HomeMy WebLinkAboutApplication and WC ��-�-�-��--.-�
a TOWN OF,YARMOUTH BOARD OF HEALTH ' - ' -% �
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APPI,ICATION FOR LICENSE/PEI�VI�- - 6 � .;� �tt��ba -� � ���� 1
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* Please complete form and attach all necessary docume,� �y l��ce�ab 1 S 2015 �
' Failure to do so will result in the return of�i�ur a'p�lication pack t. � ._ _ . _;--Y�- �
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E�TABLISHMENTNAME: Edge of the Sea TAXID:
LOCATIONADDRESS: 301 South Shore Drive So .Yarmouth TEL.#:S�A-39R-2�RR
MAILINGADDRESS: 20 North Main St. , South Yarmouth, MA 0 664
E-MAILADDRESS: mpurrier@thedavenportcompanies .com
OWNERNAME: Blue Water
CbRPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: John Veritv TEL.#: 508-398-2288
NTAILING ADDRESS: 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.
1. �Ji11 provide in spring prior to openin� 2.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
y�ars' records. You must provide new copies and maintain a file at your place of business.
1.' 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.
L 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as'defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
l,Will provide in �pring prior to opening 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ,
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1,Will provide in spring prior to opening 2,
3. 4.
RESTAURANT SEATING: TOTAL#
------ --- -- _-8�'rFI�iJ�E d�v'��c' --
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 �MOTEL $110 (0�0
INN $55 CAMP $55 SWIMMING POOL$1 l0ea.
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ /(0.OO ;
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�
ADMINISTRATION ' " 1
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 1NSURANCE ATTACHED X '
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 X NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. '
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
�
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. '
POOLS
�
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) I,
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been I
inspected and opened. �
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count I
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly �
thereafter. `,
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the ;
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health Department,or from the Town's website at www.�rmouth.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 Board of Health. i
I
OUTDOOR COOKING: ;
_ Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ;
NOTICE:Permits run annually from January 1 to December 31. IT 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 TE PLAN.
DATE: 11-1-15 SIGNATU .
PRINT NAME&TITLE: Mary Purrier, Ass t . Controller ;
Rev. ]0/01/15 �
I,
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�
; � The Commonwealth ofMassachusetts
; '' _ � Department oflndustrial Accidents
Office of Investigations
' ' 1 Congress Street, Suite 1 DO
Boston, MA 02I14-2017.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/OrganizationName: Edge of the Sea / Blue Water
Address: 301 South Shore Drive
City/State/Zip:So.Yarmouth, MA 02664 Phone#: 508-398-2288
Are you an employer? Check the appropriate boz: Business Type(required):
1.[� I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) '
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Enterta.inment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care
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#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#i.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. ',
Insurance Company Name: Zurich American Ins . Co. '
Insurer'sAddress: see attached
City/State/Zip: '
Policy#or Self-ins. Lic. # WC 819 6 0 3 5 Expiration Date: 3-1-16 �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ;
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a '
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine j
of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of '
Investigations of the DIA for insurance covera.ge verification.
I do hereby rtify,under the ' s andpenalties ofperjury that the information provided above is true and correct.
Si ature: Date: 11-1-15
Phone#: 508-398-2293
Official use only. Do not write in this area,to be completed by city or town offaciaL f
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 �
.; -
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�""'1 DAVEREA-01 KSCH162054
A�RO� CERTIFICATE OF LIABILITY INSURANCE °A�`MM,�°""",
2/5/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION 13 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER � CONTACT
NAME:
The Addis Group LLC P"o"E 610 279-8550 Fi4X (610)279-8578
2500 Renaissance Blvd. �uc No eXc:� ) iuc No:
Sulte 100 E�A��
ADDRESS:
King Of Prussia,PA 19406
, INSURER(S)AFFORDING COVERAGE NAIC#
iNsuReRa:Zurich American Insurance Co. 16535
INSURED
Biue Water LP iNsuR�e:
c/o Davenport Realty Trust INSURER C:
Mr.Stephen Aschettino INSURER D:
20 North Main St INSURER E:
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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER � MM/DDMlYY MM/DD/YYYY LIMITS
A X COMMERCIALGENERALLIABILITY EACHOCCURRENCE E 'I,OOO,OO
CLAIMS-MADE a OCCUR GL08196255 03/01/2015 03/01/2016 pREMISES Eaoccurrence E 500,00
MED EXP(Any one person) a 1,00
PERSONAL&ADVINJURY a 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z�OOO,OO
X POLICY❑PR� �LOC �
JECT PRODUCTS-COMP/OPAGG S 2�000�00
OTHER: $
AUTOMOBIIE LIABILITY C MBIN D IN L LI IT
� Eaacciderd $ �,���,00�
A X nNYnuro BAP8196256 03/01/2015 03/01/2016 BODILYINJURY(Perpereon) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) E
AUTOS AUTOS
X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE $
AUTOS Per accident
�( COMP 5100 �( COLL 8500 $
UMBRELLALIAB OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED RETENTION$ $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY STATUTE � ER
A� ANY PROPRIETOR/PARTNERlEXECUTIVE Y/N C8196035 03/01/2015 03/01/2016 E.L.EACH ACCIDENT a 1�0���0�
OFFICER/MEMBER EXCLUDED9 � N�A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 1,000,00
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 3 'I,OOO,OOO
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DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apaee Is required)
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 POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Town of Yarmouth
Route 28 ���
outh Yarmouth MA 02664
O 1988-2014 ACORD CORPORATION. Ail rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD