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� The Commonwea/!h ojMassachusetls
= Deparrment ajlndustriol.-iccidents
0 01//C001/OlCSUO�(///f
600 Washington Street
' Bosron. Mass. 02111
�
v�� Wbrkers' Compensation Insuraace Affidavit
Aoolican[ informallon• p� „� yp��, a
nam� .�v'S5 .4i�J.s/? �!o %foL L!-C' —
Lac�tion �, 'r1/ /�i^'0��!/ g�f � .��
us�_Sa� ,/•.� yA�/>c+✓/� /ZJ.G+55 O.� �GJ S�S
, � I am a homecwner pzrtormmg all µork mysel£ R��d 35�Y �-ySS1
� I am a solz propriemr=r.,'. ha�e no one uorkine in am capacih•
� I am an employer pro�idine workers' compensation for my employees aorkine on[his job.
comPanr nam.• f���I+.fi ��'x/�'jAL'%J/c /—//Jh �c�if'.�
a�dress• �L�� �ifJ/���C/�y �� � � ��C�� .
. cih': �/7��(/�t/,�'lj �A3� t/.� ij nhen a Sp�"b 'l7/ -/�l/�
insurance co. %��4�/�"s�f��'S' /.0 f':v,� %� ��J policv p G9 R X 3C�`J—Y� O'.f
� I am a sole proprieror. generai contracror. or homeowner(circle one! and have hired the contracrors listed below uho ha�e
the follu�cfng ��orker; compensation polices:
comoanv n+me•
address:
cin:
nhen e
insurancc ro, pelie� #
tomoanv name•
addrc..; _ — _
c'tLY�
phene Y
insuranee co �R�� �
f
Failure to securt covenee u requ�red uuder Secpou SSA o(MGL!S3 n�kad[o tbe iepailiw of eri�iW pndtln of�O�e op ro 51,500.00��d/or
ooe yun�imprisonment u w�dl a eivil pendtla io the form of�STOP WORK ORDER�ed a Ilee ofS100.00 a Aar K�imt m� 1��denh�d Nn a
eopy of thy sh�emem may be for.wrded to the 011iee ot Iovatig�tlom otMe DIA for eovera�e rerillutlw.
� 1 do�Arreby cmij}•unde�the paiu ond pmaf�iet ojperjury that�he injormation provided abovt frlrye and eor►at
Signature /�/��d,�
�- � T—,
Print name �'�'� Cr ' �/—c�:'r(j�Y�� Plione M ��'n �'� 77/f
.. aRcial use onl� do not rrite in this area to be completed by eiry or torvo oflleial
city or town• YA���Q miWteme N
- ' Pn nBuildioe Dep�rtmeet
check if immediate res �Lieeesioe Bo�rd
❑ ponse ie required �Seleeimen'f Officr
261 HeiltE De �nmeet
comaat person: .Pho��p._ (S08} 39$�2231 ext. �Other P
� ,� : '. : . ..
��' ' CE�iTIFICA�E +�� If�fi��3RANGE ' �A�ry��m
: . _ oz-oe-oz
r� / THIS CERTIFICATE IS ISSUED AS A MqTTEfl �OF INFORMATION �
NG & 0 NEIL INS AGC ONLY AND CONFERS NO RIGFITS UPON 7HE CERTIFICATE
� � �fWEST MAIN STREET HOLDER THIS CERTIFICATE DOES N07 AMEND, EXTEND OR
ALTER THE COVEAACaE AFFOROED BY 7HE POLICIES BELOW.
O 8OX 1990
' iYANNIS MA 02601 COMPANIES AFFORDING COVERAGE
� �22LGR COMPqwY
A THE TRAVELERS INDEMNITY COMPANV
� INSUqED
' COMPANV
VALLE CONCRETE FORM B
CORPORATIDN
107 IYANOUGH ROAD 2ND FLOOR COMPqraY
HYANNIS MA 02601 C .
COMPANY.
�
��VERAa�$ �::.,
THIS�IS TO CEiiTIFY THAT THE��POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO�
INDICATE�, NOTVJITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PEP,TAIN, THE INSURANCE AFFORDEO BY THE POLIGES DESCRIBED�HEREIN IS SUBJEC7 TO ALL THE TERMS,
IXCLUSIONS AND CONDf710NS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED fiY PAID CLAIMS.
C� TYPE OF INSUNANCE POLICY EFPECTVE I POLICV IXPIRATON
LTq POLICY NUMBER
�OATE(MM\OD1V1� IDATE(MM�pD�YY) I I1MIT5
GENEpAL(Jq9LLJN I j
I I I GcNEiqLAGGn'cGATc IS
COMMERCIAL GcNERAL LIABILI'fY
i PRODUCS-COMP/OP AGG. ,5 I
C:AIMS MADE�CCC'Jri.l I� . P�RSONAL&AOV.INJUFV -
PI OWNER'S&CONTAACTOR'S PFOT. I � � i FpCM OCCJFFENC'c - I
I FIRE DAMAGE fAny ane(irel
I ME� IXP NS (A y ll 5 I
AUTOMOBILE IJABWry I
_ � ',, ' I � _ ,
ANV AL i 0 . I I �OMBINEJ SING�
IS
ALL OWNEJ AUTCS ..'. I I'�MI i II
� i cODiLV INJl1RY
I 9CHEDUIcD A11T05 '�, � (Per Ferson) �5 �
MIRED AUTOS - - ' .
NON-OWNED AUTOS I �'�. I I BCDILY INJUaV ��i
�. � � (PerAccioenq �5 ,
I � ' �I I 'GOP��Y DAMAG' I 5 I
I GARAGE IIABILITV
ANY AUTO I j . AUTO ONLV--'_q AGCIOENT I 5 '
� . I I O'Hc'n THAN AUTO ONLV: � . I
� � � � E4CH ACGI�ENT �5 �
IXCESS llqglllTY I I I AGGREGATc I 5 i
I IcACH CCCUPFENCE I5 I
UM6RELLAFORM �', .
� ' ''� AGG'nEGA' j 5 �
I'nEP�EE-�uryn NqxOM �UB-832X309-O-^2) i I I
i I
A I i ..::...
I O 1-1 8-pp 0 1-1 8-03 I STATUTOFiY 11MIT5
�1CH ACCi�eM
PAHiNERS/EX'cCUTIVE� INCL I i � `- 500,�000��
OFFICERS AqE I c�C� DISE4SE-POLICY 11MIT �5 500,000
OTNEp I 015'cqSE-E1CH EMP!OVEE �5 500,000
I
DESCqIPT10N OF OPERAiIONS/LOGITONSNEHICLES/qESTiiICT10N5/SPECIAL ITEMS �
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HDLDER AFFECTING WORKERS COMP COVERAGE.
C£pTIFIEATE HQLDER
��� ��� � . .. CANCEELATIaN
SHOOLD pNy OF THE ABOVE OESCp16Ep ppUGES BE CANCEl1Ep BEPOqE��� TXE �
D��fiATON DA7E 7ryEqEOF, THE ISSUING COMPANY WILL ENCEqVOp TO MAIL
TOWN OF YARMOUTH BUIL�ING DEPT �� DAVS WRITfEN NO710ET07HECEq71FICAiEF10�pEpNpyEpTpTME
MAIN STREET LEFf, BUT FAIWqE TO MAI� SUCH NOTCE SHALL IMPOSE.NO OBLIGq7�ON OR
SOUTH YARMOUTH MA 02664 �N7Y pf ANy pND UPON iHE CONPANY,ITSpGEN75 Op qEPpESENTAi1VE5.
AUTHOfl17ED REPRESENTq� �� /�
ACORB 25S(3/93) �_ . ... �'" '— "'C
���� RD C6RFORAlT1UN;'1993-1
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-019 FEE: $50.00
This is to Certify that Bass River Motel LLC
891 Route 28 South Yarmouth_ MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity wiffi the auThority granted to the Board of HealUy by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subjectto tl�e p�ovisions ofthe Laws ofthe Commonwealf6 ofMassachusens relating
' thereto,a�upon such terms and wnditions,and to the niles�d regulatioag m regard to said Cabins so Gcensed as adapted
by the Boazd of Health,and earyires December 31,2003 unless sooner suspended or revoked.
December 19 ,2002 BOARD OF HEALTH: �a3![d r'�, z[lfG�ez, (�,�ra�r
— _ . _ _ __ __ _ __— _ __ __,
�D. �. �111.D:;`t�� _
Ro6ost�• $as�vc, � _
�aDrlek:�r•axratr
�du S�a�E. ,�'h.
ruce G.Mmphy, ,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN.OF YARMOUTH , _
BOARD OF HEALTH
PERMIT NUMBER: #03-037 FEE: $75.00
'rhis is to Certiry t6at Bass River Mote1 LLC
891 Route 28. South Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Pubtic, Semi-Pubtic Swimming or Wading Pool „ ,
At Bass River Motel LLC - OUTDOOR POOL
— 8��Rout�28
South Yarmouth MA —
T'his pemut is granted in conformity with Article V I of the Sanitary Code oF The Commonwealth of Massachusetts,and
e�cpires December 31.2003 unless sooner suspended or revoked.
December 19 ,2002 BOARD OF HEAL113: ��, i�plli�c, ��yafiuxqK _
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ruce .M Y, ,C
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The Commonwea/th ojMassachusetts
= Depar�ment ojlndustrro/.-Iccidents
; OJf/ceal/evesdOsdsis
600 Washington Slreel
Bosrort. Mass. 02111
` W'orkers' Compensation Insurance Affidavit
ARplicant information: p► ,. pg �.sy.
mm� �/A`�.✓` �/dF� /�'/O%�� �1!" 1/lf�l.� ��.t.L�'iP.��
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itt� SG�� `f'/.j/'9G�/� /�f�55 dr7�� ehon t! 3�15f�y��
� I am a homeoµner pert�rtning all work myself.
� I am a sole proprietor �-d ha�e no one «orking in am capatin�
�1 am an emplo�er peot,��ed:ers'{ortt�ensacion for my emplo�ees µorkine on chis job.
comnan� namr, v�`�F CCI�/G/�F%f �Dl?�i .Ci�/Yf�
,aa��t5: �y� s�A�.� yT /,'i' �t�
�,�,: s�� y��.���f�� „�„� t,.���y hR ene„y(C0�7 �7� ���/
iosuranceco. /JN/CI �ir4SciqL+� l��a�,ll� oolicyq X�C/G�c"/�5�6,�'9/G'�/"
� I am a sole proprietor. _eneral contractor, or homeoNner(circle onel and hace hired the contractors listed beloµ ��ho ha�e
the follo�cin_ ��orker_ ,ompensation polices:
snmoanv name:
address:
Ci[v�: nhene q•
insurancc to oolicv#
ssmoanv name:
addresr � --� . . � .
. eitr yhoes w .
insuranee eo. �pn.N
a
Failure m stcure covenee�s required uader Seenoo 25A a(MGL 152 w Ind to t0e iapaidw o(crisi�l ptedtles of�O�e op ro SI,500.00 a�d/or
ane ycan'imprisonmmt u w�e11 u tiril pentlHa io tAe form of�SfOP WORK ORDER��d i Opt of f100.00�dar qaimt me. 1��denh�d Hat a
eopy ot Ihia�ntement may be fonv�rded to the ORce ot I�rcftiauion.�otthe DIA for emera�e rerilfotlo�.
/do hrreby cenij}•under rhe parns and perta!lier ojperjury�hm�h[injormation provided above is bue and corrett
Signaturc � �l/ pyti ////y/�� �
Print name �aL�'j�l" � � �C/�jll+ta �� f�A�Ns°� vhon��� �7/ 77/�
.• olTicial use onic do no�.ritt in this�ra ro be complehd by city ar toan oflleial
city or town: Y�M��T$ _ permiNieeroe M nBuildiog Dep�rtmeot
�Lieensiog Bo�rd
Q check i(immediale response ia required 261 �Seleetmen'f ORcr
�Health Department
con�actpersan: pnon�p:_ �SOH� 398�2231 eat. nOther
' Client : 13862 2VALLECO
acn�rnn CERTIFICATE OF LIABILITY INSURANCE o2i`o�jo
PFODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
DOWZIRJ & O' Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ag2riCY, II1C . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
222 West Main St . PO Box 1990
Hyannis� MA 02601 . INSURERSAFPORDINGCOVERAGE
INSUqED INSURERATYclV012TS Insurance Company_�_ � �
Valle Concrete Form Corporation iNSURERB.OY110 Casualty Group
891 Main Street, Route 28 — - --
South Yarmouth, MA 02664 iNsuaeac:
INSUflER D:
� INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR hiE POLICV PERIOD INDICATED. NOPNRHSTANDING
ANY REQUIREMENT, TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED 6V iHE POLICIES DESCRIBED HEREIN IS SUBJEC7 70 ALL hiE TERMS,EXCLUSIONS AND CONDfTIONS OF SUCH
POLICIES. AGGREGATE LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR'i TypEOFINSURANCE POLICYNUMBER POLICYEFPECTNEPOLICYEXPIRRTION
LTfi�. T MM/DD/ LIMITS
AIGENEflALLIABILIiY I680862D3843TIA01 �2�26�01 �2�26��ZI,EACHOCCURRENCE ,$]_� ��� � ��Q
��, }�' '�.,COMMERCIALGENERALLIqBILITY �', ��FIREDAMAGE(Anyanefire�'y,rj�0 ��Q
',_�__ � CLAIMSMADE� OCCURI �, MEDE%P(Anyoneperson) S�j ���
�' ! I PERSONALEADVINJURY S�. OOO OOO
___....._..___— , �i
J � I � GENERALAGGREGNTE $Z OOO OOO
—__.___...._ ....._ _ _—
�GEN'LAGGREGFTELIMITAPPLIESPER:�I � PRODUCTS-COMP/OPA60 $2 OOO OOO
POLICV jR�T LOC I '
p. I AUTOMOBILELIABILITY I680862D3843TIA01 �Z/26��1 i� �2�26/�2 COMBINEOSINGLELIMIT I�$l, 000
�'.. ANYAUTO I, (Eaaccitlenq . i ���
�� l�"� NLLOWNEDAUTOS �� IBODILYINJURY
� �� SCHEDULEDAUTOS . (Perperson) $ _
X . HIREDAUTOS ' ___.____ 1� ______
�.. BODIIVINJUFY E
X ��, NON-OWNEDAUTOS � i I �I(Pe�accitlen�)
. ______. __ ___-
---- . —.-- .-.- . .-- ��.' .. � PROPERTV�AMAGE ..
