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Home My WebLink AboutApplication and WC` ,�2�5 � �� aC,tIE �Ck. CW$ � TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/PERMIT_--� �`� ��(�;[��Vj�D �� V , �, * Please complete form and attach all necessary docum�nts by�� ' � ' • 2011 Fai lure to do so wi l l resu l t in t he re turn o f your��lic�t io l�'pac e t. ESTABLISHMENT NAME: B 1 u e Ro c k C 1 ub TAX ID: � �LOCATIONADDRESS: 39 Todd Road, South Yarmouth TEL.#: 508-398-6962 MAII.INGADDRESS: 20 North Main St . , South Yarmouth OWNER NAME: Daven�ort Realty CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: 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 Pool Operator(s) and attach a copy of the certi�cation 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�le 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. 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. 3. 4, ; RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _B&B $55 _CABIN $55 � MOTEL $55 � -U(a _INN $55 _CAMP $55 I SWIMMING POOL $SOea�' -D/ ; _LODGE $55 _TRAII.ER PARK $105 1,WHIRLPOOL $80ea. �'/�g ' FOOD SERVICE: ' __-- -_----------- --_ _— ^ LICENSE REQUIRED FEE PERMIT# LICBNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �a��c _CONTINENTAL $35 _NON-PROFIT $30 100 SEATS $160 �COMMON VIC. $60 �a-�D�(o _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 sg.ft. $225 _VENDING-FOOD $25 ', _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ �_3 b Q� OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i ADMINISTRATION . Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or rene�al 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 ta�ces 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.PI,EASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WA1'ER 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. FROZEN DESSERTS: Frozen desserts must be tested by a State certi�ed 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 produc:t by a retail or food service establishment is prolubited. � 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, 2011. 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 QUIRE A S E PLAN. DATE: 11-4-11 SIGNAT ----� � PRINTNAME&TITLE: Marv Purrier� Assistant ('nntr�.],l�r Rev.10/25/l 1 � �'� The eommonwealth of Massachusetts = Department of IRdustrial AcciJents . r • ��/�� 600 Washington Street, 7`"'Floor Boston,Mass. 02111 - Worl�ers'Compensallon Issaraaee Affidavtt: �t idirmatln• Pkase P1tiNT kelbh name• addtess• �i_ty state: zin• phone# work site lacation(full addressl: ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in an ca i . 8 Y P�tY � I am an employer providing workers'compensation for my employees woricing on this job. �m�.v.��: Blue Rock Club, Inc. ,a�- 39 Todd Road �nr: South Yarmouth o�e�:508-398-6 62 tn,�,,.ee�o, Zurich American Ins Co �* WC8196024 � _ , ;.,.,: :. . ❑ I am a sole proprietor,gc�eral cwtmMr,or 6omeowwer(cirde uni)and have hired the cantr�ctors listed below who have the following workers'compensation polices: COmDYY�1!• . ��f: �: D�IOII!�. I�Qf�C!M�. � ', �O�Y�i10l: ,.�. i�f: �: p`O�!�' �l�C!C0. ppliev# I��l�w�Y��l�If. , Fa�re d sec�re awea�e as reqaired�adQ Satlw 2SA�[MGL 1S2 eu lad b!Ye 6rp��f eri�id pnaMin�f a A�e�p b f1.3M.M aMl�r ; ooe ynn'lesprbe�eet�a weY as dv�pesakb 1�the t�r�o[a 3TOT WORK ORDER aid�Au d f1M.N a da�+a6aimt se. 1 eederseud tht a ' cepy o[tth�taleseot�y be fa�waMed/s t6e O�ee�t lave�atlw of the DIA tar c�vense verMatlw. /Jo henby c xnder NFe polrs n�hiu of perjrrry dk�t NYe lwfenw�doe provi�er�bo►�r is enre awd c»rn�ct . st�� n 11-4-11 P,;m� Mary Purrier Phone# 508-398-2293 ef5c1a1 ox enty do oet write�thb arn to be ce�pietc�bp city or�ws oBicid city or town: P�� EDepartment ❑eheek Kimme�ale rcapense b reqdred �� Seleetmee s OfHm QHaitY Dcpardea! �n.,,ad s�.�mm�� p��' �Olher �� OP ID:EE ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �: 02/24/11 • 7'HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS i CER7IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED j 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 pollcy,certain policies may require an endorsement. A statement on this certiflcate does not confer rights to the certificate holder in Ifeu of such endorsement s. PRODUCER s��-279-8550 CONTACT � The Addis Group�II1C. PHONE Fnx 2500 Renaissance Blvd.Ste 700 610-279-8543 ,vc N Ext: A/C No: Kin��of Prussia,PA 19406-2772 E'�'�A�� JeTT�@�/A G�@bC PRODUCER cu r e i •DAVEN-1 INSURER S AFFORDING COVERAGE NAIC p INSURED Davenport Realty/ � � iNsur�Ra:American Zurich Insurance Co. 40142 Blue Rock Motor Inn wsu�Rs:Zurich American Insurance Co. 16535 c/o Davenport Realty Trust INSURER C: Stephen Aschettino 20 North Main St. INSURERD: South Yarmouth„MA 02664 INSURER E: INSURER P: 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.LIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE B POLICY EFF POLICY EXP �TR POLICY NUMBER MM/DD MM/DD UMITS GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO�OOO B X COMMERCIAL GENERAL LIABILITY GL08196255 03/01/71 03/01/12 pREMISES Ea occurcence a 500,00 CLAIMS-MADE a OCCUR MED EXP(Any one erson) a 10,00� PERSONAL&ADV INJURY $ 'I�OOO,OOO GENERALAGGREGATE E Z,OOO�OO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2,000,00 POLICY PR� LOC 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Eaacadent) a 1,000,000 B ANYAUTO BAP8196256 03/07/11 03/01/12 — BODI�Y INJURY(Per person) 3 X ALL OWNED AUTOS BODILY INJURY(Per accident) S SCHEDULED AUTOS X HIRED AUTOS (Pe�accid ntDAMAGE S X NON-OWNEDAUTOS $ X 250 Comp a UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE S DEDUCTIBLE a RETENTION 3 S WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY � A ANY PROPRIETOR/PARTNER/EXECU7IVE Y�N WC8196024 03/01/11 03/01/12 E.L.EACH ACCIDENT $ �t��0� OFFICER/MEMBER EXCLUDED9 ❑ N/A - . (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S �,��,0�� If yes,describe unde� DE5CRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT a 1�OOO�OOO DESCRIPiION OF OPERATIONS/LOCATIONS/VEHICLES (Attaeh ACORD 107,Additional Remarks Schedule,if more space ts required) CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN RoUt@ 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATiVE T�� O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD