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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 _i = _.�fr.,� Qw I Q�.. O✓i �� TOWN OF YARMOUTH BOARD O�'.�E�CL��'H � �`�� f�� 5� � � �� APPLICATION FOR LICENSE/PE�MIT-2009� � �� G ;� .Euu tl � * Please complete form and attach all necessary ddetiments by Dec�mber S 2008. Failure to do so will result in the return of your application pac cet. TN DEP7. NAME OF ESTABLISHMENT: $uus�de QEs�u-F TEL. # "]7S-Sl�9 LOCATIONADDRESS: Z�� 2,�_ 2g MAILING ADDRESS: w - YA-��nnv�sz!-+ vtn� o2ra73 OWNER NAME: Z��/� I-E-�xe�{-�.l�T,�n.c, TAX ID (FEIN or SSNl- �� CORRORATION NAME (IF APPLICABLE): _ �('�u.�� }�,�v�-F�.l: l N[� MANAGER'SNAME: �Ze� S(2pczC�..sl�i TEL. # 77T SC�.S MAILINGADDRESS: 22T- P�- - 't8 w. v��mTC!-� ,n�ls}- �?ro-�3 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 certificarion to this form. 1._ �inn ��-t-lk- 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cu•diopulmouary Resuscitarion(CPR). Please list these employees below and attach copies ofemployee 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. Q l 1M L l�a u � 2. 3._][�c.n�5z p�,�i�k 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food seivice 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. �i �-Ri.A�+-4 S t vtnunf-E.li.� 2. FERSON IN CHARGE: Each food establishment must have at least one Person In Chuge (PIC) on site during hours of operation. 1. FYa�I� Inl��✓e�,. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedares below and attach copies of employee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your place of business. 1. InIIG�RtJs� .p�ukl�- 2. 3.�u.ck[l i 1n.ai 4_ RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQL7RED FEE PERMIT# LICENSE REQUIRED FEE PERMIl'sl LICENSE REQUIRED FEE PERMIT ti _s&B sss cnamr �ss 1 MorEL �ss #o9-ot3 _INN 555 _CAiY� SSi Z SWII.�IL�iG POOL 58Cea. �� _LODGE S55 _TRAII,ER PARK $105 � WHIItI,pOOL 580ea. �'O CI^OO8 FOOD SERVICE: � LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMI'I# LICENS�REQUITtED FEE PERMIT# LO-100 SEArS S85 #d Q—OS7 �CONIINEN'IAL S35 9— 658 _NON-PROFIT %30 _>100 SEAI'S 5160 / COMMON VIC. 560 �� _WHOLESALE SSO RE'IAIL SERVICE: —RESID.KITCHEN 580 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQiIIRED FEE PERMIT# _<jOsq.B. S50 _>25�,OOOsq.ft.� .5225 _VENDING-FOOD�$25 QS,OOOsq.ft. S80 _FROZENDESSERT S40 ?OBACCO �55 �aizE��rcE: sio AMOUNTDUE _ $ �7S.0� `*'•"pLEASE TURr OVER At\'D CO;MPLETE OTHER SIDE OF FO&VI**^** ,,..;� � .. ADNIINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES "� NO MOTELS AND OTHER LODGING ESTABLISHIVI�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiem occupancy shail be limited to the temporazy and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety (90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opemng. Contact the Health De�artment to schedule the inspection five(�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area umii the pool has been inspected and opened. POOL R'ATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prio:to opening, ar.d 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 Yazmouth must notify the Yazmouth Health Departmem by Sling 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 Boazd ofHeahh. OUTDOOR COOKING: Outdoor cooldng,prepazarioq or display of any food product by a retail or food service establishmem is prohibited. � _ _ _ NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN _'�FI�-G�1�'I FTED-�rr��eT euur Tr n�rrnwr�&}4:N��FB�E(Sj BY DECEMBEI��§;�OL'S. _ ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR PbOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 1� �11 •J j� SIGNATURE: `��L�"� PRINT NAME&TITLE:^T7�� 5��s C��M ia.�zi�os :f �� ` ' WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY • INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI NO 26158 (800)876-2765 POLICV NO. WMZ 8003721072008 PRIOR NO. WMZ 8003721012007 ITEM 1. The Insured Travis Hospitalrty Inc.dba Bayside Resort Hotel . Mailing Address: Rt 28 West Yarmouth MA 02673 225 Main SVeet (No. 5[ree[ Town or Ciry CwMy Sfate Zip Cotle ❑ Individual ❑ Partnership � Corporation ❑ Other FEIN Other workplaces not shown above: 2. The policy period is from04l01/2008 �a 04/01/2009 12;01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state lis[ed in item 3.A. ThelimitsofourliabiliryunderPartTwoare: BoditylnjurybyAccident $ 500,000 Qachaccidenc BodilylnjurybyDisease $ 500,000 policylimit BoditylnjurybyDisease $ 500,000 eachemployee C. Other States Insurance:Coverage Replaced By EndorsemeM WC 20 03 O6A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Ra6ng plans. All information required below is subject to verificalion and change by audit. Classifications Premium Basis Rates ��e Esume[ed PerE100 Esdma[eE No. Totel Amual � Armual Remu�ra4on Remun.retlon Premium INTRA 362922 � SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 236.00 Total Estimated Annual Premium S 14,231.00 As indicated,interim adjustmerns of premium shall be made: Deposit Premium $ 3,769.00 ❑ Annually ❑ Semi Annually ❑ Quanerly � MonWly � MA Assessment Chg. $15,346.08 x 5.5000% $844.00 This policy,including all endorsements,is hereby countersigned by �\�--��-�X 02125/2008 Ailhrnk¢A SlgneWre Oa[e GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLA55 AUDIT � OFFICE OFFICE CHECK GROUP Eas[ern Insurance Group LL.0 MA 9052 6 804 0500 233 West Central Street Natick,MA 01760 WC 00 00 01 A(11-88) IxluGes wpyiighLLd material af Ns NaYa�ai Council on Cortq�ensa4on Insira�e, . usetl vrilh i1s peimission. � • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-013 FEE: 555.00 Th�s is�o Ceni£y chac Travis Hospitali(y, Inc d/b/a Bavside Resort 225 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Iltis License is issued in confomilty wi[h the authoritc granted ro Ihe Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,end is subject to the provisions of the Laa s of thz Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and ro the rules and regulations in regazd to said Motels so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner suspended or revoked. December I 1 2008 BOARD OF HEALTH: .�Re¢ft. 5�4�� ../v.� �l�CfltAf6 C��'�Q�/[-e�e�`b .`��.n.��¢�� PpIIG��,,qlCe �.�1lbY�tUIIL 'Rooms—128 ✓� �• ✓J�� '�+" Ur:n. C�x' eendacu►:, J2..N. £�eP�ec P• .`�Ea�{e° ruce G. Murph ,R.S., CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-058 FEE: S35.00 In accordanee with regulatious promulgated under authoritv uf Chapter 94, Section 30�A and Chaptec 1 I 1, Section�of the General Laws,a permit is hereby eranted to: Travis Hospitalitv Inc. 225 Route 28 West Yarmouth MA Whose place of business is: Bavside Resort Type of businesr. Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BoaRn oF HEnLiH: ,lEeBen SHaIE, JZ.N., @lEaixnecut C'Peaxfe,o .�. ,7Ce�iRen `Uice C�avcman �2a6evt s. :�3Kav�uc, C'dxxf£ Qiu�, C�'yeen&accm, J`t..AN. Ecee�re J. .`�fa��s Deczmber l l 2008 Bruce G.Murphy,MP R. .,CHO Director of Health • TOWN OF YARMOUTH BOARD OF HEALTH PERNiIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-057 FEE: 575.00 In accordance with regulations promuleared imder authority of Chaprer 94,Section 30�A and Chaprer l 11,Section 5 of the General Laws,a pern�it is bereby granted to: Travis Hospitalitv Inc. 225 Route 28 West Yarmouth MA Whose place of business is: Bavside Resort Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2009 BoaRD OF HEALTH: ,�Eeeen SllaRt, J2..N., � " Clkcu�eo .f�. 9Ce�fiPie�+c `Uice C'R�uxena�c J2a6ext s. .`.t3xaw�c, C'�ii/� Qrue C��xeee�aurn, J`t.✓V. F,�eP�jn `J'• 3Eaerl,e° December 11.2008 Bruce G. Mu�phy,MP , . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-041 FEE: S60.00 This is to Certify that Travis HospitalitX, Inc d/b/a Bayside Resort 225 Route 28, West Yarmouth, MA IS HEREBY GRAtiTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official sienatures. BOARD OF HEALTH: .7feeen SRaR,r�J2��.�.N��.., C'.Ra'vannre SE.aT�G: 36 � � ✓�� J`�a�exl 3. J�3!�eautn., C� (Irin C�'eeea6au.n, `J2.rV. Eve�n. `�• 3EcuJe,° December 1 l.?008 Bruce G. Murphy,MP , . .,CHO Director of Health • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-022 FEE: S80.00 This is�o Cenifi chat Tr vis Hos i lit In . d/b/a Ba side Resort � 225 Route 28 West Yarmout MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort - INDOOR POOL 225 Route 28 West Yarmouth MA This perntit is erantzd in conformin' �cith Article VI of the Sanitarv Code of 17ie Conunomsealth of Massachusetts,and expires Deczniber 31 2009 unless sooner suspended or reroked.� December 11 2008 BOARD OF HEALIII: ,�¢�Rft S�[((�� .JY.� �llllltttllft e�[l1�LQC� .�. �.PX �lC¢ �11ltftatt J`2aBe�tt .rl�. `�3Kotun, C�exl� �J�C�xeen�, 5t-N- ruce urp y, , Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARNiOUTH BOARD OF HEALTH PERMIT NUMBER: #09-008 FEE: S80.00 ThiS is to Cert;fi�thac Travis Hos 'ta itX Inc d/b/a Bayside Resort 225 Route 28, West Yarmouth, MA _ _ HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS �Ihis License is issued in conformiri�ciih the authonh�eranted to the Board ofHealth,bv Chaptzr 14Q Sections 51,of the General Laws,and amendmrnts thereto,and is subjeM tu the provisions ofthe La�cs of the Conunon��ealth of�(assacln�setts relating tl�ereto, and upon such ternu and conditions, and to the rules and re¢nlations in re¢ard to the cam'ing on of the ocenpation so licensed as adopted b��die Board of Health,and expires DecemUzr 31,?009 m�less sooner re��okzd. Decembzr l l 2008 BOARD OF HEALTH: .�¢e¢ft S�QPE� JZ..lv.� �• C'l£ar�ee :�. .7CeeeilEen `Uice CRaanurtan .l2o6ext s. J`3Kawn, C'�exPc Qnre Cjxeerr�acem, J`Z.✓V- £.uefr!*t `.�• .�EauJe° Bruce G. Murphy,MP , HO Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-023 FEE: 580.00 This is to Certif��tha[ T v H s i ' Inc. d/b!a B si e Resort ' 225 Route 28 West Yarmout MA '' IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At � Ba side Resort - OUTDOOR POOL 225 Route 28 West Yarmouth MA Il�is pennit is eranted in confornilN with Article VI of the Sanitarv Code of The Commonwealth of Massachttsetts, and � expires Decem�er 31.2009 miless soonet suspended or re��oked.� December 11.Z008 BOARD OF HEALTH: �S�� . �KUIUIt� � QKIL QUJft� �..lv. �. Dir ctor of Hea1tU' �, . `_�,� � � �� 'n,Sf3RNcS/DE r�°` " " TOWN OF YARMOUTH BOARD OF HEALTH ^'� ' � ��= � -I APPLICATION FOR LICENSE/PERMIT-200$,,,� l7� � z �U � �i " f),v I �, * Please complete form and attach all necessary documents by December �, 2907.; Failure to do so will result in the retum of your application packe " �'"" NAME OF ESTABLISHMENT: Fict s�ars �LQso�k TEL. # �']S SCfl(o1 LOCATION ADDRESS: 2Z,S � MAILING ADDRESS: w `�a�Q A ,.�t �,,,k cZ��3 OWNER NAME:_ TAX ID (FEIN or SSNI� CORPORATIONNAME (IF APPLICABLE): "C�u ��s l-{�sP��I.�c.� f n�L. MANAGER'SNAME: I?-o� SRocz2,,•slct � TEL. # ']��—StoL� MAILING ADDRESS: S�u.,2 POOL CERTIFICATIONS: The pool supervisor must be certiTied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. �IG1,vK�s I K-�a,� 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 beiow and attach copies ofemployee certifications to this form. The Heaith Department will not use past years' records. You must provide neK• copies and maintain a file at your place of business. �. �,�u Tl�.�,1� 2. mu��usz P��k. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-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 certification io this application. 'i'he Health Department will not use pasY years'records. You must provide new copies and maintain a 61e at your establishment. I. ��ar� sl vLi ov�G�I i 2. P�RS9N�N CI-IARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. . I. Tri��n� �I4�fDN 2. HEIMLICH CERTffICATIONS: 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 noi use past years' records. You must provide new copies aud maintain a file at your place of business. i. �Inr..N� �oi.�p ll .� 2 3- 4. RESTAURANT SEATING: TOTAL # LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PER\9I# LICENSE REQL'QtED FEE PER�i17 � LICEA'SE REQL'IItED FEE PERIIIT= _B�B S50 _CABIN S50 / M07EL S50 ��S' _� S50 _CA.'�fP � S50 2 gµT.y��G POOL S75ea. �£o9-a6� _LODGE 550 _TRAILERPARK 5100 / ��'HIRI,pOOL S75ra. �o8-O�p FOOD SERVICE: � ---- -- ._.__ . _-.. _ - --_ LICENSE REQUIRED. FEE PERMIT r� LICENSE REQLrIRED FEE PER�4I7 g LCEtiSE REQL'IRED FEE PERbiIT= �0.100SEATS S75 OS-OSI �CONTINENTAL 530 .#OA.�.j _NON-PROFIT S2i � _>100 SEATS S1i0 LCO;bL'�ION VIC. S50 #OB�6$Y _µ-HOLESALE 575 RETAIL SERVICE: —RESID.KIICHEN S75 LtCENSE REQUIItED FEE PERM17= LICENSE REQL7RED FEE PERYD7'= LICENSE REQUIRED FEE PER4DT= _<SOsq.