� '�, ! . ��'lPeraccitlent) �$
'�. GAflAGELIABILITY ''.. AUTOONLY EFACCIDENT $ ,. .
� ANYAUTO Ii EAACC $ ..��....
OTHERTHAN
�� j AUTOONLV: AGG ���.S
I EXcessuaaiurr ISFCUP862D3959IND0 02/26/O1 02/26/02 EACHOCCURRENCE $4� 00__0, 000
� XI OCCUR ���.r.J CLAIMSMADE ''�. pGGREGATE � $4 � OOO OOO�
�.i._—� _ ' _ � _ _ —
,� '' I �'� �S
� � DEDUCTIBLE ''. �.. II � I�IS
. ._. �, '. __'_._—.�.____—_. -.
� X���. RETENTION §SOOO i � ��g
B �, WORKERSCOMPENSATIONAND jXWOOZSZ6S71O9 OZ�ZH�OZ I� OZ�ZH�OZ WCSTATU- ; OTH-
�� EMPLOVERS'LIABILITY '� i ��- --
' '' i. iE.LEACHACCIDENT ,$SOO� OOO
����, E.L.DISEASE-EAEMPLOVE $SOO� OOO
�� ��E.L.DISEASE-POLICYLIMI ESOO� OOO
OTHEF �
�ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Lu.s.� 5<.e./� /.�.e,ur./.sL i�� ��
CER7IFICATE HOLDER I '�. aoomoruuNsunEo•irisuaw�R CANCELLATION
SHOULAANYOF7HEABOVE DESCRIBEDPOLICIES BE CANCELLED BEFORE THE EXPIRATION
Town Of Yarmouth DATETHEREOF,THEISSUINGINSURERWILLENDEAVORTOMAIL3Q_DAYSWRITfEN
Building Department NOTICETOTHECERIIFICATEHOLDEFNAMEDTOTFEtEFf,BUTFAILURETODO5O5HALL
Mcl1T1 Street IMPOSENOOBLIGATIONORLIABILITYOFANYKINDUPONTHEINSURER,ITSAOENTSOR
South Yarmouth� � 02664 flEPRESENTATIVES.
AUTHOHI2E D HEPRESENTATIVE
�
ACORD25-S(7/97)1 Of 2 $kS21776�M21765 ... OACORDCORPORATION7986
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-007 FEE: $50.00
This is to Certify that Bass River Motel LLC
891 Main Street/Route 28. South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140, Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or
revoked.
Mazch 1 ,2002 BOARD OF HEALTH: ��D zCoadati. .�lee
�oBF�+t'�. E"ze�evc. (!/r�rk
n�'satieklXc�Da.}r�oxyo�tC
? K � . 1G•/L•
Bruce G. iurphy R.S., CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NIJMBER: #02-009 FEE: $50.00
Th;s is to Certify that Bass River Motel LLC
891 Main StreeURoute 28. South Yazmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Pubtic Swimming or Wading Pool
At Bass River Motel LLC - OUTDOOR POOL
891 Route 28
South Yazmouth. MA
Tlvs pertnit is ganted in conformity with Article VI of the Saoitary Code of The Commonwealth of Massachusetts,and
expires Deczmber 3]_2002 unless sooner suspended or revoked.
March 1 ,2002 BOARD OF HEALTH: �a�a�f. 'Xeffiket. �ai�+�rax
. b�e.a" D. C�aado.c. '�1L.D., `Uiee ��,ka'uu�ea.c
�:� b�aoenx, e(erk
�s�rick�auxatL'
'�fefe.c Sk , .12.
,
ruce . y, . ,
Director of Health
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The Commonwealth ojMassachusetts
� Depar�menJ ojlndustria/,-lccidents
; Of//Ce 0//OYCSU�!//Nf
600 Washington Street
Boston, Mass. 02111
W'orkers' Compensation Insurance Affidavit
Annliranf infnrmaHnne P1EeSC�11pi'Tld4hht.
n�m.. /���.�1'! ���'� /�Q �/�L �!/'C/ �TK�� Vis�'•'�/�j�I�✓/�
Inr,i�on� 3 / I /���N � /`7/ �1S
�`. jC!J4/7 /i��l'% (/�� �l� �s�f�� phone p 3�Sf�Y8 O
0 1 am a homeowner ptrtorming all work myself.
� I am a sole proprietor�r.d h�cz no one «orkin� in am capacih�
� I am an emplo�er pro�idino workers' compensation for my employees working on this job.
comr � 11e�GF� l�,✓cy4r_./� G.aR�l l'��A�
�ddrecs• �9/ �•4iiv � /�/�./� .
eih•• �UUo/� y��i��L�✓J�1 �i�S� Cl��c-�7 phone p• 3`I� S7S��
C�fi'/'.s7 A .5�t.ce
insur�nce co O/�id GASe%✓�� G/�J✓�� ¢Qr��a G�'j y6�`�g
� I am a solz proprietor. _eneral contractor, or homeowner(circle onel and hace hired the contractors listed below «ho ha�e
the follu�cin_�carker_ .ompensation polices:
S�It�v n
-�dresr
�� ohone k•
insur�nce co policy#
m n m :
addres •
�. phoee X•
insurance co (l�SY K
Failure to secure coverage 9s required uoder Sectioo 25A of MGL I52 ua Ind to the impmitloo oteriai�fl peedtln of�Bae op to f1�00.00 a�d/or
one yean'imprisonmrnt ia w�Nl ae eivil pendHa io the form of�STOP WORK ORDER�od i ffee of 5109.00 a dry q�imt ma 1 a�dmh�d H�t•
eopy of thh sntement m�y be forwarded to the 011iee ot Invntig�tlonf of the DIA for eorenge veriliutlo�.
