: �/ � � - �— �o so n� THE COMMONWEALTH OF MASSAC�IUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-030 FEE: $50.00 This is co Cernfy thac Gavatrilaupa Corporarion d/b/a Ou�Inn 1314 Route 28, South Yarmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority grented to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to tLe provisions oft(te Laws of the Commonwealth ofMassachusetts relating theceto,and upou such terms and conditions,and to the rules and regularions in regard w said Motels so liceased as adopted by the Board oFHealth,and elcpires December 31,2008 unless sooner suspended or revoked. _ December 19.2007 BOARD OF HEALTH: .`�¢It$�� JZ.,IY.� ��[Xntaft Cl�iteee .�E..7f¢�li�e� `UtC¢ �i�u�uut •Units-89;Bedrooms-89 . ��7�� .,�y�.((uy��,�p�//(� . N�I[I6 � .R.✓Y. a � .M�ny, , . .,cxo Director of Health TOWN OF YARMOUTH BOARD OF HEALTH EERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #08-079 FEE: $30.00 In accordance with reg�1arions promulgated under authoriry of Chapter 94,Secrion 305A and Chepter 1 I 1,Section 5 of the Cieneral Laws,a permit is hereby�ranted to: Gavatrikrupa Corporarion 1314 Route 28 South Yarmouth MA Whose place of business is: Oaaliri Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARU oF HEALIH: ,�Ee�ett Sl�aPi, J�l..N., CR�av[ntpn ' (JfaxBea .�. .7CeP,�iPeen 9Jice '(.R�avt�na" n `taBext �. `.�iau�n, (',�exl� � December 19.2007 Bruce G. Murphy ,R.S.,CHO D'uector of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTT3 BOARD OF HEALTH PERMIT NUMBER: #08-058 FEE: $75.00 This is to Certify that ('�a�atri zna ('mm�ratinn d/h/a (hialit�inn 1314 Rrnrte 2R, S�nth Yarmnnth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-PubGc Swimming or Wading Pool At CJualitv Inn - INDOOR POOL 1314 Route 28 South Yarmouth MA This permit is granted in conformity with Article VI of tlie Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. December 19.2007 BOARD OF HEALTH: .`�¢IL SPUY� J�..lv� �Ql�[I►L1171 ClfaxFea .�f, �JCeIP.i�re�y 4Jice C'Hai�ur�an `J2aBerrt s. `J3+ieamuc, N.Pex�t (�i �� tun, J . ruce �P Y, , � , Director of Heal THE COM1170NWEALTH OF MASSACHUSEI"PS TOWN OF YARMOUTH BOARD OF HEALTT3 PERMIT NUMBER #OS-025 FEE: $75.00 This;s co Cectify chac Gayatrikrupa Corporarion d/b/a Quality Inn 1314 Ro 28 Co h y rn,o rth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS This License is issued in conforntity with tLe authoriry granted to the Board of Health,by Chap[er 140,Sections 51,of the General Laws,and amendments thereto,and is subject to t6e provisions ofthe Laws ofthe CommonwealtU ofMassachusetts relating t6ereto,and upon such terms and conditions, and[o the niles and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and exp'ues December 31,2008 unless sooner revoked. December 19.2007 BOARD OF HEALTH: ,`�E[¢Iy$�(�� f2„/�(.� �n � . �.�Q7[PRd .�. ��(¢� �lC¢ e�tQlaGFttCut `J2a6ext s. `.�Kacu�:., ('.� � �_ Bruce G.Murphy,� .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTI�I PERMIT NUMBER: #08-059 FEE: $75.00 Ihis is to Certify that C'�avatrikn a ('o nratinn !a n ,ali inn — 1't 14 Rnut R Crnrth Yarmrnrth R�A IS HEREBY GRANTED A PERMIT To Oper�te a PubGc, Semi-Public Swimming or Wading Pool At �ality Inn - OIJTnnnR P(l(li 1314 Route 28 o h y�rmouth MA Ihis pecmit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. December 19.2007 BOARD OF HEALTH: .`�¢�P,R S� ✓�...lV.� �qlXntqft �A�IfeP.d .`�. �%�4i1G� �fCC �ft ✓ZOBPXt 3. JBKOUlfL� �URXk �'xeen8acun, J - Dire tor of H�e,al y � ' - - �vauTY /Na1 =°`r"o TOWN OF YARMOUTH BOARD OF HEALTH � c � `� � n� � iJ 3�� ° APPLICATIONFORLICENSE/PERMLT-;Z(►(1 9 �(� EC 0 '] Z006 r��i � * Please compiete form and attach all necessary documents by Dece r ��0�� DEPT. Failure to do so will result in the retum of your application pac . NAMEOFESTABLISHI�fENT:�()�_TTY �/VN TEL. # �dg-39y-1� LOCATION ADDRESS: / 3ILrT�',�'J�,ii��_!2'./'�25�" ' MAILING ADDRES : OWNER NAME: S' / T r ` CORPORATION NAME(�IF APPLICABLE): p MANAGER'S NAME: (�1JNt�i�iti�.s� � �,,q�,=r, TEL. # MAILINGADDRESS: --�--_��YJ'Y!� O(� ��hn�'� --- ,� POOL CERTIFICATIONS: T6e pool supervisor must be certified as a Pooi Operator,as required by State law. Piease list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. CT��N U�`1VTRiYI s- p�C=/ 2. �UPA�/ �'7 . �1� Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of empioyee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fite at your place of business. 