The URL can be used to link to this page

Home My WebLink AboutApplication and WC �3� wE Rs�uc C�.crP� + � y TOWN OF YARMOUTH BOARD OF HEALT��G .,�� APPLICATION FOR LICENSE/PE�IIT ��10 -�0� ��f "� � ��j5 ...�• �� `' •,. * please complete form and attach all necessary cl�ct�m �ts:�I�ecem r 1 201 S, , _ a ' Failure to do so will result in the return o�y+�ur�pp�ication pac et.__ _�ya __ .� } _�r_� ESTABLISHMENT NAME: Blue Rock Club TAX ID: LOCATION ADDRESS: 39 Todd Road South Yarmouth TEL.#: 508-398-6962 MAILINGADDRESS: 20 North Main St. , South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedaven�ortcom�anies com OWNERNAME: Davenport Realty CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Ryan 0'Lou�hlin TEL.#: 508-398-6962 NIAILINGADDRESS: 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, Will provide in spring prior to opening 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 years' 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. 1, Will provice in sprin� prior to openinQ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l 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.OQ9(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 fortn. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your place of business. 1. 2. 3. 4• RESTAURANT SEATING: TOTAL# ---- -- — ---——--�` -_._`_(IFFi(''F i TCF (lNT�l LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P MIT# , B&B $55 _CABIN $55 I MOTEL $110 fo—Ol INN $55 CAMP $55 �SWIMMING POOL$110ea. b—OZ.$ _LODGE $SS TRAILER PARK $105 �WHIRLPOOL $110ea. — �{ FOOD SERVICE: LICENSE REQUIRED FEE ERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 �r7 _WHOLESALE $80 ; —RESID.KITCHEN $80 ; RETAIL SERVICE: LICENSB 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 _ $ v l 5.C�� *****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 X I 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 OTAER LODGING ESTABLISHMENTS � � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be � limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. 4 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 area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard 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 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.varmouth.ma.us under Health Department, � Downloadable Forms. i 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. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � � I 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 MA QUIRE A SIT LAN. ! � ' � DATE: 11-1-15 SIGNATU . PRINT NAME & TITLE: Mary Purrier, Ass t . Controller Rev. 10/O1/15 ! ' I I � The Commonwealih of Massachusetts � Department of Industrial Accidents Office of Investigations t 1 Congress Streei, Suite 100 Boston,MA 02114-2017 W www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Le�iblv ' Business/OrganizationName: Blue Rock Club, Ina. Address: 39 Todd Road City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-6962 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. ❑RestaurantlBaz/Eating Esta.blishment 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. ❑Entertainxnent their right of exemption per a 152, §1(4),and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 11.�Health Care ; 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other S P a c n n a], �p snr 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#1. 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's Address: s e e a t t a ch e d City/State/Zip: Policy#or Self-ins. Lic.# WC 819 6 0 3 S Expiration Date: 3-1-16 Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -�ine up�o$I,�bO:DII and/or one-year imprisonmen�,as we11 as civil penalties in the form of a STOP WORK OR33�R a�d a fi�� ' of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covera.ge verification. I do hereby ify,under the pai and penalties of perjury 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 official C i or Town• Pe rmit/License# t3' 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 � DAVEREA-01 KSCH162054 '`�Co� CERTIFICATE OF LIABILITY INSURANCE °A'EcMM�°"'-"� `-� 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the poifcy,certain policies may require an endorsement A statement on this certiflcate does not confer rights to the ' certificate holder in lieu of such endorsement s. ( ) PRODUCER CONTACT ', NAME: The Addis Group LLC PHONE (610)279-8550 ac N,:(610)279-8578 2500 Renaissance Bivd. ac o e�• Suite 100 E"�� King Of Prussia,PA 19406 ADDRESS: INSURER(S)AFFORDING COVERA(iE NAIC# � �NsuReRn:Zurich American Insurance Co. 16535 INSURED � INSURER 8: Davenport Realty/Blue Rock Motor inn clo Davenport Realty Trust INSURER C: Mr.Stephen Aschettino INSURER D: 20 North Main S� 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 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.LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE pOLICY NUMBER MM/DDY EFF MM/DD� � LIMITS lTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S ��OOO,OO CLAIMS-MADE �OCCUR GL08196255 03/01/2015 03/01/2016 pREMISES Eaoccurtence S 500,00 MED EXP(Any one person) a 1,00 PERSONAL&ADVINJURY $ 'I,OOO,OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 Y,OOO�OO X POLICY❑PR� �LOC PRODUCTS-COMP/OPAGG $ Y,OOO,OO JECT OTHER: a AUTOMOBILE LIABILITY Ea accideMSIN L LIMIT y �,OOO,OO A X ANY AUTO BAP8196256 03/01/2015 03/01/2016 BODILY INJURY(Per pereon) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS X X NON-0WNED PROPERTY DAMAGE a HIRED AUTOS AUTOS Per accident �( COMP b700 �( COLL$500 s UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTION S $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNERlEXECUTIVE Y t N CH'I9BOSS 03/0112015 03/01/2016 E.L.EACH ACCIDENT $ ��00��00 OFFICERIMEMBER EXCLUDED? a N/A (Mandetory in NH) E.L.DISEASE-EA EMPLOYE 3 1,0��,�� If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 3 �,OOO,OO DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,AddiUonal Remarks Schedule,may be attached if more space I:required) I � � i I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of Yarmouth Route 28 South Yarmouth MA 02664 � O 1988-2014 ACORD CORPORATION. Alt rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1