/do hrreby cenij}•under the p�ains and pen l�es ojperjury�hm!he injormation providtd a6ovr Is bue and correeL
�_/�� Daic �7'��G/��7
Signature�
Print name A�'O��% ����'v� J� N�9�f'�'�'�� Phone# 3�/���+�
., oRci�l use onh do not write in this area to be completed by eiry or towo olifeial
� city or town: YA��DTQ _ permilAicenu M nBuildiog Department
- �LIftOS10g BO�fd
p eheck if immedia�e response is required 261 QSeleetmen's Ofliee
ONcalt6 Dep�rtment
contact person: Pha�i p;_ �508} 398�?231 eat. �Other
Irmised i;a5 PIAI
Client : 13862 2VALLECO
ACOBQ,� CERTIFICATE OF LIABILITY INSURANCE oi%i9%oo
vRooucea THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowling & O' Neil Insurance ONLY AND CONFERS NO RIGNTS UPON THE CERTIFICATE
A enc IRC . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
g Y� ALTER THE COVERAGE AFFORDED BY'THE POLICIES BELOW.
222 West Main St . PO Box 1990
Hyannis, MA 02601 INSURERSAFFORDINGCOVERAGE
. INSUREO � INSURERA Travelers Insurance Company
Valle Concrete Form Corporation INSURERB: O�110 Casualty Group
891 Main Street , Route 28 INSURERC:
South Yarmouth, MA 02664
� INSURER D:
i INSURER E:
COVERAGES
-� THE POLICIES OF INSURANCE LiSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEflIOD INDICATED. N07WITHSTANDING
ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACT OF OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFOfiDED BY THE POLICIES �ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONSANOCONDI710NSOFSUCH
POIICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFFECTIVE 'POIICY EXPIRATION
LTR NPE OF INSUHANCE � POUCV NUMBEP DATE MM/OU/YY I OAlE MM/00/YY � LIMITS
A GENERAWABILITY II680862D3843TIA00 02/26/00 ! 02/26/O1 � �CHOCCURRENCE j51� ��� � ��Q
XICOMMEitCWLGENERALLNBILIN, �� �'i, FIRE�AMAGE(Myonefire) II53OO � 000
I � ,CLAIMS MADE ��OCCUP i i ME�E%P(My one person) I,$S � O O O
� � I' IPERSONALSADVINJURV ISZ� OOO � OOO
._ I '�, I GENERAL AGGREGATE 'I SZ , O O O � O O O
GEN'LAGGREGATELIMITAPPLIESPER: ''�, � '. IPRODUCTS -COMP/OPAGG �!52 OOO OOO
� ^ POLICY; : PE O '—l',, LOC �� ' ,� �,�.
A AUTOMOBILEl1A81LITY I680862D3843TIA00 02�26/00 � 02/26/011comeirveosiNc�uMiT ��.51, 000, 000
I nNv nUTO I � '. i (Ea acciaenp .
—f ALLOWNEDAUTOS '
,— , ', . '� BOOILY MJURV ',5
� �I SCHEOULED AUTOS '��i �,I �. �', (Per person� .
'. X ��., HIPED AUTOS I �I ' � �
� ��, � j BODIIY INJURV '�.g
� �� I(Per accitlenQ
I X I NON�OWNEDAUTOS ', I' .
'�,—� II I : PROPEPTV DAMAGE I 5
. . , �. .(Per acciaent) .
� GARAGE LIABILITY I �I �. ���.AUTO ONLY-EA ACCIDENT i g
.....�-1 ANY AUTO �� �'�'� �. � EA ACC ':'S
, i �, ��, I OTHER THAN
� ' . '� .. '', AUTOONLV: AGG i S
� � � � - O2�2Fj�O1jEACHOCWFRENCE 54 , 000 , 000
A ezcessuneiuTr ISFCUP862D3959IND0 02 26 00 :
I Xi OCWR r� CLAIMS MnDE I �'. I AGGREGATE I,54 � O O O � O O O
Ij� i . I, I IS
I� DEDUCTIBLE �' � Ii5
I XI RETENTON S5 Q�� I I 5
B I WORKERSCOMPENSATIONAND BINDER164298 �1./18��� �1/18/�l II ITOfiYLMTTS I I�Ep I
, EMPLOYERS'LJABIl1TY ' I I
�, ' ' E.L EACH ACCIDENT I SS O O O O O
I I I I E.LDISEASE-EAEMPLOYEE�,SSOO � OOO
�� � �' � E.L DISEASE-POUCV LIMIT�,$S O�O � O O O
'i OTHER '. ''. '.,. li
DES I RIPTION OF OPERATONSlLOCATIONSIVEHIClESIEXCLU510NS ApDEO BV ENOORSEMENT/SPECIAL PROVISI�IONS �I�
CERTIFICATE HOLDER '� �'� aoomoNauNsuaeo;iNsuaea�errea: CANCELLATION
c SHOULO ANYOFTH E ABOVE 0 ESCRIBE�POLICIES BE CANCELLEU BEFOflE TH E EXPIRATON
Town Ol Yarmouth DATETNEREOF, THEISSUINGINSURERWILIENDEAVORTOMAIL3�DAV5WFITfEN
Buidling Department NOTICETOTHECERTIFICATEHOLOERNAMEUTOTHELEFT,BUTFAILURETODOSOSHALL
Ma1T1 SC.TEEt. IMPOSEN009LIGATONORLIABILIT'OFANYqNDUPONTHE1NSUflER,ITSAGENT50R
S . Yarmouth� � 02664 REPflESENTATIVES.
AUTHORIZE�REPflESENTATVE
�
ACORD 25-S(7/9�1 O f 2 #17 S O 1 . O ACORD CORPORATION 1988
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMITNUMBER: #O1-049 FEE: $50.00
This is to Certify that Bass River Motel L.L.0
_ 891 M in Street/Route 28 outh Yazmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Bass River Motel - O TDOOR POOL
891 Route 28
Sou Yazmo th MA
This permit is granted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachuseds,and
e�cpires December 31.2001 unless sooner suspended or revoked.
February 16 ,2001 BOARD OF HEALTH: �� ��C.,
e���. x�e�e��
��� �, �
�a� d :['
� D,�c�• �ll, .
t , 1^YLu
Director of Ha lth �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMITNUMBER: #01-028 FEE: $50.00
This is to Certify that Bass River Motel i T C
891 Main Street/Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confomtity with the authority ganted to the Boazd of Health,by Chapter ]4Q Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such tern�s and conditions,and to the rules and regulations in regard to said
Cabi�s so licensed as adop[ed by the Board of Health, and eacpires December 31,2001 unless sooner suspended or
revoked.
February 16 ,2001 BOARD OF HEALTT-I: �� �etted,
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�a� d :L'
��� D. c�• .D.
1 . ;LI-lG�
Bruce G. Murphy,MPH R. .,CHO
Director of Health
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. �
� The Commonwealth ojMassachusetts
:.
' = = Deparlment ojlndustrial.-lccidexts
_ a Ol//ceol/aresUyaWis
600 Washington Slreel
Bosron, Mass. 01111
� �� '` Rbrkers' Compensation Insurance Aftldavit
Aoolicant infarmation• p� AeepR1RTL.s^•
nami� Y�f`{��V��iW
� . 891 M����
So
ut� ehoe p /�`1�.����
� I am a homeoµner pznurmin,all work myself.
� I am � solz proprieror ar..'. h��z no one ��orkine in am capacin•
�(am an employer pro�idins workers' compensacion for my emplo}ees workine on[his job.
m an n e:
address: 891 �11.�.�. '�$ •
South Yannouth,MA U2664 /
titv: nheneu �`��� � 3y-l/'�.S6r'�
insur�nce co. noliey p
� I am a sole proprietor. general contractor. or homeowner(circfe onel and hace hired the contractors listed below ��ho ha�e
thr follu«ins �corkzr> ;ompensation polices:
comoanv eame• �
address•
��n�� Qhone��
insurancc co yoliev#
s4moanv name:
addresr
Utv: p6oesr•
insuroneeco. � ���M
■
Failurc to securc cover�ge�s required uoder Seenoo ZSA o(MGL 133 w ind to t!e iepaidw o(eriW�l pndtln of a O�e op to 51300.00 aW/or
oae yan'imprisonment u w�ell n eiril penalHn io Me form oh STOP WORK ORDER�ad�lis of 5100.00�d�r qtimt ma 1 ndenh�d t6at•
eopy of tAy sntement m�y be fonv�rded to the ORee of Inve�tlg�tiom of the DIA tx eovera�e verilfatfw.
l do-hrreby cenijp under ihr pains and prna/ties ojperjury thm the injormalion prorided above it dut wd coneet
Signamre _�� : /,� � _///Jr�/�
Y /
Print name �tis� ��d�l-t/o ��1 Phone���`�7�1�.�J%�f�
.. a(Tcial use onh do not+.ritt in�his trn ro be rompleted by cih or tmvo ollleial
ciry or rown: Y�H�DTQ _ � permiNiteeee k n8uilding Dep�rtment
❑Lieen�io6 Board
��heck i(immediate response i�required 261 �Seleetmrn'�Ofifet
(508 3 OHn�t6 Depanmeat
contact person: pAone M:_ ____,� 98��31 eEt. I"701At�
�.
a�%���-��. CERTIFICATE OF INSURANCE OATE(MMIDDM') ;
PPODUCER � 7 � '
THIS CERTIFICA7E IS ISSUED AS A MAiTER OF INFORMATION I
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE �
L0111S MOTenO � HOLDER.�THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
105 Cakridqe Street ALTER HE COVERAGE PFORDED BY THEPOLICIES BELOW, I
LudlO;a, ;✓i; 01056 ' ' COMPANIESAPFORDINGCOVERAGE ___�
. . i COMPANY I
�r+suaeo A Panerican Interstate Ins Co �
V�lle Concrete r i coBaNv ��� i
Fo_m Corpvr3tio � ,
�
c91 i✓ain Sireet R` 28 � co:nPnNv
`- C i
=�.�t.��7 :d TP,1 O U t Y: ----
i'�IA O��i j G � ' COMPANY ��—I
COVERAGES � I
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD �
INDICATED,NOTINITHSTANDMG ANY RE�UIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
i CERTIFICATE MAY BE ISSUED OR MAV pERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. �
, EXCLUSIONS AND CONDITIONS OF SUCH POLIGES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS.
CO 7YPE OF INSUqANCE
LTR � POIICy NUMBEq i POUCY EFFECTIVE ��POLICY E%PINATON I �
� DATE(MMIDWYn ! DATE(MMIDD/Vq ; ��M� �
GENERAL�IABILITV � i. . i
COMMERCIAL GENERAL LIABILITV I i I �GENERAL AQGREGATE I§
�._ I CLAIMS MADE �_I,p�CUR� ' I PRCDUCTS-COMP/OP AGG . �,$
—� I I j PERSONAL 8 ADV INJUFY �$
__�OWNER'S&WNTPRp7 � I i � _
EACHOCCORRENCE '�,$
� I I �FIRE DAMAGE M one fire �$
I�AUTOMOBILE LIABILITY I � I �MED EXP M one rson I$
I i I�ANY AUTO . I I COMBINED SINGLE LIMR §
. '—�ALIOWNEDAVTOS � � �
_� I I '
!.. jSCHEDULE�AUT05 I �' BODIIYINJURY S
— I �(Perperson) I
- ���HIREDAUTOS �
_ � �'�
�NON�ONTJED AUTOS ' � I BODILY INJUqY
� ' , '(Peractident) '��E
I �
� � ' �.PROPERiV DA1dAGE 5 I
��GARAGE LIABILITY ' '
___'ANYAUTO � _AUTOONLV�EAACCIDENT 5 '
.___" _____ �I OTHEPTHANAUTOONLV' ' ---�_'--�{
__—_;
� _EACHACCIDENT 5___ _ i
. __"_ _.__.—.
EXCESS LIpBILITV � AGGREGP.'E 5 �
___ UIdBRELLAFpFM EACHOCCURRENCE __5 . _
OTHER THAN UMBRELLA FORIA AGGREGATE _ _§_ _ �
�WORKEflS COMPENSATION AND � S
EMPLpyERS'LIABILITY � � STATIITORV LRdITS !
� - - "—_ _—_"— . -.J
THEPROPRIETpqr ,..`�� � .��, EACHACbDENT E_ �SUC� vCO �
PARTNERS£%EGUTIVE -___ INCL � .....� �i,��ff�',1 2��(�I�O " �i�Slv'G � - --- -- -- - ----
�OFFICERSARE: 1 DISEASE-POLICYLIMR �_S JUC� JOG
EXCI _" _'—" ' _ __'_ .'_.
.OTHEB 'DISEASE-EACHEMPLOYEE 5 SUO OOG
I
iSCRIPTION OF OPEPATIONS'LOCATIONS/VEHICLES5PECIAL REM$ � I
:RTIFICATE HOLDER
I
CANCELLATION GRITT
� �
SHOULD ANY OF THE ABOVE DESCRIBED POLIGES BE CANCELLED BEFORE TME �
lO4JT� Oi l��ii(IOUt}] E%PIqpTION DATE TNEFEOF, THE ISSUING COMPANV WLLL ENOEAVOR TO MAiI I
�'-111 C:l ��,�� ?)pi�G r t m P rl r 1��AYS WqITTEN NOTCE TO THE CERTFICATE NOLOER NAMED TO THE LEFf, I
'i°i,9 1 �� `�_'�_p� BUT FAILUflE TO MAIL SVCH NOTCE SHRLL IMPOSE NO OBLIGATION ON LIABILM
�,, �i r i_�����`r�, ��/.a OL��? OF ANY KIND UPON TME COM NY, RS AGENTS ON PEVAESENTRTVES I
L�� AUTHORIZEO pEPPE `�( —
'hOn oe e�.,........ //A . �� /Ill . n , . .. . I
- THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-3 FEE: $50.00
This is to Certify that Bass River Motel
891 Ro te 28 outh Yarmo �th MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority g�anted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as arnended,and is subject to the provisions of the Laws ofthe Commonwealth of Massachusetts relating
thereto,and upon such tertns and conditions,and to the rules and regulazions in regazd to said Cabins so licensed as adopted
by the Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked.
December I , 1999 BOARD OF HEALTTI: ����+�Qj(a��@� C�i„�z
�oaa G. �u[CiwaR� K.�/•, Vic¢ C.�irmaa
�o6e,r� �33row�, C�.,&
a6„�..���G,d y-�1��,
� f0�o��1�
,
Bruce G. Murphy, MPH, R.S. C
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
�' BOARD OF HEALTH
PERMIT NUMBER: Y2K-3 FEE: $50.00
This is co Certity�hat Bass River Motel
891 Route 28. South Yannouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Bass River Motel - OUTDOOR POOL
891 Route 28
South Yarmouth. MA
'Ihis pem�it is ganted in confortnity with Article VI of the Sanitary Code of 1'he Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
December I , 1999 BOARD OF HEALTH: �d///�.+Jnekw//, ��iai.m�/a�nq �
�oan G. JuCCivan� �//.� Vita ��irman
�o6a,�� d3row,�, ��.�
a6ree"eg sa�o�i�y-�,�oopaa
' �l o �lin
ruce
Director of He�altt�i '
r
4 - p Ba55 i2�Ver Mote1
� - TOWN OF YARMOUT�BOARD OF H ALOTHZ p � � � � d � D
APPLICATION FOR LICENSE/PERMIT - 1999 D E C p 1 1998
* Please complete form and attach all necessary documents by December 31, 1998. F ' t in
the return of your application packet.
--------------------------------------------------------------------------------------------------------------------------------
NAME OF ESTABLISI�IENT: (� RiJF-.4 .�o:Y-sL 66� TEL # � h/B�
LOCATION ADDRE9S: S'9/ ,y/iN yT i9!.,r�S' Sv�H A.Qi�lc�t/f� N.9S5 0,���
M AD
S2WNER/CORPORATION NAME: S�9tis/3 ..RiUh4 y�isL �L-f- j//IGl� GaivufT �?
MANAGER'S NAME: iNa�u.4Q/� G9,Ss' TEL. # 3'9S' .iu/8'$
MAII.ING ADDRESS: 59�f�
-----------------------------------------------------------------------------------------------------------------------
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tivs form.
1. %�� (/� 2.
Pool operators must list a minimum oftwo employees currernly certiSed in basic water safety, standard First Aid and
Commumty Cazdiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certifications to tkus form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business. � ��,� ,
/�,� �/ �y 25��
1. �/� �Y (i' ��� 2�. ' �o' ��y`��
3. 4. � L f �ps
/ c,�'�
HEIMLICH CERTIFICATIONS: N/,/t
Ali 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-choldng 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 t"�e at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#� NON-SMOKING SEATS: TOTAL#
--------------------------------__--_____---------------------------------------------------------
- — — - -------___ __ _ �3FFiEE�T9�ONF�.Y --
LODGING:
LICENSE REQUIItED FEE PERMIT # LICENSE REQUIItED FEE PERMIT#
B&B $50 _CABIN $50
_INN $50 _CAMP $50
LODGE $50 _TRAILER PARK $50
�MOTEL � �_ �SWIlvINffNGPOOL 50 . q—
_WHIItLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIItED FEE PERMIT # LICENSE REQUIltED FEE PERMIT #
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
_CONIMON VICT. $50 WHOLESALE $75
�TAIL SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT #
_<50 sq.R. $45 _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200
Ntll�E CHA�TGE: $10 ,������i/y.�- ���i�'
AMOUNT DUE $ I O� `
"•'""PLEA5E TURPi OVER AND COMPLETE OTHER SIDE OF FORM•"""*
� ,
. �
ADMINISTRATION
LTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOUTH IS NOW REQiJIRED
TO �IOLD ISSUANCE OR RENEWAL OF t1NY 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 INSiJRANCE ATTACHED
2�
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 c/ NO
NOTICE: PERMITS RUN ANNUALLY FROM JANiJARY 1 TO DECEMBER 31. IT LS YOUR
RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI� HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD E5TABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIviENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR
PSEUDOMONi3S,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMR�IING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN (7) DAYS OF CLOSING.
FOOD SERVICE
ATERING POLICY:
ANYONE WHO CA'I'ERS WITHIN Tf� TOWN OF YARMOUTH MUST NOTIFY 'THE YARMOUTH
HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TF�
HEALTH DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf� HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN
Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TF�ABOVE TERMS
- -- --- — — -- --
_ - -- -
I3AVE BEEN MET.
O IDE FF :
OITTSIDE CAFES (i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR
APPROVAL FROM TF�BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISfIlv1ENT IS PROHIBTI'ED.
�� �/"j�,
DATE: /�.��i�zS� SIGNATURE:i�'/�%��' '�
PRINT NAME& TITLE: /p'�t�/Yd.c1�' J���2��" J'� u� �
f
� � �
' The Commonwealth ojMassachusetts
� Department ojfnduslria/.-Iccidents
_ b 911/Ca01/OYCSUOJtl//f
600 Washington Sbeet
Boston, Mass. 02111
W'orkers' Compensation Insurance Affidavit
Applicant information: Pf +�sePft 'u�
,.2 - �
namc' /9�%i �S �(r�/l� /��l���r� ���
location: ��1/ /�99�R/ � /�%.��
cit� ���t�f� 7•F�i9r�Lg�f�f� /�'�r� d.��6�=/ phone p �%�' �/s�✓
� 1 am a homeowner pertorming all work myself.
� I am a solz propriecor �-d hacz no one uorkine in any capacin•
,� I am an employer pro�idins µorkers' compensa[ion for my employees workine on this job.
comnanr namr. V.9LE� �d�'11�A�i�/�i fs++QH �d/�� �
address: �SI� /r/�/ti' 7� � .�� �
��t.: sv�i�! Y.4R..t!!o✓sH �9,y`�� o.,�^�,�t•/ ,�no��a• �'i9f7' �v��
insurance co. �rB.Nf1/�i�R"�s7.iG (,'I�j�.G /NScr/�Ae✓Z'rd Z��C� po�icv N �"� 0 7� �� J�E� �
� I am a sole proprietor. general contractor, or homeowner(circle onel and have hired the contractors listed beloµ ��ho ha�e
the follu�cin� ��orker_ ;ompensation polices:
somoanv name:
address:
- ��n" yhone�•
insurancc co. Dolier p
comoany namr. � �
. ..__--� -----
_ . .-- ---. _. _— _ .
. ._— . . ... --- - -- - -
address: -
[itv: phoee 1!• �
insurance ca � �Kry p �
Failurc to secure covenge as required under Setnoo 25A o(MCL ISS u�kad to the iepaitfos of eriWvl pe�Htla of�O�e ap lo f1,500.00 a�d/or
ooe yean•imprisoomrnt aa w�ell a�tivii peadHa io Me form oh SfOP WORK ORDER�ad�O�t of SI00.00 a dry a�dmt m� 1��denta�d N�t t
eopy ot thh sutemen�may be for.varded to the ORiee of Inve�tia�tioo�of tAe DIA tor eovera�e reri6e�tlw.