1. pl �US� �1T� C�� 2._ i��Qee/SD�II 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 fde at your establishment 1. ""'_, 2 `" PERSON IN CE�ARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hows of operation. 1. `—' 2. � HEIMLICH CERTIFICATIONS: All food service establislunents 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 Tile at your place of business. 1. `� 2. 3. 4. RESTAURANT SEATING: TOTAL# ^ OFFICE USE ONLY LODGIIVG: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � _68cB E50 _CABIN $50 �MOTEL $50 �FO'7'Q�S #07-QZ7 _INN $50 _CAMP $50 /t� SWIMIvIINGPOOL$75ea. .��-aa-8 - _LODGE $50 _TRAII,ERPARK $100 / WHIRI,POOL $75ea. �p7-O(O FOOD SERVICE: LICINSE REQiJIRF,D FEE PERMI'C# LICENSE REQUIR&D FEE PERMIT# LICENSE REQIIIRED FEE PERMI'I N _0-100 SEATS $75 I CONTINENTAL $30 �'1'n7�'6c57 NON-PROFIT $25 >100 SEATS $]50 COMMON VIC. S50 WHOLESAL,E S75 RETAQ.SERVICE: —RESID.KITCIIE;N $75 .- LICINSE REQUIl2ED FEE PERMIT ri LICINSE REQiJIItED FEE PERMIT fl LICINSE REQiJI2F,D FEE PERM[T# � �� _<50 sq.ft. S45 _>25,000 sq.ft. $200 _VINDING-FOOD $20 � _Q5,000 aq.ft. S75 _FROZEN DESSERT S35 _TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE _ $ 2c�d.OQ Tb •==""PLEASE TURN OV&R MiD COMPLETE OTHER SIDE OF FORM"•""• � S '� � � 3 �S �v ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or reciewal of any 6cense 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 INSiJRANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarntouth taaces and liens must be paid prior to renewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES� NO -- MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Tra�sient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotet use. Transient occupants must have and be abie to demonstrate that they maintain a principal place ofresidencc elsewhere. Transiem 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 i�s ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection Sve(5�days pnorto opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL GI�OSIlY6t Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIITY TO RET[JRN Tf�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISHIviENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIl�IENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � / 2CY� SIGNATURE: `V�"" `� PRINT NAME&TTI'LE: ✓ — 10/I'7/06 — — �-N�V. 14. 20Gb 2; 28?'� ASSQCiA�ED i�JSURANCE �G„��`� - �(g� �-�y , �.� , ' ��R u ��a.a../ �� V��E - _ , .. f ,Sa s � T�SCNAI7FLGT61Si55VEUA5AA7A'�'EIt4�' 'f � `d F 7C*C£P � COIdER4?iORIGHI'SUPONTHECEiR3�F'1CATF�k s�,� m. ; ^ . . . }s'J G I�+aE2S�i c�c 5��.,$ ¢ IIlC bDES NOT AMEND EXTEND O$AC.T£.7'A�C� s� '. ` ,.,__' ' . . � �I POL[C�BSC.OW�' . � :�3,"'.' P,E:�e08c'� �.'��1,' '��w:' . ,'" ,. ' ..._ . . 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Y . � : � r �- �. �,y ' � _ ' _, -._ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE , Asso�ciated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts (800) 876-2765 NCCI NO 26158 POLICY NO. VWC 6008047072006 ITEM PRIOR NO. VWC 6008047072005 1. The Insured Gaylri Knpa Corp dba�uality Inn 8 Sui�es Mailing Address: 1314 Route 128 . Soulh Yarmouth MA 02664 (No. Strea1 rawn or City Cwnry State 2p Cotle ❑ Individual ❑ Partnership � Corporalion ❑ plher FEIN Other workplaces not shown above: . 2. The policy period is hom03/09/2006 �0 03(09/2007 12:01 a.m.slandard lime at ihe insured's mailing address. �. 3. A. Workers Compensa�bn Insurante: Part One of the policy applies to Ihe Workers Compensation law of lhe slales listed here;� MA B. Employers Liability Insurance: Part Two of the policy applies[o work in each stale lisled in ilem 3.A. ThelimilsofourliabilityunderPaATwoare: Bodily�njurybyAccident $ 100,000 eachacciden[ 8odilyinjurybyDisease $ 500,000 policylimit ' Bodilyinjuryby0isease $ 100,000 eachemployee C. Other Sla�es Insurance:Coverege Replaced By Endorsemenl WC 20 03 06A D. This policy inGudes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be delermined by our Manuals ot Rules,Classifications,Rales and Rating plans. All information required below is subjed lo verificalion and change by audil. Classifications Premium Basis Rates '� CoJe Estlmale0 Per8100 Estlma�ed No. TolalMnual d Mrmal `�. Remuneretian Remu�ration Premium � MTRA 240870 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 231.00 Total Estimated Annual Premium y 1,421.00 ��.As Indicated,interim adjustments of premium shall be made: Deposit Premium $ 1,470.00 , ;[�'Annually ❑ SemiAnnuaity ❑ puarterly ❑ Monthly �� . MA Assessment Chg. � $1.108.00x 4.4000% $49.00 