The URL can be used to link to this page

Home My WebLink AboutApplication and WC -`_ ...f3LVE (nJH7�YL-(�SCK7 a + TOWN OF YARMOUTH BOARD OF HEALTH ' •�� APPLICATION FOR LICENSE/PE T -�116_,,, . „ E I ,;% ; (r %;�1�J � ; * Please complete form and attach all necessary Aelun�nts by Dece�n6 15 - Failure to do so will result in the return fc�i'our licah ; a , _ ' ck.��"i?'�3�� oa:o0 ESTABLISHMENTNAME: Blue Wate�:•Resort TAXID: LOCATIONADDRESS: 291 South Shore Dr. , South Yarmouth': TEL.#:508-398-2288 MAILINGADDRESS: 20:eNorth Main St . , South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Davenport CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: John Verity TEL.#: 508-398-2288 MAILINGADDRESS: 20 North Main St . , South Yarmouth, MA 02664 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. },L3�-�� pro�ide in -t�e -sprinQ- pr�or to - openi� - - - Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department wi►1 not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1.Wi11 provide in the spring prior to openi�g PERSON IN CI�ARGE: Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: A}1 food service establishments are required to have atleast one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: ` All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health DepaMment will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: _ _ � LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 �MOTEL $110 66=0 INN $55 CAMP $55 2 SWIMMING POOL$1IOea. oO�f _LODGE $55 _TRAILER PARK $l05 �WHIRLPOOL $I l0ea.�� FOOD SERVICE: WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 � �COMMON VIC. $60 �8 _��DEKITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQl11RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. � $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. � $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $TS � � � AMOUNT DUE _ $ �]00.00 . � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ADMINISTRATION � Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal oF any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar 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 principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD S�RVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 3 L TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI E PLAN. DATE: 11-1-15 SIGNATU PRINTNAME & TITLE: Mary Purrier, Asst . Controller Rev. 10/Ol/IS - � � The Commonwea[th ofMassachusetts Department of Industrial Accidents � Office of Investigations , I Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Warkers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl pp gl V Business/OrganizationName: Blue water , LP Address: ZO North Main St . C1ty/State/Zip: So.Yarmouth, MA 02664 Phone#: 508-398-2288 Are you an employer? Check the appropriate bog: Business Type(required): 1.[� I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ i a�i a sol�proprietorar partn „ ' and lmvcno - - 7, � 6�{oe andlor Sates("mcL rea-T es3afe,-auto;ecc:� employees working for me in any capaciTy. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other S e a s o n a 1 R e s o r t *Any applicant that checks box#I must also fill out the section below showing their worke:s'compensation policy iaformation. ••If the cocpornte officecs have exempted themselves,but the cocporatioa has other employees,a workers'compensation policy is requ'ued and such an organizarion should check box#I. I am an empfayer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. InsuranceCompanyName: � Zurich American Ins . Co . Insurer'sAddress: attached Ciry/State/Zip: Policy# or Self-ins. Lic. # WC8196035 Expiration Date: 3-1-16 Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies of a fine up-ts$1,SQQQO-and/oc one-year_imprisonment,_as.well.asLivil penalties inShe fnrm of a STOP-�DBK i�RDEA anda fine_ of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer�t/ify,under the p s and penalties of perjury that the information provided above is true and correct. Signature• "%/��/�'% �� Date• 11-1-15 Phone#: 508-398-2293 Offacia!use only. Do not write in tltis area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: . www.mass.gov/dia r � !� DAVEREA-01 KSCH162054 A`COROR DATE(MMLDDIYYW) `= CERTIFICATE OF LIABILITY INSURANCE y5/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTR4CT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTAN7: If the certifieate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATON IS WANED,subJect to the terms and conditions of the policy,certain policles may require an endorsement. A statement on this certiFlcate tloes not confer rights to the certiflcate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: TheAddisGroupLLC PXONE s�p 27 F^z 610 279-8578 2500RenaissanceBivd. .( ) 9-8550 acNo: ( ) SUI[8 100 E�mnIL ADDRE55: King Of Prussia,PA 19406 . . INSURER�9�AFFORDINGCOVERAGE NFICA �r+sunven:Zurfch American Insurance Co. 76535 INSURFD Blue Water LP a+sunm e: clo Davenport Realty Trust wsun�re c: Mr.Stephen Aschettino INSURER D: 20 North Main St INSURERE: South Yarmouth,MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTMTHSTANDING ANY REQUIREMENT, TERM OR CONDRION OF ANY CONTRACTOROTHERDOCUMENTNATHRESPECTTONMICHTHIS CERTIFICATE MNY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREINISSUBJECTTOALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. INSR POLICYEFF POLJCYEXP LTR ME OF INSURANCE POLICY NUMBER MMIUD MMIDD/YYYY UM� A X COMMERCIALGENERALLIABILITY EACHOCCURRENCE f 'I�ODO�OO CUIMS+nADE �OCCUR GLO$196255 03/01I2015 03/01/2016 pREMISES Eeocwrtenca f $��0� MEDE%P(Myorrepersm) § 1�00 PERSONALSAWINJURY E 'I�OOO�OO GEN'LAGGREGATELIMITAPPLIESPER: GENERALnGGREGATE S Y�OOO�OO X POLICY�jE�T � LOC PRODUCTS-COMP/OPAGG 3 ?�OOO�OO OTHER: E AUTOMOBILE LIABILITV M IN IN LE LIMIT E 'I�OOO�OO Ea ecGOeM) A X nNvnu7o BAP8196256 03/01I2015 03I07/2076 BODILVINJURY(Perperson) s A�OOWNED �HEOSULE� BODILVINJURY(PeracciEenQ S X HIREDAUTOS X AUTOS�EO Per�acErAROent�MAGE s �( COMP E100 X COLL E500 S UMBRELIALIAB ppCUR EACHOCCURRENCE 5 EXCESSLIAB CLAIMS+AADE - AGGREGATE S DED RETENTIONE y WORKERSCOMPENSATION X PER TH- FNDEMPLOYERS'LIABILITY S7ATUTE ER A ANYPROPRIEfORIPARTNEWEXECUTIVE Y�N C8196035 03/��20�$ 03/01/2018 E.I.EACHACCIDENT f �r0��4 OFFICERRr1EMBER EXCLUDEO'1 � N�A (MantlatoryinNH) E.L.DISEASE-EAEMPLOYE S 1�000,00 H yes,EascriDe untler DESCRIpfIONOFOPERAT10NS0elow E.LOISEASE-POLICYLIMIT E ��OOO�OO OESCRIViION OF OPERATONS I LOCPTIONS/VEHICLES(ACORD 101,Atltlltlonal Remarks Schetlule,m�y be�tfached Y mon spap ia requintl� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Al1THOR�D REPRESENTFIIVE Town of Yarmouth �� Route 26 South Yarmouth MA 02664 OO 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/Ot� The ACORD name and logo are registered marks of ACORD