@. S45 _>2i,000sq.ft. 5200 VENDING-FOOD S20 _Q5,000 sq.8. S75 _FROZEN DESSERT S35 _TOBACCO S50 vn,�cxavice: sto AMOUI�T DUE = S �/�30•0o •"••'PLEASE iL'R\O�'ER.i�D CO�iPLETE OTHER SIDE OF FOR�i'*•** /� . � ', ; < ADMINISTRATION ` Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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 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 t�es and Gens must be paid prior to renewal or issuance of your pemuts. PI,EASE CHECK APPROPRIATELY IF PAID: YES `� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCC[1PANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a prinapal place ofre,adence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)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. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Eaolosea Motel Census must be completed and returned w;tn r�s apPti��on. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to openu►g. Contact the Health Department to schedule the inspection Sve(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 Yarmouth must notify the Yazmouth Health Departrnent by Sling the required Temporazy 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 resuks must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemrit urnil the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking preparation,or display of any food product by a retail or food service establishment is prohibited. � NOTICE:Perntits run annually from January 1 to December 3 I. Tl'IS YOUR RESPONSIBILITY TO RET[7RN TI�COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER}3; 200?. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME?ICEME?IT. REVOVATIOVS MAY REQUIRE A SITE PLAN. DATE: II '� •0� SIGNATURE: ��' PRINT:VAME&TITLE:�ZGrRj''.?E�^�u'�., �(� �p:��o� 1 y _ _ � x- . . , WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington,Massachusetts NCCI NO 26158 (800)8762765 POLICY NO. W�8003721012007 PRIOR NO. WMZ 8003721012006 ITEM t. The insured Travis Hospitaliry Inc.dba Bayside Resort Hotel Mailing Address: Rt 28 West Yarmoulh MA 02673 225 Main Sircet (No. SbeH Tv.m o�Cily Cauny State Zip Catle ❑ Individual ❑ Partnership � Corporation ❑ Other FEIN Other workplaces not shown above: 2. The policy period is trom04/01/2007 �0 04/01/2008 12:01 a.m.standard time at ihe insured's mailing address. 3. A. Workers Compensa6on Inwrance: Part One of the pdicy applies to ihe Workers Compensation Law of the states listetl here; � MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. ThelimitsofourliabilityunderPartTwoare: BodilylnjurybyAccident $ 500,000 eachaccident BodilylnjurybyDis�se $ 500,000 policylimit BodilylnjurybyDisease $ 500,000 pa�hemployee C. Other Slates Insurance:Coverege Replaced By Endorsement WC 20 03 06A � D. This policy includes ihese endorsements and schedules: SEE SCHEDULE 4. The premium for�his policy will be de�ertnined by our Manuals o(Rules,Clas�ca6ons,Rates and Ra6ng plans. All iMormation required below is subjecl to ver�ration antl change by audit . Classifications Premium Basis Rates Cade �timated Parf100 Eslimatetl � TolalMn�al � Mnual p�� RenxmeraUon Pre�rium INTRA 362922 SEE EXT NSION OF INFOR TION PAGE Minimum premium$ 231.00 Total Estimated Mnual Premium $ 75,175.00 As indicated,interim adjustmenis of premium shall be made: Deposil Premium $ 3,968.00 � ❑ Annually ❑ Semi Annually ❑ Quarterly � Monthiy MA Assessmenf Chg. $76,610.22x 4.1920% $696.00 This policy,inGuding all endorsemenis,is hereby countersigned by ��`-�XJ!q 02/13I2007 Aulhaize0 SlgiaWre �'dle GOV GOV KIND PLACING CLAIM NAME SAFEfY � STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Eastem Insurance Group LLC MA 9052 8 804 0500 233 West Central Sheet WC 00 00 01 A(N-88) Natick,MA 01760 . Inclutles copyriy�letl ma[erial d tlre Netional Coundl an Caiyiensalion Msurance, � usetl V�i�i5 pelircssiM. � ' � TFIE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOVI'H BOARD OF HEALTH PERMIT NtJMBER: #OS-035 FEE: $50.00 This is to Certify chat Travis Ho�pitality, Inc d/b/a Bayside Resort 225 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO QPERATE MOTELS This License is issued in conformity with[he authority granted to the Boazd ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating t6ereto,and upon such terms and condiiions,and to the mles and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2008 ualess sooner suspended or revoked December 20.2007 BOARD OF HEALTH: .�F¢e¢ft SRIII�� J�.JV y �ai�lntalt � ��iU�L�Y��.¢��d n.��.d�l�Ppll��,,QlC¢ �[�lfttlY/l •Rooms-12S . ✓WVGW J.✓J�t� �^.�'�". Usec C�'xeenBau�n., fR..IV. Bmce G.M hy ,R.S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-054 FEE: 50.00 T7us is to Certify that Travis Hos�'talitv Inc d/b/a Bavside Resort 225 Route 28 West Yarmouth, MA IS HEREBY GRAN"1"ED A COMNION VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place only and expires December thirty-fust 2008 unless sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto afFixed their official signatures. BOARD OF HEALTH: 3fePee.S�ali, `Jl..N., C'Raa�eteaa SEAI'ING: 36 � � `�'� �� J`2a6ext 3. `�xo[u�t, Cpai[Pc QEur.(�ceen6acun, J2..N. December 20_2007 Bmce G.Mwphy, , .5.,CHO Director of Health ' � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMTT NUMBER: #08-081 FEE: $75.00 In accordance with re�ations promulgated under au[horily of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the eneral Laws,a permit is heteby granted to: Travis Hospitalitv Inc. 225 Route 28 West Yarmouth, MA Whose place of business is: Bavside Resort Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: .`�feeett S�aPt, J�Z..N., �taixmart � �HLY�¢6 `.�E..�K.C�.I��iG �[C¢�Q(XfHaK �s.f,S�tatutt,`�..tV. , ne�em�r zo.zoo� Bruce G.M y, H,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISI�4ENT PERNIIT NUMBER: #08-082 FEE: 75.00 In accordance witL regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the L;eoeral Laws,a permit is hereby ganted to: Travis Hospitaliry Inc. 225 Route 28 West Yarmouth MA Whose place of business is: Bavside Reson Type of business: Continental Breal�'ast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BonRD oF xEALTII: 3Ee�t S�aR�, JZ.JV., C.�ab�n+,cuz C'!lu�x�ee .�. .7Ce�iR�ex ?Iice C'�ai�rnan ✓�&ext 3. :�l3Kown,e�exk Qruuc�'tee�tBaurrc, J2..N. December 20.2007 �"- Bcuce G.Murphy, H,RS.,CHO Director of Health ' ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-061 FEE: $75.00 This is co Cenify that Travis Hos itali Inc. d/b/a Ba side Resort 225 Route 28 West Yarmou MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At Bavside Resort - INDOOR POOL _ 225 Route 28 West Yarmouth MA This peRnit is granted in conformity with Article VI of the Sanitary Code of i'tre Commonwealth of Massachusetts,and expires December 31 2008 uuless sooner suspended or revoked. December 20.2007 BOARD OF HEALTH: .`�¢PGt S�l� �..lV.� ��QU��p/tlUt �[�P.6 .�. .7�C�f�RAG �lC¢ �Q.[�lfitQ�fl `2ade�lt 3. `.,l3Kacuri, C'�es�Pi � Bruce .Murp y , . , Director of Hea THE CONIMONWEALTH OF MASSACHUSETTS TOR'N OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-026 FEE: $75.00 This is co Cemfy thac Travis Ho�gitality; Inc d/b/a B�side Resort 225 Route 28,West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authoriry granted to the Board of Health,by Chapter 140, Secrions 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto, and upon such teims and conditions, and to the rules and regulations in regard to the cazrying on of the occupation so licensed as adopted by the Board of Heakh,and expires December 31,2008 unless sooner revoked. ne��a�ao.Zoo� soAxn oF�.ai,�: .�EeYe,n SR�aR., J2N., C�aix�nan C'f�axlea .�.:ICe�P.iReac `lJice C�aixrnan � .t `�Kows,J2.rV. , Bruce G. Murphy, , .5.,CHO D'uector of Health r ' �- THE COMMONWEALTH OF MAS5ACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-062 FEE: $75.00 This is co Cenify thac Travis Hos itali Inc. d/b/a Ba side Resort 225 Route 28 West Yarmout . MA IS HEREBY GRANTED A PERNIIT To Operate a Pubfic, Semi-Public Swimming or W�ding Pool At Bavside Resort - OUTDOOR POOL 225 Route 28 West Yarmouth MA This petmit is granted in wnformity with Article VI ofthe Sanitary Code of The Commonwealth of Massachusetts,and expires December 31,2008 unless sooner suspended or revoked. December 20_2007 BOARD OF HEALITI: �¢�.Pft S�(l�� ..lv.� �IQIXttUqt �,�tIGII�¢e .�. ��l�Pfl �lC¢�IxfrilYR (laut .} ��,J2..Ar. , ruce �P Y, , • , D'uector of Healt " _ _ ' _ . . 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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts . (800)876-2765 NCCI NO 26158 POLICY NO. WMZ 8003727012006 , PRIOR NO. WMZ 8003721012005 ITEM 1. The Insured Travis Hospifality Inc.dba Bayside Resort Hotel . Mailing Address: Rt 28 Wes[Yartnouth. - MA 02673 225 Main Street (No. Streei Tovm ar Ciry Counry S1ate Lp Code ❑ Individual ❑ Partnership � Corpora6on ❑ Other FEIN Other workplaces not shown above: 2. The policy period is from�012006 �0 04/012007 � �p;p� a.m.standard time at the insured's mailing address. . 3. A. Workers Compensation insurance: Part One of ihe policy applies W the Workers Compensation Law of ihe states listed here; MA B. Employers Liabiliry Insurance: Part Two of ihe policy applies to work in each stata listed in item 3.A. ThelimitsofourliabilityunderPartTwoa2: BodilylnjurybyAcddent$ 500,000 eachacadent BodilylnjurybyDisease S 500,000 policylimit BodilylnjurybyDisease $ 500,000 eachemployee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy indudes these endorsemenGs and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Ra6ng plans. All information required below is subjecl to verification and change by audit., Classifications Premium Basis Rates � ��a Estimatetl Per5100 Esbmaletl Na ToblMnual o/ Mnual Remurieratlon Remuneratim Premium INTRtI 362922 �� SEE EXT NSION OF INFOR TION PAGE Minimum premium$ 231.00 Total Estimated Mnual Premium $ 18,576.00 As indicated,inlerim adjustments ot premium shall be made: Deposit Premium $ 4,856.00 ❑ nnnua��y ❑ Semi nnnua��y ❑ C]uartedy � Monthly _ MA Assessment Chg. $19,23825x 4.4000% $846.00 This policy,including all erMorsements,is hereby countersigned by ��'��-(�Ky OZ/13/2006 AUMaizetl SignaWra Dale GOV GOV KIND PLACING CLAIM NAME SAFEN STATE CLASS AUDIT OFFICE OPFICE CHECK GROUP Eastem Insurance Group LLC � MA 9052 8 804 0500 233 West Central Sheet � WC 00 00 01 A(1 L88) Natick,MA 01760 � Includes copyrighted matenal N the National Courwti rn Compenution Imurznce, usetl wiN ils Pe�uion. 1 ` THE COMMONWEALI'H OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-012 FEE: $50.00 This is tn Certify that Travis Hospit� Inc. d/b/a Bavside Resort Aotel 225 Route 28. West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS ' This License is issued in conformity with the authority granted to the Bo�d ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to ihe provisions ofthe Laws of the Commonwealth ofMassachusetts relating thereto,and upon such teims and conditions,and to the niles and regulations in regazd to said Motels so liceused as adapted by the Board of Health,and expires December 31,2007 untess sooner suspended or revoked. Januazy 30.2007 BOARD OF IIEALIT I: B �l. /��5., ' ��,�`Sl�, rv., v;�el�,.,�.z R�t 4.B� �k P�M�ss� � , R.N. Bruce G. Miaphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMTI'TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-044 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of[he General Laws,a pe�mit is hereby granted to: Travis Hospitality, Inc., 225 Route 28, West Yarmouth, MA Whose place of business is: Bayside Resort Hotel Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut e�cpires: December 31. 2007 BoaRD oF�ni.�: B E�c `.h. , i19.`.h., ' �"s� �`., v�e� �M� +�� a.n�. January 30,2007 Bruce G. Murphy H,RS.,CHO Director of Heal r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-031 FEE: 50.00 This is to Certify that Travis Hospitalitv Inc d/b!a Bavside Resort Hotel 225 Route 28, West Yazmouth, MA IS HF,RF.BY GRAN7'ID A C011�IMON VICT[JALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This Gcense is issued in wnformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B� 'r�aNrs+c `.15. ��N.$., G�/r�i�wc sEnTTt�rcr. 51 �c �raliy ./�. ice � Rode�it 4. B� � n�� q a.�v January30.2007 Bruce G.Murphy, RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-045 FEE: $75.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter I 1 l,Sec[ion 5 of the�eral Laws,a peimit is hereby ganted to: _ Travis Hospitalitv, Inc., 225 Route 28 West Yarmouth, MA Whose place of business is: Bayside Resort Hotel Type of business: Continental Breal�ast To operate a food estaUlishment in: Town of Yazmouth Pernut eacpires: December 31. 2007 BOARD oF HEALTH: B $. M.�S., ' ��s`�. ��e� a�� e�, e� P�6 M�# R.�.��j�..d4.