1 da�hrreby cer�rj}•under rhe pains and pena(ties o perjury�hat�he injornmlion provided above Ls true and rnrrcct
Signamrc � �� Due ���/�ga
r' '//� /
Print name ���/�e'NO .� /�A�sNci J� L�f� Phone M 31n7 ���`°�
. ol�cial use onl� do not w ritr in this area to be completed by tily or lown oflleial
ciry or town: Y��DT� permiNitcex N nBuildioe Dep�rtmeet
❑ check if immediah response ie re uired �Lieensiog Bo�rd
Q 261 OSelectmen'�ORiee
ronroct erson: �,r08 3 ❑Hnith Dep�rtmeot
P phonc p;_ _� 98-2231 e%t. nOther
Ue uM iA�p1 A1
�
THE COMMONWEALTH OF MASSACHUSETTS �
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-I FEE: $50.00
Tlils is to Cenif'y that Bass River Motel LLC
891 Route 28 South Yarsnouth MA
IS HEREBY GRANTED A PERMTT
To Operate a Public, Semi-Public Swimming or Wading Pool
At _ Bass River Motel LT C O OOR POOL
891 Route 28
South Y�rmouth �
TLis permit is granted in conformiry with qrticle VI of t6e Sanitary Code of The Commonwealth of Massachusetts,and
eapues December 31. 1999 unless sooner suspended or revoked.
December ]0 , 1998 BOARD OF HEALTI-I: C�d��/�.+�e�e�e, C'�ia(�;rn//�,aa� / /J
� �/�na/n G.��7u/�llivarz�/K�p.�//•� Vice C.�irmart
� � Kobert J. 9�rowrt� l,[erh
a6,�1�e sa�a��y/Jd�Pe�
aelO� �h :n
Director of H�ealth' '
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-1 FEE: $50.00
This is to Ce�tify that_ Bass River Motel LLC
891 Route 28, South Y�r_mouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This Licease is i.cs��ed'm confocmity with the authority granted to the Board of Health,by Chapter 140,S�tions 32A,32B,
32C,32D and 32E as emended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
fl�eteto>and upon such tern�s and condirions,and to the niles and regulations in regard to said Cabins so licen.sed as adopted
by the Boazd of Health,and exp'ues December 31, 1999 unless sooner suspended or revoked.
December 10 , 1998 BOARD OF HEALTH: G�///n. �etfee� ��w(�irm/J/r�cn� / /7
. � �/�oa/n G.c-�� /u��an�/KJa,//.� Vice l„�irman
- Kobert�}. /)rowa� l,ler�
a6,;��sa���yJd�Pe�
K�Q�O' o,���;�
ce G. Murphy,MPH,R ., C
r of Heaith
. •, .� � � � . \oZ�\£a6D
' TOWN OF YARMOUTH BO 'OF ;�.�'���',.�' ;,s � '� � '' V I� D
� ' APPLICATION FOR LICENSE�/�EP��vI�I'f — 1998
SEP 3 0 1998
* Please Compiete form and attach all rrecessary documents by December 31, 1997. - ' DEPT.
so will result in the return of yow application packet.
-------------------------------------------------------- ---------- ---------- - -��-------
----- - - - --------------
I�Al� OF ESTABLISF�VVIENT: � �4 5 S /P/✓�R /J),r1T�L TEL. # 3 9�����
�nz�ss: 8' gi r�te L siy.�.�,q�.� .� � �.�c ��
�II,INGADDRESS S /,� /',A G nt.-��i.��oi� w,r nL-�33���3�_
9__W11E$_/_�QRPORATIONNAME: l�.vss R�✓.�.a ��✓F� f�c, �/�.�/s �wcq.�f.0
MAI�IAGER'S NAME: y/i ��v Ss %IcKJR90 G�.S� TEL.# ,3t��'��'Sg
MAILING ADDRESS: SAa�� �a s f'�� v�
---------------------------------------------------------------------------------------------------------
POOL CERTIFICATIONS:
Pool Operators must list a minimum of two employees currently certified in basic water safety,
standard first aid and Community Catdiopuhnonary Resuscitatlon(CPR).Please list tliese
employees below and attach copies of employee certifications to this form. Tde Healt6
Department wili not use past years records. You mast provlde new copies and maintain a
fle at your place of basinesa.
1. �d� �/�/.1/�� 2.
3. 4.
HEIMLICH CERTIFICATIONS: ,V��,1
All food service establishments with 25 seats or more must have at least one employee trained in
the Heimlich Maneuver on the premi.4es at all times. Please list your etnployees trained in a�i-
choking procedures below and attach wpies of employee certifications to this form. The Heakh
Department wiil not use past years recorda You must provide new copies and maintaio a
file at your place of business.
L 2.
3. 4.
RESALJRANT SEATING: TOTAL#_� NON SMOKING SEATS: TOTAL#_
--------------------------------------------------------------------------------------------------_--._._---
9FFICE USE ONLY
LODGING:
LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50
_INN S50 ,�,CAMP S50
LODGE $50 LER PARK $50
�MOTEL $5 9�--�3 �/ SWIMPOOL �°� $5 8 IO
_WEIIRLPOOL $25ea.
FOOD SERVICE:
LIC. REQUIRED FEE PERMIT# LIC. REQUIItED FEE PERNIIT#
_0-100 SEATS $75 �CONTIIVENTAL S30
_>100SEATS $150 _NON-PROFIT $25
_COM. VICT. a50 _WHOLESALE $75
SETAI�
SERVICE:
LIC. REQUIRED FEE PERIvIIT# LIC. REQUIRED FEE PERMIT#
_<50 sq. ft. S45 _TOBACCO $20
_<25,000 sq. ft. S75 _FROZ. DESSERT E35
_>25,000 sq. ft. $200
AMOUNT DUE _ �►oO.00
� ������
Q4���
_� .
ADMINISTRATION 4
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH I;;S .
NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PER�IIT
TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A
CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. 'I'HE ATTACHED
STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE
COMPLETED AND SIGNED.
TOWN OF YARMOUTH TAXES AI�iD LIENS MUST BE PAID PRIOR TO RENEWAL OR
ISSUANCE OF YOUR PERMTTS.�LEASE CHECK APPROPRIATELY IF PAID:
YES V NO
NOTICE: PERMITS RUN ANNiJALLY FROM JANiJARY 1 TO DECEMBER 31. TT IS
YOUR RESPONSIBILITY TO RETURN TE�COMPLETED APPLICATION(S)AND
REQLTIRED FEE(S)$Y DECEMBER 31, 1997
SEASONAL BSTABLISHIvv1ENTS ARE TO CONTACT T�3E HEALTH DEPARTMEN'1'FOR
INSPECTION 7-10 DAXS PRIOR TO OPENING FOR THE SEASON:
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (ie. ,
PAINTING>NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY
Tf� BOARD OF HEALTH PRIOR TO COMMENCEMENT. R�NOVATIONS MAY
REQLIIRE A SITE PLAN.