t n '�� Yhis pdicy,including all endorsemeMs,is hereby countersigned by ��'-'�� 02J28/2006 i' AVMMzed Sgnature Dale GOV GOV KIND PLACING CLAIM NAME SAFETV STATE CLASS AUDIT OFFICE OFFICE CHECK GROU� 11 Cilmartin&Son Agency Inc �MA �9052 �L �60q 1293 Post Road WC 00 00 01 A(71-88) Warwick,RI 02888 ' �,wd�wny,�ctaaa�rena�w me wno�ei cw�o�ca�sa�n�i�soa�a, � uaed wIM Ae OemYa�m. THE COMMONR'EALTH OF MASSACHITSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-015 FEE: $50.00 This is w Ce,tify that Gavtrilaupa Corporation d/b/a Chiality Inn 1314 Route 28. South Yazmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confoimity with the authority granted to ihe Board ofHealth,by Chap[er 140,Secrions 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of the Commonwealth ofMsssachu.settsrelatiu� thereto,and upon such tetms and�nditions,and to tUe rules and regulations in regazd to said Motels so licensed as adopted by the Board of Health,and expires December 31,2007 unless sooner snspended or rewked. January 31.2007 BOARD OF HEALTH: B��niit�5. �, /a$., . dfelert cQ�s, K./1�., 7/ics�� R�t�. Bu�, Gl� �M�f� nxce G. Mwp ,MP , .,CHO Direcfor of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-057 F'EE: 30.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral I.aws,a peimit is hereby granted to: Gavtrikrupa Corporation, 1314 Route 28, South Yarmouth, MA Whose place ofbusiness is:_ __4uality Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yazrnouth Pemut e7cpires: December 31. 2007 BOARD oF HEALTH: B `.b. ��., ' � ��s� �., v�e� R�t�t. e�, er� n��a�u �J.� � td�.�.�, 2.�v. January�3].2007 Bruce G.Murphy, ,RS„CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-027 FEE: $75.00 This is to Certify that C�r.t�/trikru�a�mm�rxtinn d/h/x Chiality inn 1'i14 Rnnte 2R, Snnth Yarmnuth MA IS HEREBY GRAN'I`ED A PERMIT To Operate a Public, Semi-Public Swimming or R'ading Pool At Q�ty Inn -INDOOR POOL 1314 Route 28 South Yarmouth MA This permit isg��a�t�d m confomuty with Article VI of the Sanitmy Code of The Commonwealth of Ivfassachusetts,and eacpires Deceml�er 31.2007 unless sooner suspended or revoked. January 31_2007 BOARD OF HEALTH: B $. //H.�., ' ��'x`„s� �., v�e� a�t� a� e� P�k R.N. Bruce . Murphy,MP , Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-028 FEE: $75.00 This is to Certify that�it;�CIItpa('.omoration d/h/a()uali�y Tnn 1314 Ronte 28, Snnth Yarmonth TvTA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Chiali�y Inn -Oi J'iT)OOR POOL 1314 Route 28 South Yannouth_MA This peimit is�an ted in confoimity with Article VI of the Sanitary Cale of The Commonwealth of Massachusetts,and expires December 31 2007 untess sooner suspended or revoked. January 31.2007 BOARD OF HEALTH: B $. /��., • a��`�sk� �., v�e� Rod�st�. B� Gle.� P��M�� A.��ja «�, R.N t. . MmP Y, ,R �, Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEAL1'H PERMIT NUMBER: #07-010 FEE: $75.00 This is to Cert;fy rhat Gaj��clt}pa Cor�oration d/b/a O�Inn 1314 Route 28 South Y�rmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN Tf�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This Liceose is issued in conformiry with ihe authority granted to the Boazd of HealU�,by Chapter 140,Secrions 51,of the Genetal Laws,and amendments thereto,and is subject to the provisions of the Laws of the CommonwealThofMassacln�seUs relating thereto,and upon such terms and conditians,and to the niles and regulations in regard to the canying on of the occupation so licensed as adopted by the Board of Health,and e�ires December 31,2007 unless sooner revoked. 7anuary 31.2007 BOARD OF HEALTH: B �5. /��., ' efs�Slu.�i, JV., 7/res �� ' /lo6e+ct 4. B�, G�trb p�,6�b1�s� A.ui l�'+� �wrr, R.N. B . Mu�phy, S.,CHO Director of Heal . (,�(6Q0 a��q�i'�, IN�.! zo��Ry TOWN OF YARMOUTH BOARD OF HEAIpTH"�i?� r�° APPLICATION FOR LICENSE/PE�I'�-�:�iD06 ? t-^+'F""^3 4�_,. ! ' ' ?�;U v Z � Z��S * Please complete form and attach a11 necessa�d �t.s'by December 31, 2005. Failure to do so wiil result in the re�rn o ot1i=application packet. NAMEOFESTABLIS�IMENT: QJGI�+i"'� `� �/� TEL. # SaY�39y.-/fi.� LOCATION ADDRESS: 13 /4- �o�F-�- S•y F^r`me V�. rr.ca - 0 26 d 4- MAILING ADDRESS: �-- S' c.`wY-- �" OWNER NAME:�'zc�.4 k-r� Kv✓(c, 'Y i°. 11'�ft$-� TAX ID (FEIN or SSI�: CORPORATION NAME (IF APPLICABLE): ('sGy't'�� (G��Ph G rP� MANAGER'S NAME: Q 2�er/ TEL. #� �a�,ya_ � MAII,ING ADDRESS: S�,-- � o�-- 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 c.9py ofthe certificatinn to this_f�m.-_- - --- -- -_-_- 1. (�UNt//M 1 T �tl-Tl=/ 2. �(//�L►� /� , ��h17=L- � �^., Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to tlris 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. ',Q-Ro�_ -f-tce�s o-�—� 2. �'� `/ U s !� �G�-e�_ 3. 4.� FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-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 fde at your establis6ment. 1. 2. �ERSQN IN CHARC�E:_ __ _ __ __ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. Z. HEIR�;�CH 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 � attaci5 copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a£de at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGWG: LICENSE REQUII2ED FEE PERMI1'# ISCENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PF.RMIT# _B&B $50 CABIN S50 � MOTEL �'�n`�0 �D� _INN $50 _CAMP $50 I ,�SWI[vvIIviQJ��0��7Op5�{ea. . �•LI7 _LODGE $50 TRAII.ERPARK $50 �WIIIRI.POOL� �75ea. _ �S�w FOOD SERV[CE: LICINSE REQiIIItED FEE PERM[T# LICENSE REQUIIiED�F(E,E PERMI1'# LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $75 � CONTAIENTAL�'$3� 3O •OO NON-PROFIT E25 _>100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQiTIItF.D FEE PERMIT# LICINSE REQiJIItF,D FEE PERMIT# LICENSE REQUIItED FEE PERMI1'# _60 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $�2.�Q�� """""PLEASE TURN OVER AND WMPLETE OTHER SmE OF FORM""""• Q NLY a. PL1�I Cl..��t;.c...�� .l�.S��i�li 1[::-l// ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 AFFIDAVTl'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 prio to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTTIONAL REGULATIONS 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. POOL WATER T'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered wittrin seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment wtuch serves or sells ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth 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. FROZEN DESSERTS: Frozen desserts must bertested orr a manthly basis by a State cerEifie� 1a6. Test resu7ts must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemvt 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 ofHeahh. OUTDOOR COOKING: Outdoor cooking prepazation, or display of any food product by a ret '1 or f od service establishment is prohibited. �j DATE: �� ,ZOO Sl SIGNATURE: PRINT NAME&TITLE: 09/28/OS /. __ J —� The Com�nomvealth of Massachusetts � `�- � Deparinreet of Indas(rral Accidentc = = NM�.'IIi� - 600 Washiagtoa SMd, f"F/oor = Boston,Masc. 02111 .�� Workers'Compnsaho�I�Bea�oe A�davik Bo7 M�g/Eleetrieal Co�trxtors. ......<. . _ __ .«�.�e,. * ,,.,k -�f'- �w.r�,..r�.�...�,, ..,� name: add�ess: ri(Y gp{e: ZD: ObOOE K wark sih locA*i�(foll addressl• . ❑ I am a homeowttr perfo�ing all waic myself. ProJect Type: ❑New Cmst�uctiao❑R�odel I a sole 'etor and]mve no�e w � m m . ' ' AddiRoe I am an employer providing wadc�s'compeasation f�my�pbyces wodci�m this job. . . . _ . .. � T . ae�awr�ae• �/'��s" �9i./.L.,/�'� C.��. �• /�1/�, m�p�`r� 3 t, oQ.au.fP_ #�a-$' � �o�� U�ir.vr�r�i i �a: Sc� 39�1—� �ss�'�ee, �- m _ sur�— y�n/C Cbgp �DI�IJOS i�a�oeu. �'�i ❑ I am a sole proprieWr,geaval ea�trxMy or komeow�er( ' oweJ�d have hued the conhactas lis[ed below who have the following wake�s'compensation polices: �ddresK d4q• nY�e i: B add�es�• tity nYare 9: _ It FaYveraeenear�aaenRqWed SaVir2SA�fMGLLS2mkadbHedpWirdai�Wlps�ModaO�e�bSI.SMNaW�r .�ywa•�r...oe..�a,. da�w..t.srorwowcoauEem.e.�eua.w.a.y.�.e. ioaewwu�. oepy�Ws Matre�t dy a[l�veN�am at Ne DIA tar enen�e veeMeatlw 1 do henby cn6fy rndsr rpenalNes nI6M�Y M�dYe isfen��lon provired abave 6 eve w�Acerrect Sig,aatme ` Date rC � i print name 7� Phoce# .�Ll.�e e.ry na.rtke r ab,ru m be urpMd Dr dh.r r.m.mdd cNyorfawn: pvdfAoeoel �� ❑ehedc ifimsed�le�eepeme b ra�irtd �Sdu�ea'a O�ce OHnllh Dep�t reelaet Pe+wu. P�we N; OOI� t��mm) i � - - WORKERS COMPENSATION AND EMPLOYERS LIABI�ITY INSURANCE POLICY , INFORMATION P,�,E ';a Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts (BOOJ 87&2765 NCCI NO 28158 POLICY NO. VWC 6008047012005 PRIOR NO: VWC 6008047012004 ITEM 7. The Inswed Gaylrl Krupa Corp dba�ualily Inn&Suiles Mailing Address: 1314 Roule 728 Soulh Yarmoulh � MA 02664 (No. SVeel iwmaCilY Cwn1Y SlateliDGotle ❑ Indivldual ❑ PaNnership � Corporalion ❑ Olher FEIN Olher workptaces not shown ebove: 2. The policy period is fram0310912005 � �0 07/09/2006 � �z:07 a.m.slarxlard lime al Ihe insured's mailing address. 