�.,z, R.N. Januazy 30.2007 Bruce G. Murphy, �IPH .,GHO I3irector of Health ( THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUI'H BOARD OF HEALTH PERMIT NUMBER: #07-021 F'EE: $75.00 This;s to Certify that Trauis Hos itali Inc. d/b/a Ba side Resort Hotel 225 Route 28, West Yarmout MA IS HEREBY GRAN'FED A PERMIT � To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort Hotel - OUTDOOR POOL � 225 Route 28 West Yarmouth, MA This pem�it is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and eacpires December 31_2007 unless sooner suspended or revoked. Jan 30.2007 BOARD OF I-IEAI.TH: B �5. ��5. ' � e��e&�eQ�iali� �., vice e� /�afi�ic�/l�a`�a+uiw� Cf R � Bruce .Mucph ,R '�Z'H� Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #Q7-020 FEE: $75.00 This is to Certify that Travis Hos itali Inc. d/b/a Ba side Resort Hotel 225 Route 28 West Yazmout MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort Hotel -IIVDOOR POOL 225 Route 28 West Yannouth, MA This Pe�mit isgranted in conforwity with prticle VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires IJecember 31.2007 unless sooner suspended or revoked. January 30.2007 BOARD OF IIEAI,TH: B �. Qpq�, /�$., ' e�e��e��rc�s, Q./V., ?%ics G��rai�t�a�n Rode�.t�. ��iouur, (�.rr6 P�M�S�tY �4 gg o«, R.N. n;r�ector of H�e.al�th� , , i . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-006 FEE: $75.00 't'his is to Certify that Travis Hospitality Inc d/b/a Bavside Resort Hotel 225 Route 28 West Yarmouth MA HAS BEEN GRAN'TED A LICENSE TO ENGAGE IN Tf�BUSINESS OR PRACTICE OF - GIVING OF VAFOR BATHS This License is issued in confomuty with the authority gi�anted to the Board ofHeakh,by Chapter 140,Sections 51,of the General Laws,and amendmeats tl�eteto,and is subject to ihe provisions of the Laws of the CommonweakhofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the cazrying on of the occupation so licensed es adopted by the Board of Health,and e�ires DecemUer 31,2007 unless sooner revoked. January 30.2007 BOARD OF HEALTH: B �i�c�}. (fp3c�p�y I��1., e�iaiR�rwc � S!� lt.�v., v� e� R�t 4. B� � P�M� , i ' Bruce G. Murphy ,RS.,CHO Director of Heal i . � ; . cW� 2�. a3 .oi of=''^R TOWN OF YARMOUTH BOAIiD OF HEALT�� ' ° �r ' o ! -�y APPLICATION FOR LICEIVSE/PERMIT-2006'� D E C 0 7 2005 r , .s , ...- : a.�. �"y * Please complete form and attach all nec�ssttry d`ocuments by D 1 pp5� Failure to do so will result in the return ofyour application p AL H UtPT. NAME OF ESTABLISfIMENT: �Gt 5 E ��v�� TEL. # �S �'`I LOCATION ADDRESS: ZZ �L��E `�C MAILING ADDRESS: v�r . �f 2v�^ Q1Jr o71c7 OWNER NAME: Ct�. I uu� C� �. TAX ID(FEIN or SSN�� CORPORATION NAME (IF APPLIC^AB_�): MANAGER'S NAME: I� �ILUCZ�VlS C-1 TEL. # `I7 S-SLoCtS MAII.,ING ADDRESS: S k w�P POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated PAoI Qgeratoc(s�and.attacha copy of the certification to this form. L �GtIM�s �(IG�c.t.� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Departmeut will not use past years' records. You must provide new copies and maintain a file at your place of business. �. � ��,�s f 1��«l� . 2. ar�� lk�k��_� 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one fiall-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establistunents, 105 CMR 590.000. Please attach copies of certification to this application. The Heelth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. ��r�ra > i ln� G�� 1 2. PE1iSON IN CHARGE: _ _ _ _ _ _- _ _ Each food establistunent must haue at least one Person In Chazge(PIC) on site during hours of operation. 1. �� '4`L�c.�t�.-.S�i 2. HEIlbg;�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-choicmg procedures below and attae}i eopies of employee certiScations 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. �f�t� /�t1TY�in _2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMI1'# �B&B $50 CABIN $50 �MOTEL �50 �'Ob-Od u�rri aso _cnn� aso z SWIIvIIvIQQG POOL$75ea. ��j�j� LODGE $50 _TRAII,ERPARK $50 � I WIIIRI.�OL $75ea. �'OG�O07 FOOD SERVICE: . � LICINSE REQiJIRF.D FEE PERMIT# � LICENSE REQiJIItED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# � 0-100SEATS $75 }�'�&�y� � CONTININI'AL S30 #ob.a�fG NON-PROFIT $25 � >700 SEATS 5150 �COMMON VIC. E50 �'OG-439 _WHOLESALE S75 RETAIL SERV[CE: LICENSE REQUIItED FEE PERM('1'# LICINSE REQi7IItED FEE PERMIT q LICENSE REQiJIItED FEE PERMIT# d0 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 Q5,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO S25 NAMECHANGE: S10 AMOUNTDUE _ $ '�aO.oO � "•"""pLEASE TURN OVER AND WMPLETE OTHER 5IDE OF FORM•••"" .. _ - . �, .._. __ ,, - s ` , ADD�NISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any licease or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A1"1'ACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: � YES ✓ NO NOTICE:Permits iun a�u�uaily from January 1 to December 31. iT IS YOUR RESPONSIBIL.ITY TO RETURN 'Tf� 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 OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMEN'I', MO'TEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. 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 opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 under000ked animal produds aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen$esse�musf�ie ces�ed on a m�nttityi�asisi�y a Stat�c�e[ified tab: `Tesrresults must b�s�nt t6 the Heahh Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. DATE: �� . �� . �_� SIGNATURE: PRINT NAME&TTTLE: t�i ,S(�vGZCV`5L�� G�WI o9nsios WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY �� INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company � Burlington, Massachusetts � (800) 876-2765 NCCIN026158 POLICY NO. WMZ 8003721012005 � PRIOR NO. WMZ 8003721012004 ITEM . 1. The Insured Travis Hospitality Inc.tlba Bayside Resort Hotel Mailing Address: Rt 28 West YarmouN MA 02673 225 Main Street (Nn Slreet TownwCity Cwnry StateZ�pCotle ❑ Individual ❑ Partnership � Corporation ❑ Other FEIN � Other workplaces not shown above: �� 2. The policy period is from04/Ot/2005 �p 04/01/2006 12;01 a.m.standard time at the insured's mailing add�ess. 3. A. Workers Compensation Insurance: Part One of the policy applies to lhe Workers Compensation Law of Ihe states lisfed here; MA �. B. Employers Liabiliry Insurance: Part Two ot the policy applies to work in each slate listed in item 3.A. ThelimitsofourliabilityunderPartTwoare: BodilylnjurybyAccidenl$ 500,000 eachaccident . BodilylnjurybyDisease $ 500,000 pplicylimit BodilylnjurybyDisease $ 500,000 eachemployee ' Q O[her States Insurance:See Endorsement WC 20 03 O6 A D. This policy includes these entlorsements antl schetlules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. � All information required below is subjecl to verification and change by audit. Classifications Premium Basis Rates �� Estimatetl Per$100 Estlmatetl I Npe TotalMnual of Mnual �. Remu�ratlon RemuneraGon Premium � INTRA 362922 I � SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 225.00 Total Estimafed Annual Premium $ 27,849.00 � As indicated,interim adjustments of premium shall be made: Deposit Premium $ 5,738.00 ❑ Annually ❑ Semi Annually � Quarterly ❑ Monthly MA Assessment Chg. $22,461.08x 4.9000% $1,10t.00 This policy,including all entlorsements,is hereby countersignetl by s��s3" 02J08/2005 Authonzetl Signatum Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Eastem Insurance Group LLC MA 9052 14 804 0500 233 West Central Stree[ WC 00 00 01 A(i t-88) Na[ick,MA OI760 InGutles wpyrightetl matenal of t�e National Council on Compensatlon Insurance, usetl wit�its permission. 1`HE COMMONWEAL`I`H OF MASSACH[JSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMB�� #D5-Q09_ __ ____ FEE: $59.-QQ- ___ _ _ _ This is to Certify t},at Travis Hospitality Inc d/b/a Bavside Resort 225 Route 28. West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS , This License is issued in confoimity with the authority granted to the Board of Heakh,by Chapter 140,Sections 32A,32B, �, 32C,32D and 32E as amended,and is subjec[to the provisions ofthe Laws ofthe Commonwealth of Mncee�l,»ce+±�re]ating tl�ereto,and upon such temis and conditions,and tn the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and er�ires December 31,2006 unless sooner suspended or revoked. n�b�a.zoos soa�oF�ni.�: B.�a«...c 95. (�'a3do.�M.$. • P�.af� v:�e� Rodp�rt� 8�,. Gl� � Sl,�k, R.N. ��, R.N. ] Bruce G. Miaphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�NT PERNIIT NUMBER: #06-045 FEE: $75.00 In accordance with regulations promulgated�mder authoriry of Chapter 94,Section 305A mmd Chapter 111,Section 5 ofthe General Laws,a pemrit is hereby granted to: Travis Hospitality, Inc., 225 Route 28 West Yarmouth, MA Whose place of business is: Bayside Resort Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Pemvt eacpires: December 31 2006 BoaRD oF HEALTH: l3e�c�wru�c $. (�'a�o.s, M.$. ' ��.H� v:�e� e� Sl�, R.N.� �4.��j�6�.,�, R.N. December 8_2005 x Bruce G. Miuphy, >I� S CHO � �3;� Dqector of Health � � M1 Ly . '4.. �.' a � �iu��. �Y� . <� „ r� � _ � �; _.v . ; ' , . : , � . � ' .. . . . �. . � ..�.._ , _ .:. .�r�_,..¢'- . � :� . _ . _ ._.:.. .. �_ , . �,_ � ._ _. ,r _ ��- . . , � , . ,�,, , ' .. ., _' __ TOWN OF YARMOUTH BOARD OF HEAI.TH PERMIT TO OPERATE A FOOD ESTABLISHMENT __ ____ _—.___. . _- _ _ PERMIT NLIMBER: #06-046 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Travis Hospitality, Inc., 225 Route 28, West Yarmouth, MA Whose place of business is: —_Bavside Resort Type of business: Continental Breakfast To operate a food establishmem in: Town of Yazmouth Pernut expires: December 31_ 2006 BOARD oF HFAI,TH: Be�a.�ri.c `15. (fo+u/o�r, /17`.b. ' p�af�� v�e�w Rod�t� B�, � � �, R.N. ��j"��+x, R.N. D�t�a.zoos Bruce G.M hy, H S.,CHO Director of Health THE CObIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-039 FEE: $50.00 This is to Certify that Travis Hospit� Inc d/b/a B�yside Resort 225 Route 28, West Yarmouth, MA IS HII�EBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only ande�cpires December thirty-first 2006 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing ofcommon victuallers: This license is issued in conformity wi�t the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B $. Cjauloa,M.`.b., G�� SEATTNG 5� � p i�M�� v�e� a�t�. a� e!� � �l�, R.A! �J� �j�, R.N. December 8 2005 • � �vice G.Muiph T S�CHO '�+ >, or of Heafi� ., : ,.. . . . _� .r , _ � .-. . _. , g . �r �. . , ; . _N .:�..� ., � . . .._._ ..� T-�-- - ' - ..-. . ___ . . . . . . ,:� . „ . .. . . _.�. . ' . �.., .. .. h� ". � .. - . • f� :e,. . .5y �, ^ � �., ` THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH _�EI�11�II-T-NUMBER: #06-019 _ _ _ _ _ __—__— �FE:-$75.00 _ — . _ This is to Certify that Trauis Hos itali Inc. d/b/a Ba side Resort 225 Route 28, West Yarmout MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort - INDOOR POOL 225 Route 28 West Yarmouth. MA This pemut is�n ted in conformity with Article VI of the S�itary Code of The Commonwealth of Massachusetts,and eacpires December 31 2006 unless sooner suspended or revoked. n�n�a zoos soaxD oF�u.�: B��. lfoado.�M.�. • o�� v�ef� a�t�a.� e� � � R.N. a.�g a.�v. � , Director of HealUj THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-020 FEE: $75.00 This is to Certify that Travis Hos itali Inc. d/b/a Ba side Resort 225 Route 28 West Yarmou MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort -OUTDOOR POOL 225 Route 28 ___ _ West Yarmettth�3�4 __ �___ _ . This pemut is granted in conformity with ARicle VI of the Sanitary Code of The Commonwealth of Massachusetts,and eacpires December 31.2006 unless sooner suspeuded or revoked. D��s.Zoos sonx�oF�.�rx: B��. �j�do,�M.�'i, • o�M��u, v�ef� R�t 4.B� �1�.,& ��l�k, R.NR.N. ruce M y, . H y, , I?irector of Hea� � , � � , � ,, - '. ,. � _ r� t � � r�.: . . _ w. � r � . ; �; .. _�. _ z_ ; .__:__ . <,. -- , .. � ,: , . ,�, — , _ , � �- .-..5 . __ - _ =�s --,_ , c�• -, -t' ._— _ . . .. . � . THE CONIl1-IOIV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH _ __ PEItlkli'�-N�I11rffiEIL:—#96=OOZ ____ FE&:-$'�5-0�_ _—__ Tlils is w Ce�tify that Travis H�cpitali Inc d/b/a Bavside Resort 225 Route 28 West Yarmout MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS Tfris License is issued in confoimity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of ihe Genetal Laws,and mmendments thereto,and is subject to the provisions of the Laws of the Commonwealthof'Massachusetts relating thereto,and upon such tecros and conditions,and to the niles aad regulations in regard to the cazrying on of the occupation so]icensed as adopted by ihe Board of Health,and expues December 31,2006 unless sooner revoked. 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WMZ 8003721012004 PRIOR NO. WMZ 8003721072003 ITEM 1. The Insured 7ravis Hospitality Inc.dba Bayside Resort Holel Mailing Address: R�28 West Yarmoulh MA 02673 225 Main S�reet (No. Slreet Twm or Ciry Counly State Zip Cotle ❑ Individual ❑ Parinership � Corporation ❑ Other FEIN Other workplaces nol shown above: 2. The policy periotl is from��01/2004 �o 04/Ot/2005 72:01 a.m.slandard lime al lhe insured's mailing address. 