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Home My WebLink AboutApplication and WCr �� u8 � � TOWN OF YARMOUTH BOARD OF HEALTH�i�-`�. : ' � �� APPLICATION FOR LICENSE/PERMIT-2 ��, NOU 1 � 2012 � „�.e f * Please complete form and attach all necess a n��oc�-� ay��ts�1�5� ce�L�-��• Failure to do so will result in the retu f yo'�"ir applicatio ac e . ESTABLISHMENTNAME: $lue Rock Club TAXID: LOCATIONADDRESS: 39 Todd Road, South Yarmouth TEL.#: 508-398-6962 MAILINGADDRESS: 20 Nort Main St . , South Yarmouth ? OWNERNAME: Davenport Realty 1 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Ryan 0'Loughlin TEL.#: 508-398-6962 MAILINGADDRESS: 20 North Main St . , South Yarmouth POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated i Pool Operator(s) and attach a copy of the certification to this form. 1. To be supplied at opening 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 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 �le at your establishment. l. To be supplied at opening 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 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. 2. I 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 I MOTEL $55 ( O( _INN $55 _CAMP $55 �SWIMMING POOL $80ea.�I 3�� _LODGE $55 _TRAILER PARK $105 �,WHIRLPOOL $80ea.�!3''(�O'7 ' _ ______FD�I?SERVI�E�-- -- ______ _----- ---___ ---- � LtCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERMTT# I 0-100 SEATS $85 ( �'I� _CONTINENTAL $35 NON-PROFIT $30 , >100 SEATS $160 �COMMON VIC. $60 �f 3—d 3� _WHOLESALE $80 , RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 36 O�OO ' I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � i � _ I ADMINISTRATION ' ' r 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 I 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 or Hotel use,Transient occupancy shall 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}days prior to opening.PLEASE NOTE:People are NOT allowed to srt m 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 obta.ined 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 Board of Health. 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, 2012. 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: 11-1-12 SIGNATUR� . � PRINTNAME&TITLE: Mary Pur ier, Assistant �ontroller Rev. 10/09/12 1 _ { _ i � , The Commonwealth of Massachusetts � � . Department of Industrial Accidents ; - � - Office of Investigations � 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Legiblv Business/OrganizationName: B1ue Rock C1ub, Inc. Address: 39 Todd Road City/State/Zip:so: Yarmouth, MA 02664 Phone#: 508-398-2293 I 1 Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 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 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy informatdon. Insurance CompanyName: Zurich American Ins . , Co. Insurer's Address: s e e a t t a ch e d � City/State/Zip: I WC8196024 3-1-13 = Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 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 coverage verification. ', � I do hereby ' ,under the pains penalties of perjury that the information provided above is true and correct. ; Si atur�/,G�� 11-1-12 Date: Phone#: 508-398-2 93 Officia[use only. Do not write in thas area,to be eompleted by city or town officiaL , Ci or Town: �' tY ��(�T}f Permit/License# ing A ori ' cle one): ; 1:Board of Health 2. uilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office i Contact Person: Phone#: �DR—3 f8—c�a-�j� x/�� www.mass.gov/dia i � i ' '""�`� OP 1D: KD - � A�RL7� CERTIFICATE OF LIABILITY INSURANCE °ATE,M�,°°""'", 01/10/12 . THIS CERTIFICATE IS ISSUED AS A MA7TER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AITER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE OOES 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 IS WAIVED,subject to the terms and conditions of the policy,certain poiicies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. PRODUCER � B�O-279-HSSO CONTACT � The Addis Group�IIIC. NAME: 2500 Renaissance Bivd.Ste 100. 610-279-8543 �CNNo Ext: FAX A/C No: King of Prussia,PA 19406-2772 E-MAIL Jeffrey A.Grebe ADDRESS: PRODUCER DAVEN-1 CU MER ID : INSURER S AFFORDWG COVERAGE NAIC# INSURED Davenport Realty/ iNsuReRa:American Zurich Insurance Co. 40142 Blue Rock Motor Inn �NsuReRe:Zurich American Insurance Co. 16535 c/o Davenport Realty Trust Stephen Aschettino iNsuReR c: 20 North Main St. iNsuReR o: South Yarmouth„MA OZBG4 INSURERE: . 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 HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUB � LTR TYPE OF INSURANCE pOLICY NUMBER MM/DDY� MM/DDY� � LIMITS � GENERALLIABILITY EACHOCCURRENCE $ 'I,OOO,OOO i B X COMMERCIAL GENERAL LIABILITY GL08196255 03/01/12 03/01/13 pREMISES Ea occu ence S 500,000 � CLAIMS-MADE �OCCUR MED EXP(Any one person) 3 10,000 PERSONAL&ADV INJURY a 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPlOPAGG S Y,OOO,OOO POLICY PR� LOC y AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B nNVAuro BAP8196256 03/01/12 03/01/13 �Eaaccident) $ 1,000,000 BODILY INJURY(Per person) $ j X ALLOWNEDAUTOS a BODILY INJURY(Per accident) 5 SCHEDULED AUTOS PROPERTY DAMAGE X HIREDAUTOS (Peraccident) $ X NON-OWNEDAUTOS s X 250 Comp s UMBRELLA LIAB OCCUR EACH OCCURRENCE a EXCESS LIAB CLAIMS-MADE AGGREGATE $ ( DEDUCTIBLE $ RETENTION E a WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY R A ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N C$�96OY4 O$/O'I/'IY � O3/O'II'I$ E.L.EACHACCIDENT $ ��0� OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ � ��,�� If yes,describe under � � DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additionai Remarks Schedule,Ii more space is required) � CERTIFICATE HOLDER CANCELLATtON YARMO-0 SHOULD ANY OF THE ABOVE DESCi216ED POLICIES BE CANCELLED BEFORE Town of Yarmouth THe EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth�MA O26F14 pUTHORIZED REPRESENTATNE T�� p� �'�- O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and Iogo are registered marks of ACORD