3. A. Workers CompensaUon lnsuronce: PaA One of Ihe policy applies io Ihe Worke�s Compensalion Law of the slales lisled here; MA � B. Empbyers Liabilily Insurence: PaA Two of the policy applies lo work in each slale lisled in item 3.A. � The limils of our iiabililyunder Parl Two are: Bodi�y Injury by Accidenl $ 300,000 each accidenl BodilylnjurybyDisease $ 500,000 poiicylimil Bodily Injury by Oisease $ 100,000 each employee C. Oiher Slales Insurance:See Endorsement WC 20 03 06 A D. This policy includes lhese endorsemenls and schedules: SEE SCHEDUIE 4' The premium for Ihis policy will tie determined by om Manuals o!Rules.Classificalions,Rales and Ralinq pians. All Informalion required below is su6jecl lo verilication and change by audil. Classilicalions Premium Basis Rales - Code Eslimaled PeiE100 EslimaleE � 1olalMn�al d pnrnlal Rertnrneralbn Remu�reralbn P�amium IMRA 240870 � SEE EXT NSION OF INFOR ATION PAGE Minimum premlum E; 225.00 To(al Eslimaled Mnual Premlum E 7,664.00 � As Indicaled,inledm 8djustmenfs of premium shall be made: Deposil Premium E 1,731.00 � [� Mnually ❑ 5emi Annually ❑ �uarledy ❑ Monlhly � � � MA Assessmenl Chg. -. � 31,389.00x 4.9000h 587.00 ��TAis policy,Including all endasemeols,is hereby counlersigned by ` 02/18/2005 N�Ibited Signelue Date GOV GOV KINO PLACING CLAIM NAME SAFETY STATE CU155 _AUDIT OFFICE OFFICE CHECK GROUP 11 Gilmartin&Son Agency Inc MA 9052 :-2 � 604 1297 Posl Road WC 00 00 01 A(11-88) � � Warwick,RI 02888 uiclWes wc��ed maiera�d me Pleeond coMCM«�coimM:eRm Msurance. � used vAN ils pem�lasbn. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiJMBER: #06-005 FEE: $50.00 This is to Ce�Tify that GaVtn Knlpa Colp d/b/a ,Oualitv I[ln 1314 Route 28_ South Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformily with the authority grmmted to the Boazd ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D a¢d 32E as amended,and is subject to ihe pmvisions of the Laws ofthe Commonwealth of Massacl�useltsielating thereto,and upon such tem�s and canditions,and to the rules and regulations in regazd to said Motels so licen.sed as adopted by the Boazd of Health,and expires December 31,2006 uuless sooner susp�ded or revoked. December 2 2005 BOARD OF HEALTH: Be�c�rtf�t�. 4'o+tt�ott� ��1. ' �.�t��, v�e� �t�. a�, e� � s�, a.�rR ,a.�� ruce G. �uphy RS.,CHO Director of Heai TOWN OF YARMOUTH BOARD OF HEALTH , PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-028 FEE: $30.00 In accordance with reaulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�ieneral Laws,a peixnit is hereby ganted to: _ Gaytri Krupa Corp., 1314 Route 28 South Yarmouth, MA Whose place of business is: Ouality Inn Type of business: Continental Breal�ast To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2006 BOARD OF HEALTH: L�eit�rtf�t�l. C�'o3A.ott, M.�. ' � ��.c�� v� e��.� a�t�.a� e� �Sl�, R.NR.N. , Deceniber 2,2005 �``'� Bruce G. wphy,n S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-010 FEE: $75.00 17ils is to Certify that 1'i 14 Rnnte �R onth Yannnnt A�A IS HEREBY GRANT'ED A PERMIT To Operate a Public, Semi-Pubfic Swimming or Wading Pool At Quali�y Inn -INDOOR POOT, 1314 Route 28 South Yazmouth, MA 17us peimit is ganted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts, and eacpues December 31.2006 unless sooner susqended or revoked. n��z 2oos son�oF�fu.�: B�.�5. �jo�fok,M.�S. � v�.r�� v� e�.�.� a�t�. a�, e� � s�, R.�v. A.t.z R.N. Directo�of x�ealUi ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH , PERMIT NUMBER: #06-004 FEE: $75.00 This is to Ce�tify rhat Craytri Krupa Corp d/b/a Ou�Inn 1314 Route 28 South Yarmoutl� MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This Liceose is issued in confoimity with the authority granted to the Board of Health,by Chapter 140,Sections 51,oFthe General Laws,and amendments thereto,and is subject to the provisions of the Laws of the CommonweallhofMasSachusetts relating thereto,and upon such teims and conditions, and[o the niles and regulations in regard to the cazrying on of the occupation so licensed as adopted by the Boazd of Health,and expires December 31,2006 unless sooner revoked. �t�z.Zoos so.axD oF�ni.�: 8��. �jo3do.�,�L1.�5. � p��t, v�ef�„�,� Ro6�3t 4. e�, � � Sl�k. R.N. A.� , R:N. t. ce . 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Ai2III.L�I O.L A.LI'IIHISNIOdS�NllOd SI.LI i£laqutaaaQ o�j ,Sienuer uio�,Cpznuue um s�nuiad��LLOl�t OAI S� QIF�d,�A'I�,L�RIdO2Iddt� ?I��I� �5��'Id �si�ad ino,i3o a�venssi io �Smauai o�ioud pred aq�snui sua�pue sa�c8i c{ulouue�3o unnoZ /� Q�3�V.L.L� QN� Q�I�IrJIS .LIAF��33d �dNtO� S��I�?RIOM / 2l0 / Q�I�H,L.LF� ��IS��If1SI�II 30 ".LZI�� xo `Q�u�is aut�a�.i.