3. A. Workers Compensation Insurance: Part One of ihe policy applies to the Workers Compensation Law of the slates listed here; MA B. Employers Liabilily Insurance: Part Two ot the policy applies to work in each s�ate listed in item 3.A. ThelimilsofourliabilityunderParlTwoare: BodilylnjurybyAccident $ 500,000 yachaccident BodilylnjurybyDisease $ 500,000 policylimil BodilylnjurybyDisease $ 500,000 eachemployee C. O�her S[ates Insurance:See Endorsement WC 20 03 OB A D. This policy includes lhese endorsemenls and schedules: SEE SCHEDULE 4. The premium for lhis policy wiil be de�ermined by our Manuals o(Rules,Classifica�ions,Rates and Raling plans. All informalion required below is subjecl�o verificalion and change by audi�. Classifica�ions Premium Basis Rales Cotle Es�imaled Per$1W Estimated No. TOIaI Mrmal � Mnoal Remunera6on Remuneration P�emiom INTRA 362922 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 225.00 Total Es�imaled Annual Premium $ 13,559.00 As indicated,interim adjuslmenls o(premium shall be made: �eposit Premium $ 3,527.00 ❑ Annually ❑ Semi Annually � Quarterly ❑ Monthly MA Assessmenl Chg. � 514,873.46x 3.7000% $550.00 This policy,including ali endorsemen�s,is hereby countersigned by 02/21/2004 ` Iw�honzed SignaNre Dale GOV GOV KIND PLACING CLAIM NAME SAfETY STA7E CLASS AUDIT OFFICE OFFICE CHECK GROUP Eastem Insurance Group LLC MA 9052 14 804 0500 233 West Cenhal Slreet WC 00 00 01 A(71-88) Natick,MA 01760 Iricludes copyn9��a�he Nalional Cour�cil on Compenution Msu�arica, � usetl wil�ils permissian. THE CONIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-016 FEE: $50.00 This is to Certify that Travis Hospitality, Inc. d!b/a Bayside Resort 225 Route 28, West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS TLis License is issued in conformity with the authority ganted to the Board ofHealth,by Chapter 140,Secrions 32A,32B, 32C,32D and 32E as am�ded,and is subject to the provisions of the Laws ofthe Commonwealth ofMassac]msdtsielaling theceto,and upon such terms and conditions,and to the niles and regnlations in regazd to said Motels so licensed as adopted by the Board of Healtb,and eacpires December 31,2005 unless soona saspended or revoked. Januazy ao_aoos Bo.4itn oF HEnI.TH: Bs.,yr.�rri.��1. y'o�,dois, M.�f. � n�� v�ef.� a�t�. a� et� ��l�. R.NR.N. ruce G. Murphy, S.,CHO Director of Healih TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERM[T NUMBER: #OS-063 FEE: 75.00 In accordance with re�ons promulgated under authority of Chapter 94,Section 305A and Chapta 11 l,Section 5 of the Laws,a peim�t is hereby ganted to: Travis Hospitality, Inc., 225 Route 28, West Yarmouth,MA Whose place of business is: Bavside Resort Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 3 L 2005 BOARD OF HEALTH: Berrfa�c$. Cjo�id.orq�1.`.b. ' �� v:�ef� ��e� a.�.�r�, a.�r. .r�,�y zo.zoos Bnuz G. Murphy,T H,/R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-064 FEE: $30.00 In accordance with reaulations promulga[ed under authority of Chapter 94,Section 305A a�Chapter 111,Section 5 of the�iene.ral Laws,a Permit is hereby granted to: Travis Aospitality, Inc., 225 Route 28, West Yarmouth,MA Whose place of business is: ___Ba�side Resort Type of business: Continentai Breal�ast To operate a food establishment in: Town of Yacmouth Pe[mit�pires: December 31 2004 BonRD oF I IEALTH: Be�sjw�c$. �M$. �.�t�� v�ef,� a�,r� a� e� �� a.n�. �� R.N. January 20_2005 Bmce G. urphy, , S.,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-047 FEE: $50.00 This is to Certify that Travis Hos}�i�_Inc. d/b/a Bavside Resort 225 Route 28, West Yarmouth, MA IS I IEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazrnouth and at that place only and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomvty with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B `�!. �'o3c�wc, M.`.15., elrai�uicar� sEn�rua� 51 P��`/11 v:ce elrai�t�a�C Rod�at4. B�e�ub a�l� Sl�, R.N. a.� q ��.� a.n�. J�,�y Zo.Zoos Bruce G. Mutphy, S.,CHO Director of Health • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiJMBER: #OS-028 FEE: $75.00 This is to certify tnat Travis Hos itali In . d/b/a Ba side Re rt 225 Route 28, West Yarmou MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort -INDOOR POOL 225 Route 28 West Yarmouth, MA This permit isgranted in conformity with Article VI of the S�itary Cale of The Cammrnnvealth of Massachusetts,and expires December 31 2005 unless sooner snspended or revoked. .r�a,�zo.2oos Bon�oF i�ni.Tx: B�95. lfaulwj, �19.95. ' n��w�� v�e� a�s�.�.�, e� � a.n�. A,�.� �j R.N. ruce . urn , , Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-027 FEE: $75.00 Th;��to Ce�tity that Trauis Hos itali Inc. d/b/a Ba side Resort 225 Route 28, West Yarmou MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort -OUTDOOR POOL 225 Route 28 West Yarmouth, MA This permit is�n ted in confoimity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and eacpires December 31 2005 uuless sooner suspended or revoked .r��,y ao.zoos soa�oF�.�: B�$. l'j�do.�,M.�S. ' p�tif� v�e� Ro6e�rt 4. B�«w., G1�.4 Q��!� R.NR.N. ruce .M , H Director of Healtli , THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT N[JMBER: #OS-013 FEE: $75.00 This is to Certify that Trauis Hospitality Ina d/b/a Bavside Resort 225 Route 28, West Yazmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN Tf�BUSINESS OR PRACTICE OF , - GIVING OF VAPOR BATHS This License is issued in conformity with the suthority granted to the Boazd of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the I.aws of tLe CommonwealthofMassacUusettti relating thereto,and upon such tetms and conditions,and to the rules and regulations in regazd to the canying on of the occ;upation so liceozed as adopted by the Boazd of Health,and eacpires December 31,2005 unless sooner revoked. .rffi�Zo.2oos son�oF�u.�: B..�.��. lfo3do.�M.2. � p��f� v:�e� R�t 4. B� L/�6 d� �k�l�, R.N. R.� R.N. Bruce G.Murphy,MP .,CHO Director of Heakh MrtQ ,-� . ��.YA�'�o TOWN OF YARMOUTH � '� ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 H MFTTMCMEES � �^�,,,a'��a,�*^�d Telephone (508) 398-2231, Ext. 241 — Fax (508) 760-3472 B O A R D O F H E A L T H �, ,� --_",_.__.� To: Yarmouth Board of Health Permit Holders :� �l [i��''�5 From David D. Flaherty Jr., RS. ;1D r HEALTH UEP�(. Heahh Inspector � Town of Yarmouth Re: Federal Ta�c ID Number Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishmem's Federal Employer lde�ification Number(FEIIV)otherwise imown as your"T�ID Number". This is pwely for adminish�ative purposes only. So� busi�sses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishmern, be assured that we will not allow this information to be public record Please fill out the fields below and return this letter to Yarmouth Health Departme� 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding tUis matter, please do not hesitate to cal!. The o�ce hours are Menday tc Frida�, E:30 a.m. to 4:30 p.m The telepho� number is(508) 398-2231,ext. 241. i Establishment: I�ct�d S ��G iG£�'v�l FEIN or SSN: � Location Address: Z7,� ��'[� 7� Signature: I�' _ � Print: �1� SfZ��-2�n1 S lc-\ Titie: -1 �l ;'� � Prin[ed on ! Recycled � S Pacer � � ��. .� �rwrWNOd d0 3UIS N3H.L0 3.L8'IdWOJ aNtl N'3R0 NNfiJ.3Stl37drrrr• 00� o£}� s = �na sunowd o�s �a SZ3 O��N90.L S£3 .LN:iSSBa N3'LON� SLS '8'�1H10`SZ> OZ$ QOOd-�JM�aNBA OOZ$ 'U'�000'SZ< S4S '8'�pS> N.LIYVN3d 33d 48NIf1d�13SN8�11 N,LIWN3d 39d 48NIf1U3�13SN3J1'I #llWb9d 333 Q3211(1d�13SP1H�I1 .� p , �y , SL$ 3'IVS3'IOHM � -�0. 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NM1Z 8003721012003 PRIOR NO. � WMZ 8003721012002 � ITEM i. The Insured 7ravis Hospitality Inc,dba Bayside Resori Hotel Mailing Address: Rt 28 West Yartnouth MA 02673 225 Main Street (No. 51reH Twvn w Cily Coonty S1ate 2p Code ❑ Individual ❑ Partnership � Corporation ❑ Oiher FEIN Other workplaces not sFrown above: 2. The policy period is from��01/2003 �0 04l01/2004 12:01 a.m.standard time al the insured's mailing address. 3. A. Workers Compensation Insurance: Part One ot the policy applies to the Workers Compensation Law of lhe states listed here; MA B. Employers liability Insurance: Part Two of the policy applfes to work in each sNate lisled in item 3.A. The limi[s of our liability under Part Two are: Bodily Injury by Accident $- 500,000 each accidenl BodilylnjurybyDisease $ 500,00o pplicylimit BodilylnjurybyDisease $ 500,000 eachemployee C. Other SWtes Insurance: See Endorsement WC 20 03 O6 A � D. This policy includes ihese endorsements and schedules: SEE SCHEDULE 4. The premium for tliis policy will be determined by our Manuals of Rules,Classifications,Rales and Rating plans. All information required bebw is subject M verificaHon and change by audit. Classifications Premium Basis Rates �8 EstimaleC P�5100 Estimefetl Totai Annuel � Annual NO' Remuneration Rem�neraHon Pr¢mium INTRA 362922 SEE EXT NSION OF INFOR TION PAGE Minimum premium$ 223.00 Total Estimated Annual Premium $ 12,012.00 As indicated,inlerim adjustments of premlum shall be made: Deposit Premium $ 3,152.00 l ❑ nnnuany ❑ Semi Annually � Quartedy ❑ Monihly � MA Assessmenl Chg. . $13,272.14 x 4.5000°/ $597.00 This policy,including all endorsemenis,is hereby countersigned by 02I08/2003 � -� Authorized Slgnelure Date GOV GOV KIND PLACING CLAIM NAME SAFETY � STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Cadin Insurance Agency � MA 9052 14 804 0500 233 West Central Street WC 000001 A(11-88) Natick,MA 01760 � IncluAes copytlghletl metenel oi 1�e National Councii an CanPensalion Insurance, used wilh Ns permisSion. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-017 FEE: $50.00 This is to Certify that Travis HosQit�y, Inc d�/a Bayside Resort Hotel 225 Route 28, West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Tlus License is issued in confoimity with the authority granted to the Boazd ofHealth,by Chapter 140,Sectio�s 32A,32B, 32C,32D and 32E as amendetl,and is subject to the provisions of the Laws of the Commonwealth ofMaSsachusetts relating there[o,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2004 unless sooner s�spended or revoked .r�,�y z2.Zooa son�oF��.�: B�a«u.s�. �., M.2. . p�M�� v� ef.�,� �4S.�B�lti.�R ".N� 8ruce G. Miuphy, H S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMI'P TO OPERATE A FOOD ESTABLLSHMENT PERMIT NiJMBER: #04-074 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 44,Section 305A and Chapter 111,Section 5 of the General Laws,a permtt is hereby ganted to: Trauis Hospitalitv Inc. 225 Route 28 West Yarmouth, MA Whose place of business is: Bayside Resort Hotel Type ofbusiness: Food Service To operate a food establislunent in: Town of Yarmouth Permit expires: December 31. 2004 BOARD oF HEALTH: Bes�ja�i+c `.b. y'mtdorc, /�$. ' p�M��, v� e� ��a.ro� J�„�v zz.zooa Bruce G.Murphy, H, .,CHO . Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-075 FEE: $30.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chaptet I I 1,Section 5 of the eral Laws,a peimrt is hereby granied to: Travis Hospitalitv Inc. 225 Route 28 West Yarmouth, MA Whose place of business is: Ba;eide Re�rt Hotel Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Peimit elipires: December 31. 2004 soaRD oF i1F'aLT[-i: Be�cj�+»s,a 2. (�'o3do.s, �1.�. 1: p�tif� v:� e�� Red�t 61. B�, � � Sl�k, R.N. .r�„u�zz.aooa � Bruce G.Murphy,MP , ,CHO Director of Health THE COMMONWF.ALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-059 FEE: $50.00 This is to Certify that Travis Hospitality�Inc d/b/a Bayside Resort Hotel 225 Route 28 West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and e�cpires December thirty-first 2004 unless . sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This Gcense is issued in confomrity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendmerns thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOAItn OF HEAI,TH: B/7 `1�5i.a �j'o3do�c, M..$., G'kaia��c SEATMG: S 1 Y'11�JL��sMf3JJeNG�l�[tB.L��Gl3Nf41G ROl�'u�. Bd0[WL� � S�k, R.N. / January 22.2004 Bruce G. Mu[phy S.,CHO Director of He � THE CObIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-029 FEE: $75.00 This is co Ce�tify ihat Travis Ho it � Inc. d/b/a Ba side Resort Hotel 225 Route 28 West Yazmou MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort Hotel -INDOOR POOL _ 225 Route 28 — West Yarmouth MA This pe�mit is granted in conformity with Article VI of the Sanitazy Code of 17�e Commonwealth of Massachusetts,and expires December 31_2004 unless sooner saspended or revoked. Jam,ary zz.2ooa sonRD oF HEfv.TH: Be.,�c�i�s:h. Cjo�,�o.�, M.�. ' �,w,� v:�e� Rod�el�. B� Gl� � �k, R.N. Duector of He�alth� P THE COMMONWEAI,TH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-013 FEE: $75.00 This is co Certify that Travis Hospitality, Inc d/b/a Bakside Resort Hotel 225 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority ganted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and aznendments thereto,and is subject to the provisions of the Laws of the Coaunonwealth ofMaesacliusetfs relating[hereto, and upon such terms and conditions, and to the niles and regularions in regard to[he canying on of[he occupation so licen.sed as adopted by the Board of Health,and eacpires Deceuiber 31,2004 unless sooner revoked. .ram,an,22 zooa BonRD oF HEnt.TH: Be�a�s �i. �'u�rdok, M.1f. CYioi� p�tif��tt, v:� e� Rad�t 4. B� G/�6 � sk�k, R.N. ruce G. M ,MP HO Director of Health /. . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMITNIJMBER: #04-030 FEE: $75.00 This is to Cercify tt,a� Tra �s Hos itali Inc. d/b/a Ba side ResoR Hotel 225 Route 28 West Yazmou . MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bavside Resort Hotel - OUTDOOR POOL 225 Route 28 West Yazmouth, MA This petmit is ganted in confo�ntity with Ar[icle V[of the Sanitary Code of The Commouwealth�of Massachusetts,and e7cpires December 31.2004 u�iless sooner suspe��ded or revoked. 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'} _ ✓ _ : '� � The Commonwealth ojMassachusetts � Department ojlndustria/.-�ccidents ; Omce ol/eresalosdNs 600 Washrngton Streef � Bnston.Mass. 02111 " Workers' Compensation Insunnce Affidavit Aoolicant information: PfesaePR[N7'Ted��iidt namr loc�tinn: � � . cit� ohane M � I am a homecµner pzrfortning all work myself. � I am a sole proprieror �r.,', ha�z no one��orkine in am capaciry � 1 am an emplo�er pro�iding workers' compensation for my employees uorkine on this job. com(�an�� name: .��,51� �'^'�✓� ''�� . �JAres�• 2.2�� f(�v�� /�O — ��.. (/� . 6�Q-�f��-�-� Y'` �� ohone k: �� t�`.�' C �insur�nceco YI� YVI oolievf7 v.tv�2Yoe� 37Zllu(�o�? � I am a solz proprietor. _enerai contractor. or homeowner(circle onU and haee hired the contractors listed below ��ho ha�e thz follo�cin2 �corker compensation polices vn ^�dres • ��n�� ohone q• insunncc co oeliev# vn _Adrc••• _ - - - -_ . . _ _. --- --.___ ... . �• ehoee N• insuranceco � ' ��'M � � � � f F�ilure m seaure coverqe�s«qu�red uader Seenoo 25A af MGL 152 n�ind to Ne inpai�oteridW peultld of�O�e ap m f1�00.00 aW/or one rean' imprisonment n a�ell n eiril penalHa in tAe form o(�STOP WORK OADER�ed�Ilee of 5109.00 i A�r q�imt sa (��derstt�d��h�t■ eopy of tAy sh[emrnt m�r be(onvvded to the Olfiee of Investlp6om of Me DU tor eoven�e verifintlw. � � I do-hrreby crrtij}•under the pnins andpenaUies ojperjury thm the injorrrntion providtd above fs trrt and rnn�ct Signaturc ��-_ Dste �� IIS�I �-- Printname T�4� S�l�7.�i✓1 - �l� � PhoneM 7�S ��S � ., aRcial use onl� do no�wriee in this trea to be completed by cily or tmrn olfltial ' eitv ar rown: Y�M�DT$ .permiNieeeee M nBuildiog Depinmcut " � pLieeosios 8o�rd �check if immrdiate responne ie required 261 �Selectmen'e Ofifee �HnItA Dep�nmeat � con�ac� person: Ppop�p;_ �SOS� 398-2231 eat. �Other � ACORD�, CERTIFICATE OF LIABILITY INSURANCE iiio4i2 0 PRODUCER ($00)333-7234 FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ALLIED AMERICAN INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Carl i n Insurance ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 233 West Central Street NdtiCk, MA 01760 INSURERSAFFORDINGCOVERAGE wsuneo Travis Hospita ity Inc � �.= rsErsn: Arbella Protection Ins. Co. DBA: dba Bayside Resort Hotel �' � � �_ � � is uReaa: Associated Industries Of Ma. Rt 28 225 Main Street irv uaeaa ... W Yarmouth, MA�02673 . . . . . .�.a� O $� ,��z iN uaeaa . . . . .. - . � � IN URER E: COVERAGES � �- � THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOiN/1THSTAN�ING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA7E MAV BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR rypE OF INSURANCE POLICV NUMBER P LCY EFFECTNE P L EXPIRATION LIMIT$ LTR DATE MMIDD/YY DATE MhVDD GENERALLIABILITY SOOOZZOOZ OZ�ZG�ZOOI OZ�ZG�Z003 EACHOCCURRENCE S 1�000�00 X COMMERCIALGENERALLIABILITV FIREDAMAGE(Anyonefre) $ SO�OO CLAIMS MADE �OCCUR MED EXP(Any one person) $ S��0 /� PERSONAL 8 ADV INJURY $ 1�OOO�OO GENERAL AGGREGATE $ 2�OOO�OO GEN'LAGGREGAiELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG s Include POLICV jRa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANVAUTO (EaeCdtlenl) S ALL OWNED AUTOS BO�IIV INJURV SCHEDULEDAUTOS (pe�p�pn) E HIRED AUTOS BODILY INJURV NON-OWNEOAUTOS (Peraccitlenp S . � PROPER7V�AMAGE� E . (PeracciCenQ. GARAGELIABILATY � � � �� AUTOONLY-EAACCIDENT E � � � - ANV AUTO � � FA ACC E . . OTHER THAN . . AUTOONLY: AGG E . . EXCE55 LIABILITY 6000012005 �� 02/26/2002 02�26�20�3 EACH OCCURRENCE E Z�0�0�0� X OCCUR �CLAIMS MADE AGGREGATE E A s 2,000,00 DEDUCTIBLE S RETENTION S lO�OO E WORKERSCOMPENSATIONAND Z80037ZLOLZOO2 OS�OI�ZOOZ OM1�OZ�Z003 TORVLIMRS ER EMPLOVERS'LIABILITY E.L.EACN ACCIDENT $ SOO�OO B - . .—..-- . . _ _—_.__ . . —__. . . E.1.P�SEASE-EAEMPLOVE $ SOO�OO. E.L.DISFASE-POLICY LIMIT $ SOO�OO OTHER DESCRIP710N OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS AOOEO BY ENOORSEMENT/SPECIIU.PROVISIONS CERTIFICATEHOLDER pDDITIONALIN5URE0;IN3URERLETfER: CANCELLATION SHOULD ANY OF TXE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING GOMPANV WILLENDEAVOR TO MPJL . ZO OAVSWRITTENNOTICETOiHECERTIFICATEHOLDERNAMEOTOTHELEFT, Town of Yarmouth Heal th Department BUT FAILURE TO MAIL SUCH NOTiCE SHALL IMPOSE NOOBLIGATION OR LUIBILITY 1146 Main Street - Route ZH OFANVqNDUPONTHECOMPANV,ITSAGENT50RREPRESENTAi1VE5. South Yarmouth, MA 02664 AUTHORIZEDREPRESENT �� ACORD 25S(7197) OACORD RPORATION 1968 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #03-014 FEE: $50.00 'Chis is to Certify thaz Travis Hos_pitality Inc d/b/a B�side Resort Hotel 225 Route 28 West Yarmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority ganted to the Board of Hea1Ny by Chapter 140,Sections 32A,32B, - �2E-,32D and�2E as amend�aed issubjearta Ehe-provis�ons ofthel�aws offihe-Gommonwealtla ofMassach�uu�rei � theretu;and upon such teims and�nditiona,and to tfie rules and regulations in regard to said Cabins so liceosed as adopted by the Board of Health,and eacp'ves December 31,2003 unless sooner suspended or revoked. December 13 ,2002 BOARD OF HEALTH: �rlaa�• i�d�as. ��a�ra+C __ S�eajaMc:.cD. Cfosde�c. 71C.D.. `!/fec : ,�a6aet 3. �wa�. � �a�ste�yXdDara�atl �du Ska+E, k 12. / Bruce G.Murphy, .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-055 FEE: $75.00 In accordance with reguladons promulgated under aut6ority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Iaws,a permit is hereby ganted to: Travis Hospitality Ina 225 Route 28 West Yarmoutb, MA Whose place of business is: Ba�ide Resort Hotel Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2003 BOARD oF t�aJ,TH: �ee'+�. zellt�foc. �fatwra+r �tajax�t.c D. Cjm�dea. 7i1C.D.. ?/r.a �ie�art�. �soa�. � �aArluO�ararott 'r�elr�c S�ak .'!P. Decemberl3 ,2002 ruce G.Murphy, ,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-056 FEE: $30.00 In accordance wifh regulations promulgated under autbority of Chapter 94,Section 305A and Chapter 111,Section 5 of ihe General Laws,a permR is hereby ganted to: Travis HospitaL',ty I�. 225 Route 28 West Yarniouth, MA Whose place of business is: Bayside Resort Hotel _ __ Type of bnsiness: _ Conti�nt�l-Bre�st --_ _ __ _ To operate a food establish�ent in: Town of Yarmouth Peimit expires: December 3-1:2003 soARD OF HEAi.'1'[i: (�Ea�r[ea'�. ZdU4aa. �ai�raK �,ya«�r«D. �. 9AG.D.. 4iru ' �e�t'3. $te�c. � �aArtek'jXdDo►wratt :�e[aw Ska . .�Z. December 13 ,2002 nice G.M Y, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER #03-033 FEE: $50.00 This is to Certify that Travis Hospitality,.Inc d/b/a Bayside Resort Hotel 225 Route 28 West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2003 unless soonersuspended or revoked for violahon of tl�laws of the Commonwealth respecting the licensing of common victuaIler's. This license is issued in conformity with the authorrty granted to the licensu�g authorities by General Laws, Chapter 140, and amendments thereto. In Testimo�Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �(rwtlea +'�. ZdU�. �m.c sercruac: st Surfawr�s D. �je*�1°'l �1lC.D.. `Utu �fadurra.c ,�a6est�. �wavc. ��lark �a�1ek 9X.dDor.xatl � Ska . .?t. December 13 ,2002 � r, �, DirecWr of Health THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-025 FEE: $75.00 'rhis is to certify that Travis Ho i ' Inc. d/b/a Ba 'de Resort Hotel 225 Route 28. West Yarmou MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-PubGc Swimming or Wading Pool At Bayside Resort Hotel - INDOOR POOL 225 Route 28 West Yarmou MA � This permit is granted in conformity with Article VI of the Sauitary Code of The Commonwealth of Massachusetts,and expires December 31.2003 unless sooner suspended or revok�. December 13 ,2002 BOARD OF HEAI,TH: �i(raalta�. i��e�t, (�adtMraa �a«rca D. Cje:dac. '!K.D.. �tee ,�o�ost'�. S�'�teaew. �la� �a�rsek'l�ar�raffi i S �?Z. � I ce G.M p , •, Director of Heahh THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-026 FEE: $75.00 'rhis�s�o Cerflty tl�at Tra`+is Ho i ' Inc. d/b/a Ba ide Resort Hotel 225 Route 28 West Yarmou MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Pubfic Swimming or Wading Pool At BaXside Resort Hotel -OUTDOOR POOL 225 Route 28 West Yarmouth. MA This petmit is ganted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachuseus,and e�ires December 31 2003 unless sooner suspended or revoked. December 13 ,2002 BOARD OF HEALTH: �DiC�Y �� 7....,��.. ,�o6oet�. $'soarac. �ox� . �a�rlek�a.xett �du S��ak .7P. Director of HeatUi� , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-010 FEE: $75.00 Th�s is co cerafy tnat Travis Hos�itah_"ty Inc d/b/a Bayside Resort Hotel 225 Route 28 West Yarmouth. MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING 4F VAPOR BATHS Thia License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 51,of the Ge�ral Iaws,and amendmerts ih�eto,and is subject to ihe provisions ofihe Laws ofthe CanmonweaNh ofMassachusetts relating thereto,and upon such tem�s and conditions,and to ffie rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and e�'ves December 31,2003 unless sooner revoked. ', December 13 ,2002 BOARD OF HEALITI: �a�lea�• iCdlliEet. �avrNra�c 8'e.afaw�s D. Cfsrda�c. '�11.D.. `l/iee �a�uiraa ,�asort�. �aeara. (,lark �a,deie+��e�a�xatt �eleK S�fuk. 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'IOOd 2I0 'I�.LONi `.LN�L�iHSI'Ifld.LS� Q003 1�NH O.L SNOI.LdAON�I 'I'IF� 'I�IOS��S 3H.L 2I03 tJNII�I3d0 O.L�IORId S1�dQ OI-L NOI.L��dSI�II 2I03.LN�I.L2IVd�Q H.I.'I`J�I�I.L.L�F�.LNO�O.L�2Id S.LN3Y�3SI'I�H.LS�'IF�NOSH�S 'I OOZ `I£2I3HNI��Q.Ig �S)��3 Q�2IIf1a�I QNd �S)NOI.LF��I'Idd� Q3.L�'IdY�IO��H.L N2IfLL�2I O.I.1i.LI'IIgISAIOdS�i 2IROJC SI.LI 'I£zaquzaoaQ o� j �aenue f uzo.g,illeriuue utu sltuuad��I.LOAi ON / S� / �QIHd 3I 1�'I�.LdRId02Iddd ?I��H��SH�'Id 's;tuuad mo�f 3o a�uenssi.�o izmaua.�o�ioud pizd aq;snw suatj ptre sa��notuie�;o umoZ QgH�y,L,LH QI�IF�Q3I�IfJIS .LIAdQI33t� 'dY�IO� S�2I�}I2IOM � / Q�H�`d.L.LF��NF�II1SISI 30 '.L�I�� xo`a�u�is an�a�i�za�o� �g isn� iinvai�,� ��AIV2IRSAiI AiOI.LVSAI�dNtO� S�2I�?[2IOAA �.LV,LS Q�H�d.L,LV �H.L 'aouemsuI uoi�esuadwo� s�.�axioM 3o ale�grua� z anzq ;ou saop �fu�dmoo zo uosiad e 3i ssauisnq � aaeiado o11[uuad io asua�tl ,iuE 30 jamauai io a�uumsst pjoq o�pa.�mbaz n�ou st�nouue�3o un�os ac�`9 uoi��asqns `�SZ uoi��as `Z5 j ia�dzq�iapun uoii�isiui�Qv , ACORD CERTIFICATE OF LIABILITY INSURANCE o�io3 00 PR06t10ER (SOS)655-0522 FAX (SOS)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Carlin I115U�dnCC ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 West Central StPCCt ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFPORDING COVERAGE � INSURED Travis Hospita lty IIIC � INSURERA: API7C��a PPOtCCt7011 Ins. Co. - - -- ,- � , DBA:. dba Bayside Resont Hotel iNsuaeae: Eastern Casua7ty Insurance Co. - Rt 28 Z25 Main Stree£ iNsuaeac .. W YarinoULFI� MA O2G73 INSURERD: . _. ___ .___ '--. . . INSURERE . . . . � .. . . .. ______.. cov�ruces THE POLIGES OF WSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING -- - ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO W HICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,THE INSUR4NCE AFFORDED BY THE POLICIE5 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGA7E LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICV EFFECTIVE POLICV E%PIRATION LTR TYPE OF INSURANCE POLICV NUMBER DATE MMIDD DATE M�rVDD LIMITS GENERALLIABILITV SOOOZZOOZ OZ�ZG�ZOOZ OZ�ZG�ZOO; EACHOCCURRENCE $ Z�OOO�OO X COMMERCIALGENERALLIABILITY FIFEEDAMAGE(Anyonefre) $ SO�OO CLAIMS MADE O OCCUR MED E%P(My one person) S S�� /� PERSONALBADVINJURV $ Z�OOO�OO GENERALAGGREGATE E Z�OOO�OO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGCa s Includ POLICV PR� LOC JECT AUTOMOBILE LIABILRY COMBINEO SINGIE LIMIT ANVAUTO (Eaacddent) S ALL OW NED AUTOS BODILV INJURV SCHEDULE�AUTOS � (p�pe�On) E HIREDAUTOS BODILYINJURY E NON-0WNEDAUTOS . (Peracdtlen�) , . � � � . ... . .__._� . . . . . . . � . . .. PROPERNDAMAGE .. E ..- __. � � (Paracdtlenp. . . ..._.... ._..__._ GARAGELIABILITV � . . � . . . ... . .. . AUTOONLV-EA�ACGDENT E � ANVAUTO�.. . . . �.. � � � . _EAACC E .. ___. ._._""_ � � � �- �- � � � OTHERTHAN �� . � AUTOONLV:.. . .. AGG E ..-.-.. ....