AnDITION�AFGUi.ATIONS
POOLS
POOL OPEI�TING: ALL SWIMMING}, WADING AND WHIRLPOOLS WfIICH HAVE BEEN
CLOSED FOR'1'HE SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT>
AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO
OPENING.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE
DRAINED OR COVERED WITHIN SEVEN(�)DAYS OF CLOSING.
FOOD SERVICE
SATERiNG POLICY:
ANYONE WHO CATERS WITHIN TI-IE TOWN OF YARMOUTH M(JST NOTIFY THE
YARMOUTH HEALTH DEPARTMENT BY FILING'fE�REQUIRED TEMPORARY
FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT.
THESE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. '
FK02.EN i��SERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI..Y BASIS BY A STATE
CERTTFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT.
FAILURE TO DO SO WILL RESULT IN TFiE SUSPENSION OR REVOCATIdN OF YOUR
FROZEN DESSERT PERMIT UNTIL TI�ABUVE'TERM3 HAVE BEEN MET.
OL1TSiD • C,�FE4:
OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITA WAI1'ER/WAITRESS SERVICE),
�,T HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH.
oUTDOOR COOI�nvG:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A
RETAIL OR FOOD SERVICE ESTABLISHNIENT IS PROHIBTTED.
DATE: r��/��a� SIGNATURE:���
PRINT Nt1ME Bc TITLE: 9•v'.Ym.e,/% .���o�uo �it,
��
10/97
page 2 of 2
t ', �
' The Commonwealth ojMassachusetts
: = Department ojlndustria/.-fccidents
; Offleeo/ler�sU�salia
600 Washington S�reet
' Boston.Mass. 02111
°�y'` W'orkers' Compensation Insurance Affidavit
ApQlicant informallon: PI *sePRiN7'Ti�rci.sp
nam�: /���5 /QiVF� �/d���- /��C
n: � / A/N 57 h'%.,��
�'oui/� S',r1/,'F/o�/� .�1�� G��E�f 50�3)
���� nhon u 3���
� 1 am a homeoµner pzrtorming all work myself.
� I am a sole proprietor _^� ha�z no one norkine in am capacin�
,g) i am an employer pro�iding workers' compensa[ion for my employees w�orking on this job.
eomoan�� n�me: f�•ddL.Q �!''�if/C�R�'.�/C ��1/Q�/ l�st�ll0
addrexs: ��Y e�/•0/.v ST
titv: l.�f� !`1�/�/OC�i'�f' �,.��j CJ'�� /� nhene M� ��c'� / 7�� `7 ��J
insuranceco. ���i1/�✓�G/A� tJ.t//�N /.VS"Ur6'.OAK�f Ct7 oolievp G':7 0 /7 7� d`(�
� I am a solz proprietor. _eneral contractor, or homeowner(circle onel and hace hired the wntractors listed below ��ho ha�e
thr follu«in_«orkers' ;ompensation polices:
comoanv name: �
address
t�': yhone p:
insurancc co �oliev#
eomnany name: '
addresr
tiri: phoee M:
insvnnee ce. eelin M
Failure�o seeure eoveraee as required uoder Secnoe 25A of MGL IS3 n�ind to tbe iepaitloe o(erieiul pndtla ot���e ap w 51,500.00 a�d/or
oae yean'imprisonment u wxll o tiril pendtla iu�he torm oh STOP WORK ORDER�W�Ilx of S100A9�d�r Kdort me. �e�denh�d that a
rnpy of thy satement m�y be for.v�rded to the Olfiee otlnvestig��iom of�e DIA far eoven�e verillutle�.
1 do hereby certij}•ander rhr parns and prnalties ojpery'nry rhat rhe injormation prorided abovt ls aur and correa
Signaturc /�//'ir��%/ �?� Dne 7/ 3�1�r�
Printname i9�� J' `c�/�'-a.�c � ✓�� Phone/Vl�`�7 �7/�j'�7�
o?cial use onlv do not.rite in�his area to be eompieted by eiry or M�va ollleial
cirv or town: Y�MODTQ _ � permiUlieenu M nBuildinp Dep�rtmcut
. ❑Lieemios Bo�rd
� eheck if immediate response i�required Z61 QStleetmeo'�Oftfes
� pNnl�h Depanmeet .
conmct person: p6onc M:_ �508) 398—?231 eat. nOther
r
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� 07Ylo/i998 11:00 SBS--C66-0245 VOLt-NTEER INS AGCV P'.1CiE O1
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TFrys pINUER IS A TENPCflA��N��CE CONTfWCT�9t78JECT TOATH�ONDtTIONS SHOWN ON THE REVEHSE 61DE OF THiS FORM.
��� ;(978 486-1000
Vermont MuCual �,,,or
Vol�nteer Ineurance Agency F nw
294 GYeat Rd. 07/16/'8 12:01 Y ' +.M � 07/16f99 Y n:maM
P.O.BOX 278 �u i 12 :C1 N�
Littleton MA 01460-
PF.R OP�/1�m'6 PCSICY�;O EXTEN��VERGG!IN'ME 437VE NM�W COMPANV
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2928 Frama 20 Unit Motel lecaterl at above s
um�uo
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891 Ma�n Street
8ou}h "armou*h MA o2664 ��� � �Q
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THE COMNIONWEALTH OF MASSACHUSETTS 1
' � TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 98-63 FEE: $50.00
This is to Certify that a River Mot 1 c'
891 Ro t 8 Cnn�y�rmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is i.ssued'm c�formity with the authority granted to the Boerd of Health,by Chapter 140,Sections 32A,32B,
32C,32D a�32E as nmended,and is subject to the provisions ofthe Laws of the Commonwealth of Massachusetts relating
thereto,arai npon soch teims and conditions,and to the roles end regniations in regard to said Cabins so licensed as adopted
by the Board of Heaith,and expires December 31, 199�unless sooner suspended or revoked.
October 9 , 1998 BOARD OF HEALTH: G��n,}(e�lla�eg, ��ia[�irm/J/a)nn / /J
� �(�oan C„ Jun[livan�/KJa.//.� Vica (..�i.rman
Ko�r[� O�rowa� (,/er�
a6,a�.�a�o�G�...11�Pa�
���0' o�l,�,.
Bruce G. Murphy,MPH,RS. CH
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER 98-105 FEE: $50.00
This is to Cetify tliat_ Bass River Motel T.T ('
891 Ro te 28 on h y „na , h A
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Bass �ver Mot 1 .r.r _ p �nu pnnr
891 Rot+P�8
Soui Y *mo 1�MA
TLis permit is ganted in conformiry with Article VI of the Saaitsry Code of The Commonwealth of Massachusetts,and
expires December 31. 1998 uukss sooner suspended or tevoked.
October 9 , 1998 BOARD OF HEALTH: �t���+�ellea, l��iairm///a)nn ' /!
. �(�oan G.c�� an�an�/�Je//.� Vice l,�irma.n
- Ko�rt J. 03rown� (..(e�
as,��s�c���Pe�
� 01L(�� N
Director of H alth' ' '