�z�nto� �g.tsn�.r.inv�� l�i�'2IRSN[ 1�TOI,L�'SAI3dLN0� S<�I�RIOAA �.LV.LS Q�H�V.L.L�' �H,L a�ueinsuI uoi;Esuadwo� s,iax�o�3o a;e�g�ua� � anEq �ou saop ,Cvedazoo io uos�ad z 3t ssamsnq e a��iado o; �tuuad lo asuaail due 30 remaua.[io ao�renssi p�oq o�pannba�mou s�q�nouuz�3o w�noy ay�`cJ uot;�asqns `�SZ uo�3oaS `ZS I ia�deq�iapun NIOI.LVN.LSll�IINiQV ` ; - „ ' . ��_- The Coinnronwealth of Massachrrset�c = DeQarlment oflndwstrial Accidextc � -- = N�cIN� = 600 Washingtoe Street, 7tb Floor -' �3 Boston,Mass. 02111 � Work�s'ComRnsatioe Lsea�ee A�d�v�Bo7 ' bi�g/Ekehical Co�traeters � �., o� - � . _ ' �' "�"- � �,,,�� '�;`� namc: add[ess: gly smte: ao: �# �_site locatim(fiull addressl: ❑ I am a homeowner perfo�ing eR wwk myaelf. Pcojed Type: ❑New Conshuction�R�odel I mm a sole �dor and Lave no�e w in� B � ' Addition I��employer providing workas'compensatian f�my�pbyees wodcing a�n thia job. �i.�: f��0.Lz� �.Rs�.r_�; , f�-A.-P��u��a�/ �� .�,.: I �I 4 � tzr,.�u �: ,. ��,�„��, ,,�.��r,�: ��: �� - .3q1�-- yno� �'..F��."4I,r„�1 • �m�s n,��l,.� V tiooSo4�► nD4 ❑ I am a sole proprietoy gaa�sl to�traeMy or Yomeowoer(drde oweJ aod have hiied the co�actois liated below wlw have the following workeis'compensation polices: oe�e��: �i�: dtv Nre#: A �r re: 4�i' titt: d�a�e/: __ . _ _._ __ ._ _ _ .. _ . . _ ._ _ _ . M . FaiRe Y feeae e�erade n Rq�ad odQ Satlr 2SA d MGL 152 m kM M IYe IrpwYY�da'i�itl polb d a eoe�p b fl¢M-M aYhr ae ynn'ly�ein�t n wd u d�i pmltln 1�tYe fi's da 310!WORK OAD&R ud t me dS1M.N�day aplet�e. 1 mdeshW Htl a npy Ktlb MaMmeet my he[rwnded b Ne Omcce dL�n Kth DIA fir anerge veeiRntlw /�o hnsby ceitltlfj rnder tMe G�a m�dP��D�MY dY�Ms n�forow�lton provl/elabeve b�e iwd osirsct SiBoato�e DMe loC— � 1 —��`'f' Primname Phoce# �n�S�J��{--�-n(J[l .�i�l.feo.ry a...t...frerew.re,aaca�pl�dbrdlr.rw...mdd dlyartawa: perdtli�cB "' De�t ❑c6edc Himae�Be wpeeee h rtqQN ❑Sd[cdn§O�e �HnIM Dep��t n�tet Peteon: PYwe N; (�101� lk+ioa S,R 306T) � . � ti • . WORKERS COMPF_NSATION AND EMPI.OYERS LIABIU iY INSURANCE POLICY W�ORMA�ION FFlC':F Associated Induskries of Massachusetts Mutual Insurance Company F3urlington, Massachusetts • (soo) 876-z7s5 N�a No zsvsa F�oi_ic,v No vwc sooaon�oizoon ' PRIOR NO- NEW f3U5MESS ITFGA -- 1 I he Insured �;ayin Krupa Corp d6a(Juality Inn 8 Suiles Mziliny Address- 131A Roule 128 Soulh Yarinou�h MA 02664 �uo Simai I.rvvnuifnW Counlv SUIe]IPC.odn ❑ Indivfdual U Parinership � Corporalion ❑ Olher FEIN ? Olher workplaces nuf shown above: 2. 1 he poficy period is from03(091200A �0 03i0917_005 17_'01 a.m.s�andard time at the insured's mailing address_ 3 /�. Workers Compensaiion Insurance-. Parl One of�he policy appiies b lhe Workers Compensalion Law o(Ihe s�a�es lisled here', ro�n R. Employeis liabilily Insurance�. Parl Two of Ihe policy applies lo work in each slale lisled in iLem J�_ ThelimllsofourliabilltyunderPartTwoare' f3odilylnjurybyAccidenl $ ____ �� eachaccltlenl � BodilylnjurybyDlsease $ . �� ,��-�� policylimil HoditylnjurybyDisease $ . _ I�� _ eachemployee � Olher Stales Insurance:5ee Eidorsemerd wC 7_0 03 06 A fI_ ihis policy includes lhese endorsements and schedules- SFE SCHEDULE 4. I he premium for this policy will be Aele�mined by our Manuals of Rutes,Classificalions.Rales and Raling plans. NI informzlion required below is subject lo verificalion and chanqe by audi�. �C�assifcations Premium Basis Rales [dunatel �er$IDO Estimaled Crnle 7��alNmual of Annual plo. Ran�uneia�ion Remunmalian prcrnivm INIHA 240R%0 SEE EX f.NSION OF MFOR IATIOP!PAGE Minimum premium$ 225.00 -I'otal Esiimaled Annual Premium $ 1,610.00 As indicated,in�erim adjuslments of premium shall be inade: Deposit Premium $ 7,659.00 � [� Annually ❑ Semi Annually ❑ Ouarterly ❑ Monthly MA Assessmenf Chg. $1,316.00x 37000% $49.00 7his policy,including all endorsements,is hereby countersigned by _d2�f�e� _ _ 03/23I20G4 T nwn�nzen s�a�„��rF oaie STATE I CLFl�S�AUDIDT C�)FFICE �OFFICL CF FCK GROUP� S/�FE�V . J J(ii6narlin&Son Agcncy Inc MA 9052 2 804 1291 Posl Road WC 000001 A(11-88) �Vanvick,RI 02R8R Incluaes copyd9hted matFrlal of Ine Na�lonal Cooncil on Compensztlon Inswance, �e�n.Mm r nrnn�:-�on. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-020 FEE: $50.00 This is to Certify that Gaytri Krupa orp d/61a Oualitv Inn 1314 Route 28. South Yarmouth MA � HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confoimiTy with the authority granted to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of the Commonwealth ofMassachusdtsrelatmg thereto,and upon such tern�s and conditions,ffid to the rules and regulations in regard to said Motels so licensed as adapted by the Board of Health,and expires DecemUer 31,2005 uuless sooner suspended or revoked January 21_2005 BOARD OF HEALTH: Beir�c�. (fo3dort,M�. ' n�M� v:�e� Ro6errt 4. B�iawvr, Glotk e� Sl�r, R.N. ��j� R.N. Bruce G. Mwphy,MP .5.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLLSHMENT PERMIT NUMBER: #OS-073 FEE: $30.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a Permrt is hereby ganted to: Craytri Krupa Corp., 1314 Route 28, South Yarmouth, MA Whose place of business is: Qualitv Inn Type of business: Continental Breal�ast To operate a food establishment in: Town of Yazmouth • Pernut expires: December 31_ 2005 BOARD oF AF,ALTH: Be�«urs `�. (�'atdoK, M.`.21. ' � �.�� v�ef� R�t�. a�, e�,� eV�.�Sl,�, R R.N .r��y 2i.zoos Bn�ce G.Minphy, ,RS.,CHO Director of Health G THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERIvIIT NUMBER: #OS-035 FEE: $75.00 This is to Certify that 1'i14 Rrnite 2R nuth Yarmart MA IS HEREBY GRANTED A PERMTT To Operate a Public, Semi-Public Swimming or Wading Pool At Ql�ty Inn - O OOR POO 1314 Route 28 South Yazmouth MA T6is pennit is anted in conformity with ARicle VI of the Sanitary Code of The Coromonwealth of Msssachusetts,and e�spires Decem�31.2005 unless sooner suspended or revoked. January 21.2005 son�oF�u,Tx: B�2. �jo.rdo� M.2. • �� v:� ef� a�t�. a� et� ��w R.N. � K r, R.N. Director of Heal�tli ' THE COMI�IONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-034 FEE: $75.00 This is to Certify that ('�a�tri K��na(�nm d/h/a�al�inn 7 314 Rnirte 2R Snuth Yarm�nth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Pubtic Swimmiug or Wading Pool At (h�l'�y Inn -INDOOR POOL 1314 Route 28 South Yatmouth, MA This permit isgranted in confoanity with Article VI of the Sanitacy Code of The Commonwealth of Massachusetts,and e�ires December 31.2005 unless sooner suspeuded or revoked. . .►�,�y Zi.Zoos sontz�oF�ni.�: B�$. �o3do.�,M.�. � P�+rc�/1'!o$e�xok, ?/i.� (�u.�i�c Roie�t 4. B� � dk�.� Sl.�k. R.N. R.uc(j�i do.W,c, R.N. ruce G. Miup R ., Director of Health • THE COIVIlIIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-015 FEE: $75.00 Tlus is to Ce�tify that C'�aytri Kn�pa orp d/b/a Ch�ai tv Inn 1314 Ro t 28 outh Y rmo t� MA HAS BEEN GRANTEp A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in confoimity with the auUiority granted to the Boazd of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,ffid is subject to tLe provisions of the Laws ofthe Commonwealthofrs�neco;:.�cesrc relating thereto,and upon such tetms and conditions,and to the rules and regulations in regard to tbe carrying on of[he occupation so licen.sed as adopted by the Boazd of HealUy and expires Decemb�31,2005 unless sooner revoked. J��y Zi_Zoos sonxD oF�ni.�: B��5, lj�+uG+.z,M.$. • �� v:�e�k a�t�e� er.� �Sl.�, RrV. A�uC Cj�sead4.u� R.N. ruce G.Mwphy, S.,CHO Director of Health , - C4..,#� co6� � �Eo _oo �KM�l2-(.y o�qa,y TOWN OF YARMOUTH BOARD OF HEALTH ` " 3r � APpLICATION FOR LIC �E�,E �$p4 y �+ �n lI\�S �.�.t-. l�r� �� '� n� Ifl�� 4 Y �IJJy ��: * Please complete form and attach all nece�� ydocuments by Deeembe 3��Q�:H DEPT. Failure to do so will result in the ret�Ph of your application packe . NAME OF ESTABLISI�MENT• g ° �� TEL # �7SS- �9L�-!r�(,1('J L CAT N AD RE S: I IN ADD YY) - OWNER/C ORAT ON NA E: , AGER'S NAME: - T L. # D MAII,ING ADDRE4S• — .Sc�vv, e — ' 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 th�s form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your place of business. 1. 2, 3• 4. FOOD PROTECTION MA�IAGERS - C RTIFICATIONS• All food service establishments aze 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. 2_ PERSON IN CHARGE• Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2, HEIMLICH CERTIFICATION • 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 Deparhnent will not use past years' records. You must provide new copies and maintain a £le at your place of business. L 2. 