--.. IXCESS�LIABILITY � GOOOOZZOOS Oz�Z6�2��1 OZ�ZG�ZOO2. EACHOCCURRENCE � E � �- iZ��OOO� OCCUR �CLAIMS MADE � . AGGREGATE �E � � � �� -- A S 2�ODU� DEDUCTIBLE S � RETENTION 5 5 WORKERSGOMPENSATIONAND 98601189 OH�OZ�ZOOl OH�OZ�ZOOZ 70RVLIMRS ER EMPLOYERS'LIABILRY E.L.EACHACCIDENT S SOO� B E.L.DISEASE-EAEMPLOV S SOO�OO _ . . _ . .. _. .. _ . . ... . _ _ � ------- f.i:�asense-��cvte.xr s._._--i9 , OTHER DESCRIPTION OF OPERAT�ONS/LOCATIONSNEXILLESIEXCLUSIONS AUOED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDfF10NAL INSURED;INSUftER LETfER: CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE GANCELLED BEFORE THE E%PIRAT�ON DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MNL TOW11 of Yarmouth lO DAVS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE IEFf, ��. �,�.a BUT FAILURE TO MAIL SUCH NOiiCE SHALL IMPOSE NO OBLIGATION OR LIABILITV 1146 Mai n SLI'CCt� Route 28 OF ANV qND UPON THE COMPANY,ITS AGEN O PRESENTATNES. South Yarmouth, hIA 02664 AUTHORIZEOREPR e • ACORD 25S(7/97) OOACO CORPORATION 1988 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-049 FEE: $50.00 Tlus is to Certify that Travis Ho�gitality,ir�c d/b/a Bayside Resort ��S_�tr Z$„West Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'5 LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vrnth the authonty granted w the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned haue hereunto affixed their official signatures. BOARD OF HEALTH: (�a�lea�. ze[liket. (� sEnn�rw�: 51 �cj�uc D. Cjmidow 'l�D.. ?/iee �ab�a� �z 3. �. !� P�� s�ele� s . .�1. Merch 1 ,2002 nice G.Murp y, .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�NT PERMIT NUMBER: #02-072 FEE: $30.00 In accordance with regulatiansprom�under authority of Chapter 94,Secrion 305A and Chapter I 11,Sechion 5 of the General Laws,a permit is hereby granted to: Travia Ho�iLl_i�C IllC.,�,�5 Rnute 2R V�7Pet Yarmnnth_ MA Whose place of business is: B�yside Resort Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEAL'rH: �ks� +'� xellGfea. � �a. �, �a., v� �s� �. G� P�� Skak. R.�t. March 1 ,2002 nxce G.Murphy,MP R .,CHO Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-008 FEE: $50.00 'Ibis is to Certify that Travis Hosoitali;y Inc. d/b/a Bavside Resort 225 Route 28 West Yazmouth.MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS 'll�is Lic�se is issued'm conformity with riie authority ganted to 1he Board of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to �e provisions of t6e Laws of the Commomvealth of Massachusetts relating therebo,and upon suc�terms and conditions,and to the niles arid regulaflons in regard W said Cabins so licensed as adopted by the Board of HeaNly and expires Ikcember 31,20(12�mless soa�ea suspended or revoked. �b i ,zoo2 son�oF�ai.rx: ��D� .�� ,�t+eets 3 �. L� �� +� S�a ,�� Bruce G.Murphy,T S.,CHO Director of Heahh TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NUMBER: #02-071 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and C1�ap0er 111,Section 5 of the Ga�eral Laws,a permit is hereby gantad w. Travia Hocnitali�,�, �,25 Rnute 2A WP�*�'?�**t��l(}l; MA Whose place of business is: Ba�sidP Resort Type of business: Food�ryice To operate a food establishment in: Town of Yarmouth Permit expires: D 3 2 BOARD OF HEALTH: �a�a+�• xdlG4e�. ��a'a�a�C D. Cj�. �X..D.. ?/�ee �',od� �. Ll� �a��owre�z 'rl�efas S�fadc. ,��l. March t ,2002 Bruce G.Murphy, H .5.,CHO Director of Health THE COMMONWEALTH OF MASSACIiUSETT5 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #02-010 �FEE: $50.00 17vs is w Certify that T ' Ho i " d/b/ B ide 225 Route 8 est Yarmou� MA IS HEREBY GRANTED A PERMIT To Operate a Pablic, Semi-Pnblic Swimming or Wading Pool At B i -INDOOR P 22 Route 28 Wes�Yarmourh_MA This permft is g�anted in conformity with.vticle VI of the Sani�ry Code of 1Le CommonweaNh of Massachusetts,and expires December 31.2002 wless soonea suspended or revoked. �b � ,zooa Bo�oF�n�.�: ��D z� �� ,�adozt� �rreaMc, elork Pa��ez�xott '+� S�a1(c. ��l. NCR . Director of Hea1Ni � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-01 l FEE: $50.00 'ILis is to Cettify tbat T ' Ho i ' / B ' rt 225 Route S est Yarmouth_MA — IS HEREBY GRANTED A PERNIIT To Operate a Pablic, Semi-Pablic Swimming or Wading Pool At B ' Re - UTDO R POO 22 Route 28 Wea�Yarmou hL_MA 'I'his permit is granted'm conformity with Atticle VI of ihe Sanilary Code of The Commonwealth of Massachusetts,and eacpires D�hQr 31_2002 unless sooner suspended or revoked March 1 ,2002 BOARD OF I-IEAI.TH: �r�. i�aPlGFaa, �� '�ae'��'«D. C1m�d�c. D.. �[ee ,�e6�t� �oaMc. � �a�rlck�et.sots s'�e�S�rak, ?Z. Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-006 FEE: $25.00 This is to Certify rhat Travis Hospital� Inc d/b/a Bayside Resort 225 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN Tf-IE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued'm conformity with the authority��rted to the Bosrd oF Heelth,by Chapter 140,Sections 51,of the General Laws,and amendmeuts thereto, and is subject to ihe provisians of the Laws of the Commonweahh of Massachusetts relating thereto,and upon such terms az�d conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by ihe Board of HeahU,and expues December 31,2002 unless soonerrevoked. Msrch 1 ,2002 BOARD OF HEALT'H: L `r�, i�aClL(rat. $''ia�j�.c D. 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N2If1.L�O.L A.LI'II$ISNIOdS�I ZIf101i SI,LI 'i£ja4��Q�l I��f��$�[l��S►T.�ad ��I.LOAI ON /� S�A �QIHd 3I�I'I�.LdRId02Iddd ?I��H��SH�'Id 'situuad mo,C3o aouenssi io�Mauaz o�.�oud pred aq tsntu suai�pue saace��nowse�;o uMos Q�H�d,L.LF�QAtd Q�NrJIS .LIAF�QI33H 'dY�tO� S�2I�RIOM � Q�H�d.L.LF�3�I�I`d2II1SNI 30 '.L�I�� 2I0`Q�AI�IS QAIV Q�.L�'IdNIO� �g .LSIINt .LIAVQI33� �aAIV2IRSAII AIOI.LVSAI�dL1i0� S.2I�?I2IOM �.L�.LS Q�H��.L,L� �H.L 'aouemsui uot;esuadtuo� s�iaxio�3o a�eagtua� e aneq �ou saop �iusdruoo ao uosiad e 3t ssaatsnq e alraado ol �tuuad io asua�c� ,fue�o ismauaa io aouenssi ptoq o�pa.nnba.�mou st t{inouu��{3o urt�oZ a[�`9 uot�oasqnS `�SZ u�?l��Si`zSi';��3�PuI1 a AIOI.L�'2I,LSIAIILIIQ� __ s . __,. ._.._._...:..�_.: c � � � The Conrmonwea/[h ojMassachusetts � : Department ojlndustria/.-lccidents ; I/nisot/arestl�s//iis 600 Washington Slreet Boston, Mass. 01111 Wbrkers' Compensation Insurance Affidavit o�olinnnf infnrmofinn• �e9lC��f[. 1�Li�.r IG1f Q�Sor f- [-�� loc tion ZZS � `� ��. i/��-t`l� �� T C�10��3 phoneq �7.5 �SG,CZ`I � 1 am a homeowner pertorming all work myself. � I am a solz proprietor��d hacz no one ��orkine in am capacity � I am an employer pro�idine uorkers' compensation for my employees working on this job. comnan�� name• ddress: � ohone M• ' "t��C�� ' 75�7 ur�nceco �itw��h �c,evG oolicy# l �� 1 am a sole proprietor. general contractor, or homeowner(ci�c(e onel and hace hired the contracton listed beloa �cho ha�e the follo�cin��corker,' compensation polices: nv n a res • � ohone#• insur�nce co D°.��53'� m a addrese• � � phoeeX• --- insurante to RQ�'� —— Failure ro secure covenEe�s«quired uoder Secrioo 25A otMGL IS3 e��lad to the inpaidoe o(erisiul peultln ot�e�e ap ro f1,500.00 a�d/or ont yean'imprisoament��wxll aa eivil pendtla io the torm of a STOP WORK ORDER�ed�6ot o(SI00.00�d�y q�iert me I��denfa�d t4at a topy ot thia eutement may be forw�rded to tht Oliice of Inveftig�tiom of the DU for eoverage veriRt�tlo�. 1 do�hrreby certijp under�he pnrns and penalfies ojperjury lbal�he injormalion provided above is but and corred Signamrc �—' Date �?.'l T. —(� Print name��C�'�� I Phone M ��1'�{�`t ., oRci�l use only do no��rite in this area ro be eompleted by cih or�o.vn otlleiil - ciry or town• Y��DTQ _ permiNiteex M nBuildiog Dep�rtmeut -- . pLicenaing Bo�rd �check if immediate response ie requircd 261 �SNectmen'�011iee pH-alth Departmeat con�act person: phone a:_ �508� 398t2231 eat. nOther Ira�seE i;95 PIAI •ACORD�, CERTIFICATE OF LIABILITY INSURANCE oZ�Z3izo i PRODUGER (508)655-0522 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Carl i n Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 West Central Street A TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, rv► oi�ea p [� 6 � p d � pp INSURERS AFFORDING COVERAGE INSURED Travis Nospitality Inc ur� n: Arbella Protection Ins. Co. DBA: dba Bayside Resort Hotel irvsuae e: Eastern Casualty Insurance Co. Rt 28 225 Main street HEALTH DE uae c: W Yarmouth� MA OZG73 INSVRERD: WSURERE: �� . COVERAGES � � � � �� THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PPJD CLAIMS. IN R TypEOFINSURANCE POLICVNUMBER DA7E��AypFE�n�E pp��7E y�ID LIMITS lTR GENEnuuaslLln 500012001 O2/26/2001 O2/26/2002 enCNOccUaaeNCE $ 1,000,00 X COMMERCIALGENERALLIABILITV FIREOAMAGE(Myonefire) S ZOO�OO CLAIMS MADE �OCCUR MED EXP(Any one persan) $ S�OO A PERSONAL&ADV INJURV S 1�OOO�OO GENERAL AGGREGATE $ Z�OOO�OO GEN'LAGGREGATELIh11TFPPLIESPER: PRODUCTS-CAMP/OPAGG a Include POLICY �E� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANVAUTO (�acdAeM) E ALLOWNEDAUTOS BpDILV INJURV SCHEDULEDAUTOS (�rce�n) E HIREO AUTOS BODILV INJURV NON-OWNEDAUTOS (Paratdtlenl) $ PROPERTVDAMAGE $ � (Per 2cCtlenl) GARAGELIABILITY . . � AUTOONLV-EAACCIDEN� $ � ANV AUTO. ..... .. . . . � � � OTHER THAN �ACC�S . AUTOONLV: A� § E%GESSLIABILRV 000012005 � 02/26/2001 02/26/2002 EqCHOCCURFiENCE� $ 2,000,00 OCCUR �CLAIMS MADE AGGREGATE $ 2�OOO�OO A a DEDUCTIBLE S RETENTION E S WORKERSCOMPENSATIONAND 98601189 OH�OI�ZOOO OS�OI�ZOOZ TORVLIMRS ER EMPLOYERS'LIABILITY � E.L.EACH ACCIDENT $ SOO�OO B E.L.DISFASE-EAEMPLOVE § SOO�OO _ _. _ _.. _ _ ..__ �_. � _._._. __ . E.L.DiSEASE•POLACYUMR $ .._-_SOQiO - OTHER DESCRIP'fION OF OPERATIONSILOGATIONSNEHICLES/E%CLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATEHOLDER AUDITONALINSURED;INSURERLETTER: CANCELLATION SHWLD ANY OF TXE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWII of Yarmouth �IRATIONDATETHEREOF,TNEISSUINGGOMPANVWILLENOEAVORTOMAIL Health Department lO DAYSWRITfENNOfICETOTHECERTIFlGATEHOLDERNAMEOTOTHELEFf, 1146 Mai n St reet BIf�FAILURE TO MAIL SUCX NOTICE SHALL IMPOSE NO OBLIGATION OR LIA&LITY Route ZH OFANYKINDUPONTHECOMPANY,RSAGENTSORREPRESENT 7NE3. South Yarmouth� � 026� /1UTXORIZEDftEPRESENTA7NE � ACORD 25S(7/97) �ACORD CO RATION 7988 THE CONIMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMITNUMBER: #O1-020 FEE: $50.00 This is to Certify that Rod Smczenski d/b/a Bayside Resort Hotel 225 Route 28. West Yarntouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This Licecise is issued in confortnity with the authority ganted to the Board of Health,by Chapter 140,SecNons 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating there[o,and upan 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 e�cpires December 31,2001 unless sooner suspended or revoked. February 9 ,2001 BOARD OF HEALTH: ��. �e�t'edQ��['�,�t,aLtMcc� e� �, z � v� �� . �, � �� a :� a� a. , �a. ��-��- �- Bruce G.Murphy,MPH,R.S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #O1-034 FEE: $50.00 This is to Certify that Rod Sroczenski d/b/a Bayside Resort Hotel 225 Route 28. West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Bayside Resort Hotel -INDOOR POOL 225 Route 28 West Yarmouth. MA This permit is granted in confortnity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. February 9 ,2001 BOARD OF HEALTH: �� e2Yed, �aduxu� ��, z�, v� �� , � ��ad d :C' b'e} ' ucac D��. !K.D / ,�uc_v� ..u. ruce . urp y, , Director of Health • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMITNUMBER: #01-033 FEE: $50.00 This is to Certify that Rod Sroczenski d/i/a B�yside Resort Hotel 225 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Publiq Semi-Public Swimming or Wading Pool At B�yside Resort Hotel -O TDOOR POOL 225 Route 28 West Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspended or revoked. Februarv 9 ,2001 BOARD OF HEALTT-I: ��. �d�'P.Q�. � �tQ3�ed�. /� � �/iC¢ �tQi/toltc[a 1�0��. �A1011�Ii. � �R� � l� ��i C� , I/G.L/ �I t_.t.l.Gs� ruce urp y, , , Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-061 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General L,aws,a pertnit is hereby granted to: Rnd 4mc�enzki 225 Route 28 �S7��r Vo,,,,�„th MA Whose place of business is: $�yside Resort Hotel j Type of business: Food SPrvice ' To operate a food establishment in: Town of Yarmouth Permit expires: nP��mber 31 2001 BOARD OF HEALTH: �d�1l• e#teo• �a�xa� �lea� Zellikaa. `l/lee �ai�uxak se�g:s� �� ' � ° �ltckaeP 0 :c' � �� j Februarv 9 ,2001 Bruce G.Murphy,MPH,RS. H j Director of Health .' 1 t . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-062 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby ganted to: Rod Smc�encki 225 Rnnte 7�$, West Yarmouth MA Whose place of business is: BaXside Resort Hotel Type of business: Continental Breakfast To operate a food establishment in: Town of yannouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d� etrea, �(�ia'arara�c ��.�. x�, v� �� , ee� ��e o :�� ,� xja�� ozdoac. '�x . Februarv 9 ,2001 �— Bruce G.Murphy,MPH, R.S C Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #O1-038 FEE: $50.00 This is to Certify that Rod Sroczenski d/b/a Bayside Resort Hotel � 5 Ro� . R West Yarmnuth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouttt and at that place only and expires December thirty-first 2001 unless sooner suspended or revoked for violation of the laws of the Commonweaith respecting the licensing of common victuatler's. T'his license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �d'j11. �etlea, ��xax sEa.ru�G: s� �'�. zdlc�rez. ?/iee �auu�ax �o��t� �'�. �k �ad 0 :C� , Februarv 9 ,2001 � � � � Bruce G.Murphy,MPH, .,C O Director of Health i I 0 0 � � � � � c O y � � � s .� � �,N A 7 o N � .G � � � � Q c� " ` '�. ,'s : � a`� � � aE, � .;�� a W Q,a, � � � � - � � fW s o°, �� >;� F f' a. � �° ` (ip� �a`°i � W � � ..� � •a �:L v� " O U 's � = ; C�.C'��o� �o x x H �, � ; � 9 yg c� o � V � U V] w � � � ��T;� 'Y � � y d �q� Q z � ° � 3 '� �I�a�a 2•= ' � � F � � U '� � o .o � � � �'�Ct� \'Y.1 W� '�iQa aOWoa c, C c v v � � ; Q o �, � W Qmp '� � •� � a Od '�L' OC QW � .nBow° w x i E, � O H � > `� �,� � u., �l �' A/�/ ��] r'" �? � a � i � Oy M4 ^ � ^ O � H N � K � � d' CNC7Li1 � � 'O � o Q � O � o v � � � � �y � m G � � � '� a � 0 v� W ra, " �n a � o � QC7 � � � II O , b � -. x � �� a w Z o oy F W � a�i � o w •5 � � '_ m � � o ~m $ � .5 `� N � � N � � � ' ._ a � o $ F V � � � o ° s � = ;a � � ._ �' y �, v y � c u, a �` � � � � ° ' '` �,�icuL kc�rt-� - r�� , � G�3C�� GOMC� DD TOWN OF YARMOUTH BOARD OF HEAL�'H l � 2�EC 2 2 1999 APPLICATION FOR LICENSE/PERM1`i'- 2000 , ��a , ` �' �r � '�,�� "�'� EALTH DEPT. * Please complete form and attach all necessary documents by Dacembe �,�I;199 F ure resu t m the return of your application packet. ` --------------------------------------------------------------------------------------------_--------- NAMF OF ESTAi3LISfIMENT• `�uuS �� O�so�d— ��l �L # 'i��-s(�5 m..-.�.r •rrnnnn. . ZZ� Q-r � L.{ .`��Qi 1/Ll..,�;- CJz�� _.. ��1.11� lVl� ["iLLl\LiJU. MAILING Ai�D�F S S� �' ]�j C Hvs �Z�u�Y nf t, "iS'�1V�iVir, CR�Lzcv�Sk-1 TEL # '715�(cf�C MAILING P nDRESS� POOL CERTIFICATIONS^ The pooi 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 ttus form. 1. J 1 W` �-A-l.� 1L- 2. Pool operators must fist a minimum of two employees cunendy certified in basic water safety, standard F'vst Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Deparhnent will not use past years' records. You must provide new copies and maintain �file at your place of business. 1. (Lad S ra �a e�s l�i a.�,l„�. `��- 3. � C � i 4• 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 a11 times. Please list your employees trained in anti-chokmg procedures beiow 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. J�� [oVv� 2. 3. 4' REST�URANP SEATING: T�TAL# NON-SMOIfH�16 SEATS: TOTAL# ' -------_�________----_�______��---------_—_-----____��--------- OFFICE USE ONIIY i.[�DGING: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 : IPII�I $50 _CAMP $50 LODGE $50 _TRAILER PARK $50 �o) Y a1�'42 � MOTEL $50 �I�'� Z SWIIvIlvffNG POOL $SOea. (T)�3 �WHIItI-POOL $25ea. V2k-��_ , FOOD SERVICE; LICENSE REQUIItED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 VZK'�o 1 � CONTINENTAL $30 YZK-1o2 >100 SEATS 5150 NON-PROFIT $25 �COMMON VICT. $50 Y21F's7 WHOLESALE $'15 RFTAii. SF,RVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIltED FEE PERMIT # <50 sq.ft. $45 _TOBACCO $20 <25,000 sq.ft. $75 FROZEN DESSERT $35 >25,000 sq.ft. $Z� NAME GAANGE: $10 AMOUNT DUE _ $ �� •••••PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM••••• � -.,�.F�-" " ` �....�.�.'�a.��'�.. . . . -"ee.=:...��.+.,-- ..As�— fr ___ _.-, ADMINISTRATION LINDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW RE�UIRED � TD�I�OLD I�SUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF wA PERSON� OA CQnIPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED .Q$ 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 PROPRIATELY IF PAID: YES� NO NOTICE: PERMITS RUN ANNUALLY FROM JANLJARy 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEB(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DBPARTMENT FOR INSPECTION'7-10 DAYS PRIOR TO OPENING FOR 1'HE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISI-Ilv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH pRIOR TO COr�IMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION r FC'iti ATI PT� POOLS POOL OPENING: ALL SWIl�A�NG, WADING AND WHIRI.pppLs WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEAI,1'H DEp,ARTMENT A1�JD T�-�WATER 7.ESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD pLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLy TI�REAFTER POOL CLOSING: EVERY OUTDOpR IN GROUND SWIlHIIvIING POOL MUST BE DRAIlVED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CAT .RTN pp i y ANYONE WHO CATERS WPI'HIN Tf�TOWN OF YARMOUTH Mi.TST NO'I'IFY Tf�yARMpUTH HEt1LTH DEPARTMENT BY FILING TFIE REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS pRIOR TO THE CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT THE HE,AI,TH DEPARTMENT. FAOZF'N DR��ERTS FROZEN DESSERTS MUST BE TESTED ON A MONTHi,y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEAI,TH DEpART1�qgNT p,AII,Ui�TO DO SO WII,L RESULT IN Tf� SUSPENSION ORREVOCATION QF Y9URFROZENDESSERT PERMIT UNTIL,Tf�AgpVE TERMS HAVE BEEN MET. Oi1T$IDF . FFR• OtTfSIDE CAFES(i.e, OUTDOOR SEATING WITH WAiTEg/WAITRESS SERVICE), �JST HAVE pRIOR APPROVAL FROM THE BOARD OF HEAI,TH_ O OOR .00KTI`T:• ��R COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII, OR FOOD SERVICE ESTABLISfAZENT IS PROHIBITED, DATE: SIGNATURE; �„� PRINT NAME& TITLE: -�n �yj�.��a�� l lh�/99 �� "'"�4+o � - -...:..�..sd', �-1� — � The Commonweal�h ojMassachusetls s" � Deparrment ojlxdustria/.-�cciden�s ' ; 0/1/Ce01/ar7estlof!l�is 600 Washington Street ' Baston, Mass. 02111 ` �� ,` W'orAers' Compensation Insurance Affidavit ARnlicant informaHon: p► ne�� namc. lucatian cit� ehon # � I am a homeoµner penorming all work myself. � I am a solz proprie[or ar.,'. ha�z no one �corking in am capatin� I�' I am an employer pro�iding workers' compensa[ion for my emplocees workine on this job. ��. comnanr name: � �1 ��i `��a'�l 1 �O � �� adAress: �� 1v� 23 titv: 1/�S � l �'� phone p• / /� �� 1 iDsuronceco �.��'N L' �Zsv.�r1.Q� yolicvu WZ. ��g�0��1 b l � I am a sole proprietor. general contractor. or homeowner(circle onel and ha�e hired the contractors listed below ��ho ha�e the follu�cin2 �corktr, ;ompensation polices: snmoanv nnme: � ad d ress: ��n'� phone k• ins�r�nce co policr# tomn.�nv name: -- ------ ----. ___—_. _ __- - - �---- - -��--------__. iddresr [it�': phoee Ih insuranee co. eeRev M • F�ilurc to sccure toveraee u rcquirrd uoder Seenoa 25A of MGL IS2 n�Ind to tbe i�paidw of eri�iul peWtln of a O�e sp W 51,500.00��d/or ane ynn' imprisonment u w�ell u civii pendHn in the form of�STOP WORK ORDER a�d i Ilae of 5100.00 i d�y Kfiort ma i ndenta�d t6u■ eopy of thy stalement may be fonv�rded to tAe 011icr of IevaNpuonf of Me DIA far eoven�e verilfutlw. 1 da hrreby cenij}•under the pains and penal�ies ajperjury rhm rhe injormalion provid�d above is bue and carrca Signaturc ^/�f'/// Due Print name Phprrc N .• olTicial use onh do no��ritt in this area m bt tompleted by tiry w fmre o01eia1 ciry or town: Y�M�DT$ _ - permiNieeeu M nBuildiog Depanmem pLieemios Board p check if immrdiate response i�required Z61 �Selettmeo'�Oflfee (508) 398-2231 p�t, �Hea110Dep�rtment con�ace person: pAone N:_ __ _ nOther ACORD ��RT^ FI(��,�v � �� 1��l1� } � �N �i7, � "� ji �jE} -'�'�i�`� K� onrelmmroom� TM t �'�E ' 11/03/1999 PRODUCER (508)655-0522 FAX (508)655-8853 THISCERTIFICATEISISSUEDASAMATTEROFINFORMATION arl i n Insdrance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NHtICk, MA 01760 '��. COMPANIES AFFORDING COVERAGE �I COMPANV Arbella Protection Ins. Co. � Attn: Ext: �' A iNsuaen , �MPANY Eastern Casualty Insurance Co. Travis -Hospitality, Inc ... B Bayside Resort Hotel , Inc __ _.. _ __ _ . Rt. 28, 225 Main Street ' coManNv W. Yarmouth, MA 02673 � _ _ _ _ I COMPANY � . 3�i6. ... .' '.:: .. .. .,:. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY RE�UIREMENT,TERM OR CONDITION OF ANY CON7R4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN,THE INSURANCE AFFORDED BV 7HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PIX.ICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. ..... ..... ._.. . . ._.. _. . _. __. ... .... . ..._.. . _..... .. . . ..... ... . . .... . . � � TVPEOFINSURANCE �� POIICYNUMBER '� POLIGYEFFECT7VE ��.POLICYEXPIIiAiION�.. LTR.. � I DATE(MMIDUM/) i DATE(MMIDDIYY) ..,. lIM1T5 'GENERALLIA&UTY ',.. ',,, '.,, ,'GENERALAGGREGATE ��, E Z�OOO�OOO X �COMMERCIALGENERAlLU1BILITV '�, � I '�..,. PROWCTS-CAMP/OPAGG I S � 2�OOO�OOO � :CIAIMS MADE X 'OCCUR- ' PERSONHL 8 ADV INJURV � S 1 OOO OOO A 'OWNER'SbCONTRACTOR'SPROTBSOOOOHS4H � OB�ZS�I9BS : OZ�26�ZOOO '-�CHOCCURRENCE . - f 1��0 ' �� , . -FIftE DAMAGE(My wce Bre) ', S �LOO�� . , _ _._._ .._..... ,, ,,,�MFAEXP(MyoneOerson) !S _.._....Sr0�0 AUTOMOBILELU181LITY _ �.� ��'�.COMBINEDSINGLELIMIT '�;S .I ANVAU�O .., ,, , ,, ,,.. ; �, .. ._ ._. ... _..... . �. AtLOWNEDAUTOS . . '.. . �'. SCHEDULFDAUTOS ,,. I ,,.... ,(BODIce I�NNRY �I S � HIREDAUTOS . . .,. � ... ... ... .. . . .. ... .. � '� BODILV INJURV : s .� NON-0WNEDAIfr05 ...�'. �'. '� (Perecdtlenl) _... _.. �',, ,� PROPERN DAMAGE ,�'.. S ,GARAGELIABILI7V ��,,, ',, ��,, '�.AUTOONIY-EAACCIDENT '�.� S � �ANY AUTO .''._ ��,. i�OTHER THAN AlRO ONLV: �� __' EACH ACCIDENT! f _ . J ._" ..__._.__ ._..___I � _. :.. .""__""_.. _._. � �'. �' ' ._ ._"_AGGREGATEiS E%CE55 LIABILITY .., ,, ,. '�, EACH OCCURRENCE �;.S 2,000,000 A X.� UMBRELLAFORM p600050645I �, 09/28/1998 ��,. 02/26/2000 ;.nccr�cnre . �s 2,000,000 ! �OTHER TINN UMBRELLA FORM '.. , '.s -.._- ..... ... WORKERSCOMPENSA710NAN0 �. ., . ' X ..''.TORYLIMITS '.. ER-. I EMPLOYERS'WIBILRY ,.. ', '., .. ... . ... . . . B - WC98601189 ' OS Ol 1999 '; 08 01 2000 -E�E"cNncaoeNr s 500 000 ' TME vrs°°Ri�r°w ''. ��i ,.. ; � � � / ,.EL DISERSE-PoLICV LIMR �� S 500,000 i anRTMeRs�xEcurrve . .. ''�, OFFICFRS ARE: ;EXCL' j ' �I EL DISEASE-EA EMPLOYEE; E �SOO OOO �O7HER ' ,,, ', ,.. I ,',. ,',, ,'.� �.,. DESCRIPTION OF OPERA710NSILOCATIONSIVENICLESISPECIAL ITEMS � # .. . .. . . . . . . . _ .. . .. . SHOULD ANV OF TXE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIMTION DATE 7HEREOF,THE ISSUING COMPANY N7LL ENDEAVOR TO MAII Town of Ya rmouth 1� ��WaTTEN NOTICE TO TNE CEItTIFlCATE NOLOER NAMED TO THE LEFT, Board of Health BUTFNI.URETOMNLSUCHN0710ESHRLLIMPOSENOOBIJGAiIONORlJA81LITY 1146 Mai n St reet OF ANY qND UPON TNE COMYANY,ITS AGENTS OR REPRESENTAl1VE3. South Yar'mouth, MA 02664 AUTM�WZEDREPRESENTAiiVE �� i Rosemar Fulham/SKML THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: Y2K-57 FEE: $50.00 This is to Certify that Travis Hospitalit�Inc d/b/a Bayside Resort Hotel 225 Route 2R West Yarmouth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity wrth the authonty granted to the licensing authoriries by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��In. �.tfe/a/, C�a(i��mqa�n q � n SEA7'MG: 51 oan G. �ulCurart� K.//.� Vice `�iairman �o6�,e� t3,�,,,„, C�.� a6.;el�s,�o�,&y-JJ�p� �l o �!n Januarv 13 ,2000 ruce G. Murphy,MP , R. CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-42 FEE: $50.00 This is to Certify chat Travis Hp�pitali�yJnc d/b/a Bayside Resort Hotel 225 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERNIIT To Operate a Public,Semi-Public Swimming or Wading Pool At Bay�ide Resort Hotel -OUTDOOR POOL 225 Route 28 West Yazmouth A This pertnit is granted in conFormity with ARicle VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked Januarv 13 ,2000 BOARD OF HEALTH: Gt�///�.+Jslfags/, l��iayi�rmq/a�nq � /� �oan G. �u[lwan� K.�/•� Vice l��irman �a6�.r.� l3,�„�, CG.� Cr(//a�6,;61��a�p��y-�../d�� ///' e� Co�� Cin ce . urP Y, � • Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-102 FEE: $75.00 In accordance with regulafions promulgated under authority of Chapter 94,Section 305A and Chapter I 11, Section 5 of the General Laws,a pertmt is hereby ganted to: Travis Hn. i ali Tnc_ 225 Route 2R West Yarmnuth_ MA Whose place of business is: Bayside Resort Hotel Type of business: Continentai Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�P/. .�g[��/.,, C'/w:.�y// ^ / /� �oan Gc.7�/u�llivan�n�g�!•� Vice C..�irma . �o�rE/J/ .C/�row/n� l.(ar� C�ja��.ie[ls J'�G��y�-g._/�on e� ///ic ou9hGa January 13 ,2000 � ruce G.Murphy,MP R. ,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-14 FEE: $25.00 This is to Certify thaz Travis Hocni litv nc d/b/a Bavside Resort Hotel 225 Route 28 Wect Yarmouth 1�A HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF -GNING OF VAPOR BATHS This License is issued in confortnity with the authority ganted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and arnendments thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relazing thereto,and upon such terms and conditions,and to the mles and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner revoked. Januaty],� ,2000 BOARD OF HEALTH: �d ///�.'