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN E50 _MOTEL $50 ttQy�lro� _1N7`I $50 _CAMP $50 _SWIMMINGPOOL$75ea #��t.n� _LODGE $50 _TRAILERPARK $50 _WHIRLPOOL $75ea. �-0�( FOOD 5 RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS 575 �CONTINENTAL $30 �o�Lg�{ _NON-PROFIT $25 _>I00 SEATS $I50 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. � $200 _VENDING-FOOD $20 <25,000 sq.R. S75 _FROZEN DESSERT $35 _TOBACCO S25 x^ME�H^N� ' $�° AMOUNT DUE _ $ �� e d **"•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•***• ADMINISTRATION • Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pernvt to operate a business if a person or company does not have a Certificate of Worker's Compensation Insarance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED 22� 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 NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003. SEASONAL ESTABLISI-IMENTS ARE TO CONTACT'I'I-IE HEALTH DEPAR'TMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIHING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,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 CONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF. NG 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. Thses forms can be obtazned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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. oiTTSIDE C�Ffi:S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a tail or f service establishment is prohibited. DATE: � � 0 SIGNATURE: PRINT NAME & TITLE:��,lMGt��/ �,cO� - /�'M�%��f' 10/22/03 THE CONIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-061 FEE: $50.00 T6is is to Certify that Gavatri pa Cor�. d/b/a Ouality Inn 1314 Route 28. South Yarmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is iss�xed'm cbafoimiry with the authoriry ganted to the Bomd ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the I.aws ofdie Commonwealth ofMassach�asetts relaling thereto,end upon such terms and conditions,and to the rules and regulatirn�s in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2004 uuless soo�r su.speaded or revoked. Mey 20.zooa sonxn oF t�ai.Tx: B�9!. �joada.r., A/.$. ' P�:�,W� v�ef� Rod.�t�. a.�, e1�,6 �Q s�.�k. R.NQrv. ruce G.Murphy, , S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-194 FEE: $30.00 In accordance with reQulations promulgated under authority of Chapter 94,Section 305A azui Chapter 111,Section 5 of the Cieneral Laws,a pernut is hereby granted to: Gayatri Krupa Corp., 1314 Route 28, South Yarmouth, MA Whose place of business is: Oualitv Inn Type of business: Continental Breakfast To operate a food establishmem in: Town of Yarmouth Permit e�'ves: December 31_ 2004 BOARD OF HEALTH: Ben�.a. 4mu�oia, M.$. ' � �,�� v.� � �� a�r�, arv. May 20.2004 B�vice G. Mucphy, S.,CHO Duector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-096 FEE: $75.00 This is to Certify that C�a�,atri Kn�na c��;, d/hla �ali inn 1 14 Rnnte R„ Snnth Yarmoi�th MA IS HEREBY GRANTED A PERMIT To Operate a Pub6c, Semi-PubGc Swimming or Wading Pool At R P 1314 oute 28 South Yarmouth MA This permit isgranted in confonniry with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�cpires December 31.2004 unless sooner svspend�ar revoked. �Zo.zooa soaxD oF t�u.�: Be.y�.o$. l}oado.�, M.�. � �.a�s,�rt, v:�ei� a��.a�, er� �S!�!� R.N. � � ��Y R.N. Bv,�r�ofxeat�th ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-Q97 FEE: $75.00 This is to Certify that Crn�atri z»a('.nrn rl/t�/a(h l�a i Yinn 1314 Rnnte 2R, Scurth Yarmnnth MA IS HEREBY GRANTED A PERMIT To Operate a PubGc, Semi-Public Swimming or R'�ding Pool At Qualitv Inn - O[ITDOOR POOL 1314 fioute 28 South Yarmouth. MA This pemui isgan ted in confmmity with Article VI of the Sanitary Code of T'he Commonwealth of Msssachu.setts,and eacpires I�Cember 31_2004 uoless sooner suspended or revoked. �zo.Zooa soaxD oF�nt.�: B..�.�:h. �jardo.�, M.2. � Pabric�4 Mo95es�xotf„ 'Uiaa G''�rai�xa� RoGmr#�. Bawwc, �k �filea Sl�ok, RJY. � er.r aw, R.N. ru . Murp ,MPH Director of Health THE COMMONWEALTH OF MASSACHUSETI'S TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-041 FEE: $75.00 17�is is to Certify t6at Gayatri }pa Corp. d/b/a �alifv inn 1314 RoLte 28 0 � h y rmo �t}y MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is iasued in confomuty with ihe authority ganted to the Boffid of Health,by Chapter 140,Sections 51,of the General I,aws,�d amendments thereto,�d is subject bo the provisions of the Laws of the CommonweallhofMassacdmxtb relatmg thereto,and upon such te:ms�d c;onditions, and to the niles and regrilations in regard to the carrying�of the occupation so licensed as adopted by the Board of Hea1tU,md eacpires Dacember 31,2004 unless sooner revok�. �y zo.Zooa Bonxn oF�.�: Bw.j�.,:.b�. l�eeda�, M.�. � ��U��« ��• R R.N. , nu;e G.Murp ,MP , . .,CHO Ditector of Health