+Je�a0� (��zairmq/a�nn / n/ �yo�aa G.c 7�nuCCivan�/��g/`l.� Vece l.hairman Ko�arE J. /.�rowrt� C�lerk Cr/��a6,/�1��a,�G�y�/ l�� ///' hao� • o �lin ruce G.Murphy,MP , ., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-43 FEE: $50.00 This is to Certify that � 225 Route 2 West Yarmouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At �ayside Resort Hotel - INDOOR POOL 225 Route 28 West Yannouth MA 'It�is pem�it is ganted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. Januarv 13 >2000 BOARD OF HEALTH: Gd ///P• -l�e7lta@�� (��eay��mtanq � /� �oan C�. Ju!lerran� K.�� Viu l.�irman � �o6�,t�B c/3„/�„/�, CL.� a6.iaflae J'akola�y-p../loopa+ ae[ ou �lin i � iUCC . IITp }'� � •. D/[CCTO[Of HCSIYII THE COMMONWEALTH OF MASSACHUSETTS • TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT NUMBER: Y2K-26 FEE: $50.00 This is to Certify thaz Travis Hos itali Lnc. d/b/a Bavside Resort Hotet 225 Route 28. West Yazmouttt. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authoriry granted to the Board of Health,by ChapUer 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws ofthe Commonwealih of Massachusetts relating tliereto,and upon such tertns and conditions,and W the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked. Januarv 13 ,2000 BOARD OF HEALTH: C�t ��+JeNepa/, ��iayi�.mq/a�nq� n �nan G. �u[[ivan� K.1/•, Vica C.�irman �060,�q.� t3,�.,gR, C�/,/� �a��ieCle�a�ola�y-,./Joopea • �..10� o�y�f� ruce G.Murphy,MP R. CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-101 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: Travis Hn. itali Tnc. 225 Route 2R West Yarmnuth_ MA Whose place of business is: �ayside Resort Hotel Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31_2000 BOARD OF HEALTH:��/. �ottR,, C'l,Qa..,�„ �o��c'7.�/u�l�,a�,/��?/�1, 1/;� C�• Seating: 51 /�o�art/J/ . kJ.»uiBn, l.G/r/�r �a�tisl[a�a�l��y-✓�oo� �� 0' �l�n i�,�ary i2 ,z000 ruce G. Murphy, MP .S. HO Director of Health � ' y�� a� �� Lr t �lo?e f ;Ji�, '� �}_ r �'` �? G�3 [� C� C� � MCDD f ' TOW�� YARMOUTH BOARD OF HEALTH ' � DEC ZAFP�A IONFORLICENSE/P�IT,�.1999 : , z;-=, DEC 2 8 1gg8 • Please complete �f�� Tu ssary documents by Decetnber 3'1, 1998. FAilure the retum of your applicadon packet. --------------------------------------------------------------------------- ----_----------------------------------------- T I ��Nsi� �svZT �a7c� r.. � 775- � LOCATION ADDRFSS� �ZS 2 ZS' l.� ��2121�-tTT /L!A �tfl�73 OWNER/CORPORATION NA1�iF� 'J .¢✓I S S P17�-'L�7T�nr� I�A.NAGER'S NA1�tF: ,�a7 ��2 a c2 cN sk-! TEL # '7�S-SCc�4 MAILING ADDRESS• S�Jtit C ------------------------___--____------------------------------------------------------------------------------ POOL CERTIFICATIONS� TLe pool supervisor must be certified as a Pooi Operator, as re�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certificarion to ttus form. 1. __ .�� iN1 ��1 G I ��. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safery, standard First Aid and Community CardioQulmonary Resuscitation(CPR). Please list t}�ese employees below and attach copies of employee certifications to t}us form. The Health DepaMment wili not use past years' records. You must provide new copies and maintaiu a file at your place of business. �. Qod Sro��►s�.� 2. J�d� caW, 3. <) �y�(��JG['. G�1s 4. NFIMLICH CERTIFI ATIONS� 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 wilt not use past years' records. You must provide new copies and maintain a Tde at your place of business. 1. �.['.�tr� e �3C'ta�l�� J 2, 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# -------____--_—_______--------------------------------------- --------------------------- OFFIeE �F. �NT V _ LODGING• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 _CABIN $50 —� $50 _CANIP $50 _ LODGE $50 _TRAII,ER PARK $50 �MOTEL $50 Q+�O �SW�y�GPOOL $SOea. �� FOOD SFRVI F• ��'�'�-P�OL $25�� j 9—� LICENSE REQUIltED FEE PERMIT # LICENSE REQUIRgD FfiE PERMIT# �0-100 SEATS $75 � �CO�� $30 g9�b _>100 SEATS $I50 _NON-PROFIT $25 �COMMON VICT. $50 _3 � _WHOLESALE $'75 �TAIL SFRVICF• LICENSE REQUIRED FEE PERMIT# LICENSE REQiIIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO — $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $25 _>25,000 sq.ft. $200 1�II�MF� _. [�AAN(�� $10 AMOUNT DUE $ �-- ! '"'""PLEASE TURN OVER APiD COMPLETE OTHER 5IDE OF FORM••••• F p � � 1 ' ADMINISTRATION � � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOi1TH IS NOW REQLJIItED 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'1'E WORKER'S COMPENSATION INSURANCE AFFIDAVTP M[JST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1/ 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: PERMITS RUN ANNUALI,Y FROM JANUARY 1 TO DECEMBER 31. TI' I6 YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISffivIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COD�IIvIEENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION i REGULATIONS POOLS POOL OPENING: ALL SWIlvIlvIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND'CHE WATER TESTED FOR ___—�SE , ' PRIOR TO OPENING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlv1R�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE ['ATF.RTNG POLICY: ANYONE WHO CATERS WITHIN 'I'I� TOWN OF YARMOUTH MUST NOTIFY Tf� YARMOUTH HEALTH DEPARTMENT BY FILING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DE�SERTS FROZEN DESSERTS MUST BE TESTED ON A MONTHI.Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII..L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS - HAVE�EEN 1vIET. _ _ OU'TSIDE CAF��: HAVE PRIOR piTTSIDE CAFES (i.e.,OiTfDOOR SEATING WiTH WAITER/WAITRESS SERVICE),1�Z�.T APPROVAL FROM THE BOARD OF HEALTH. p 1T� DOOR COOKTNG: ��pR Cpp�{�i(},pREpARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHIvIENT IS PROHIBTI'ED• DATE: P! �7��* Y SIGNATURE:� PRINT NAME &TITLE: �t>� STL'a GZ��IG I G/ •� , - ' } � The Commonwea![h ojMassachusetls � � = Deparlmenl ojfndustria/,-Iccidents ; Ofllcs ot/rrest/osUiis 600 Washington Street Boslan, Mass. 01111 W'orkers' Compensation Insurance Affidavit . ARplicant information: pl asepRllQ7"4dG1da v ❑amc � L�tcation: i ��`� phone M � I am a homeowner ptrtormin�all work myself. � I am a sole proprietor �cd ha�e no one��orking in am capaciry �I am an employer pro�iding workers' compensation for my employees workinc on[his job. �' �7 � . . I -_.com�an� name � P�GLC/ -�l/v� �/ ��L- ' zzs' 2T � address: � tih': � - 1�t�'� �'CT� Y�'L�� ,�hone M. �7.5� �ua'( � SSs�rance co. C�'��G�/J � .4��e..Zy policv# W G9S �9d1� a 1 I � I am a sole proprietor. general contractor, or homeowner(ci�cle onel and hace hired the contractors listed below �cho ha�e 'i thz follo�cin_ «orker: compensation polices: � sompany name: address: ��n'� phone p• insurancc to. polin•# tom a�ny name: ._ _._-_ _ _ _... . . . _ _ _. _..____ . addrese: _ _ . ... . .— -. . _ -- - -- . _. . . titv: ehoe 1!• insnrance co. portev M Faiiurc ro sccure covengt u required under See000 25A of MCL 152 ua Ipd to t6e iepaidos of eriaiW pndtla oh Os ap to f1,500.00 aM/or oae ye�n'imprisonment�s w�ell af civil penalHa io thc form of�SiOP WORK ORDER�ed�Ifx of f100.00 a d�r qdett mo 1 a�denh�d N�t t topy of thia stnement m�y be for.v�rded to t�t ORce of fovatlg�8om of the DIA for eovera�e veri6utlo�. /do hrreby cerii/j�under�hr pains and pertallies ojperjury�hat the rnjormation provided above is nut and corrce� Signaturc —�%�� r�� h �ZS' �C� Print name �Z� S�eZcNS�t PhoneX '1 � S �`��i .. oRci�l use onl�� do not wri�e in�his area to be tompleted by ciry or tow�n otlieial city or town: Y��DT$ permiNieeeu M nBuilding Departmeot � ❑Liemsiag Bo�rd �eheck if immediate response ia required Z61 �Seleetmen's Otliee (5�$} 398-2231 eat. �Healt6 Depanment conmct person: phont N:_ __ _ nOther Um uM;,05 vin� 911gaH3�i�l!Q OH� `�S'�I`HdY�I`�9�Ni J aon.cg v,��roi/ �00 8��/ . �ed��--��5�"°Y J �Y� /� `GG d' .Lm�s 3 09�� uasw+� a.N vvno n uvo vmurp»�� `ce�a{- /s� P� ;jjy-�7�30 Q2i�Og 866I ` 8Z�4�a�Q L� vaG pa�onai iauoos ssaryn 66 6I `I£�9��aQ saz!�P�`4�I�H3�P��fi aRi�4 Paldops se pasaa�q os Qoqsdn�o aqi3o ao 8m,iueo aql vl PieBa[m saons�ttSas pue sal�aR1 M P�`�4!Puo�pae scaial qons uodn pas`olazay�BaqeTai ��"9��L�I3�QiIBa.Nnomcao�aqi;o sme-j aqi;o saorsTnard a�ul loafqns s�pae`°iara�s�uamPuame P�`�B'I le�J a413�`I S�A�S`OYI �ld�[��4`RA�H3�R��H a�ll ol pal��tuoq�ne aq;q�ta eG�o;aoo m pai�s�asua��7 scqy SH.Ldg�IOd6'A d0 sJNL1IJ ' 30 ��I.L�VZId?IO SS�I�IISflg�I.L 1�II�iJHrJN� O.L �SN��I'I�Q�.LNIF�ZI'J 1�I��g S�'H � 8Z ZI S Z i [ ; H ?I ? g . iE H . i.L �lt��m s�S!9.L 1 � OO�SZ$ 3ffd 9-66 ��I��NIf]N.LII'�RI�d � H.L'I��H 30 Q2IV0g j H.LROIAt2IV�i 301�ih10.L S.L.L�SIIH�VSS�I�I 30 H.L'IV�Ac1AiOLQL1i0� �HL THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH ' PERMIT NUMBER: 99-10 FEE: $50.00 This is w Certify rhat Travis Hospit�y Inc. d/b/a B�yside Resort Hotel 225 Route 28 West Yazmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS 11is Licwse is iss�l'm canfoimiry weh the authority granted W ihe Board of HeaNL,by Chapter 140,Sections 32A,32B, 32C,32D imd 32E as�ended,�d is subject to ihe provisions of�e Laws of the Commanweatth of Mas.sachusetts relating iheieto,and upon such te�ms aud conditions,a�to the rnles and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and eapires December 31, 1992 unles.4 sooner su.cpended or revoked. December 28 , 1998 BOARD OF HEALTH: �d� .}al�e�ep, ��ia(�irm/�ajn� / /J � � �Oa.n � �ullivan�K.//.� Vice l.�irmaa �o6�,t � f3rowpn, C�,� a�rie�g�a�old��eoo�oea � eL Or �lin ruce G. Murphy,MPH,RS. CH Dirador of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-14 FEE: $50.00 This is to Certify chat Travis Hospitali4v Inc. d/b/a Bauside Resort Hotel 225 Route 28 We t Y�rmouth iVLA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-PubGc Swimming or Wading Pool At Bayside Resort Hotel - OIJTDOOR POOL 225 Route 28 Wect Yarmouth,MA 'TLis pecmit is ganted in wnfornuty with Article VI of the Sanitary Code of The Commonweaith of Massachusetts,and expires December 31. 1999 uuless soona suspended or revoked. Dece�nber 28 , 1998 BOARD OF HEALTH: ��r Jeffa�ep� l��ia/�irmQ/a�nn / /J �(�oan C�. �nullivaa�/K7p.�/•� Vice l.�irman Ko�ort� /�rowrt� l,.(ar� a6.;��Gp Sa�o��y�-a�l�Po� ' usaL O� ou hlia Director of Health' ' � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-15 FEE: $50.00 This;s to Certify that Travis Hospi ity Inc d/b/a Bavside Resort Hotel 225 Ro te 28 Wect Y�**n�uih MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At_ Bavcir�e Resort Hotel - INDOOR POOT 225 Route 28 Wec+ Yarmouth MA This Peimit is granted in conformity wtith Article VI of the Senitary Code of The Commonwealth of Massachusetts,and expires December 31_ 1999 unless sooner suspended or revoked. December 28 , 19Q8 BOARD OF HEALTH: Gd�n,}a�� w{�irmIJ/a/an ' /J . � � �(�oan G.c�7nu�art�/KJ.//.� Uico (��i'man Ko�rt J. /,rown� C.�� a6,;��sal��y_.J.I�Po� � �f 0' 0 9/ � � r of H�ealth' ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-60 FEE: $75.00 In accordance with regulations promulgated mder authority of Chapter 94,SecGon 305A and Chaptet 11],Section 5 of ihe General Laws,a peimit is hereby granted to: . . Travis Ho. itali �+ T_S Ro �t 28 West Yarmo�y�, MA Whose place of business is: Bayside ResoR Hotel Type of business: Conrinental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 1999 BOARD OF HEALTH:��f. �.tt��, C�� a��7snu�„az,/,��e�, vKe c�:.�n o�ert J. i�+'/owen� C.lar� � a�rie��aho(d��eo a9 K� OcC'ou�lalia. December 28 , 19 98 i ruce G. Murphy,MP RS. HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-35 F'EE: $50.00 This is to Certify that Trauis Hosnitalitv In� d/b/a Bavside ResoR Hotel 225 Route 2R W Y +m� rth MA IS HEBEBY GRANTID A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and eacpires December thirty-first 1999 unless sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confomutY with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendmerns thereto. Tn Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��YY�/.r.��e7t�p�s, C�(�;..�./�//nq � /�/ SEA1'ING: 51 - �(�oa/n G.�J/ u/�lGvan�/K!e.///.� Vice l.Nairma.n Kobe�J• /�rowa� C.la�k a6,:.��al��y.�UooPa� �.f o. � December 28 , 19 98 ��•� ruce G. Murphy,MP RS, 0 Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-59 • FEE: �75.00 In accordance wi[h regulations ptomulgated under authority of Chapter 94,Section 305A and Chapter 1 I 1,Secfion 5 of the General Laws,a peimit is hereby gtauted to: Travis Hn i ali is. Ro � R Wect Yarmrnrth 1��A Whose place of business is: Bayside Resort Hotel Type ofbusiness: Food ervice To operate a food establishment in: Town of Yazmouth Pemut expires: December 31. 1999 BOARD OF HEALTH:��/.+�ot��pe, C'�a/�:,�,/�)/a/nn ' /7 �joan G.c 7�/u�llwan�/K�a.//,� Vice l..�irman � See[Ing:51 K///777o�evt�Jp .�/�iro/wpn� (_./e/r/�r (,�a�rial(e Jahol��y-,.J�tooPed %/ hl n December 28 , 19 98 mce G. Mucphy,MPH, S., O Director of Health