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Home My WebLink AboutApplication and WC ,��EROG�GCW4 �NC. � ._ � �.��_ �* TOWN OF YARMOIITH BOARD OF HEALTH f��,r, � v� �' `` � � APPLICATION FOR LICENSE/PE T- 1 ' �� QO��I��( ! '.F �� ,; � � * Please complete form and attach all necessary doc r�'ii en��,l�e'°e�' m�er`I� Zbl`D�`"j F a i lure to do so wi l l resu lt in t he return o f your,ap p lication ac k�� ESTABLISHMENTNAME: Blue' Rock Club, Inc. TAXID04- LOCATION ADDRESS: 39 Todd Road South Yarmouth TEL.#: 508-398-6962 MAILINGADDRESS: 20 North Main St , Sout Yarmout OWNERNAME: D�venport Realtv CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Diane Kingu�an TEL.#508-398-6962 ' MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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. �,��.� .: ,� �� :- �� 2. �� Pool operators must list a minimum of two employees cun ently certified in basic water safety,standard Fu st Aid aud ; Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee � certifications to this form. The Health Department wilt 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 establislunents are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'ui the State Salutary Code for Food Seivice Establislunents, 10� CMR 590.400. Please attach copies of cei-tification to tlus application. The Health Department will not use past y�ears'records. You must provide new copies and maintain a file at your establishment. 1. �,�`� �'�k�� -� �� 2 PERSON IN CHARGE: Each food establislunent must have at least one Person In Char�e (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 em�loyee t�ained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attacli 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 vour place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER1y1IT# LICENSE REQL1IRED FEE PER'�IIT# _B&B S55 _CABIN S55 ( 1YIOTEL S5� � —0/�y _INN S55 _CAMP S55 �SWLVIl�1ING POOL S80ea. (-0 Z�1 _LODGE S5� �TRAII.ERPARK S105 I �4�iIRLPOOL S80ea. �-ll—009 FOOD SER��ICE: ' LICENSE REQUIRED FEE PERMII'� LICENSE REQUIRED FEE PERVIIT# LICENSE REQUIRED FEE PERivIIT# � 0-100 SEATS S8� -k��I-65�0 � _CONTINENTAL S35 _NON-PROFIT S30 _>100 SEATS S160 � COMMON VIC. S60 �(�—Q3� �'�'HOLESALE S80 REI'AIL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERNII?� LICENSE REQUIRED FEE PER�IIT# LICENSE REQUIRED FEE PERiV1IT~ _<50 sq.ft. S50 _>25,000 sq.ft. S?25 _VENDING-FOOD S25 ' <25,000 sq.ft. S30 _FROZEN DESSERT S40 TOBACCO S» � — — � ��v�E cx��cE: sis AMOUNT Dt7E _ $ 3 F�O.Ob I **""`*PLEASE TLR�OVER A\D COviPLETE OTHER SIDE OF FOR�1***** � � � , - 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 STAT'E WORKER'S CO PENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � � CERT. OF INSURANCE ATTACHED OR � WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS , I 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 ofresidence 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, sha11 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 De�artment to schedule the inspection three(3)days pnor 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. � POQL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of j closing. � FOOD SERVICE ( SEASONAL FOOD SERVICE OPENING: � All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the ! Health Department to schedule the inspection three (3) days prior to opemng. 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.varmouth.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 waiterJwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: . 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 RESPONSIBILTI'Y TO RET'iJRN � THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVVIEENT, 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 REQUIRE A SI PLAN. � DATE:_ ��—�j-�/� SIGNAT . �;�.�� PRINT NAME&TITLE: r� � c,(�'r� Py � � , 10�06!10 i ' � , ' � � • � The Commonwealth ofMassachusetts ; Depart�►ent of Industri�r!Accidents � NNfeiK�� ; 600 Washington Street, 7`"'Floor ' Boston,Mass. 02111 , Workers'Compensation insarance Aflidavit;gu�iding/plambie�/Ekctric9t Contractors �: Plea�e PRI1�1'k�dbh narce: address• _ — --------- -------- ; citv state• ziP' ohont# !I work site location(full addiessl. ; ❑ I am a homeowner performmg all work myself. Project Type: ❑New Constnx,�tion ORemodel ti ❑ I am a sole proprietor and 6ave no one worlcing Yn any capacity. ❑Buitding Addition [� I am an employer providing workers'compensation f�my employees working on t6is job. ��o„��„o�. Blue Rock Club, Inc. � � ,d�,,: 39 Todd Road � e3�,: South Yarmouth, MA 02664 ��,� 508-398-6962 ' t,�4ra.o��o. Zurich American Ins Co ,�# W�� q602�� , ❑ I am a sole proprietor,geaenl eootractor,or homeo�vner(cinc/t onu)and have hired the contractors listed below who have the fo(lowing workers'compensation polices: i . COmOSLY O!m!' . addnss- ��— ohoee!{ i Iffimaace co. oolkv# 'i I aomouv oame: i ad�ress: j °r°�e M I imea�ee ea oolicv# A11�e1�ai�l+i�tt r�rau�u� 1 Failve 0�setare ooterase n reqeirad udv Seetlo�2SA�f MGL 132 eu k�d b fYe �b 11,3M�N aid/K i ��!'QioiW pnaNle da�e o�e Yan tespti�o»nt�s wdl as dvi peealtks le t6e fir�o(a 3TOr WORK ORDBR apd a Qne d t189.0�a day aa�imt�e, 1 oedersla�d t6at a c�py�t tYh�tahmed m�y be forwarded os the OR{ce�t Idve�tl�of t6e DIA far arerase verleeatlN. , /do hmeby ctrEiJy wnder NYe pelws ae�nsltits of perJyry NYat tlie iafonwatton provfdel abo►�e is trwe awd corrert s;g�t„re �r"' �Y'.�...� , ��1� nat� 11-19-2 010 P�„t„� Mary Purrier (as aQent onlv� Phone# 508- 8- 9� effieial use oNy do not�vrfte�thf�area to 6e map{efed by dty or l�wo o�ich� - eity or t.wn: permitlltcemrc At �❑,Buid��Department ❑check Himmediale rc�peme h req�rcd �� -Sd�eetmn'a(�ae ceafact penen: pho�e tl; OHq��t t�a s�many �Q � • OP ID EE DATE(MM/DD/YYYY) ' AcoRD CERTIFICATE OF LIABILITY INSURANCE DA�N-1 os oa�io PRODUCER THIS CERTIFICATE IS ISSUED AS A MAITER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE The Addis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2500 Renaissance Blvd. Ste 100 ALTER THE GOVERAGE AFFORDED BY THE POLICIES BELOW. King of Prussia PA 19406-2772 Phone: 610-279-8550 Fax:610-279-8543 INSURERS AFFORDING COVERAGE NAIC# INSURED Q 0�.42 Davenp0l^t Realty� INSURER A: American Zuxich Iasusance Co. B�ue Rock Motor IIA INSURER B: Zurich American Inaurance co. 16535 c o Davenport Realty Trust : wsuRER c S ephen Aschettino 20 North Main St. INSURER D: South Yarmouth, MA 02664 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDING � � ANY RE�UIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHEFi DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR . � � MAY PERTAIN,THEINSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCIUSIONS AND CONDITIONS OF SUCH � � � POLIGES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. . � � � LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD�/YY �PDATE MMIDD�lYY� LIMRS � � . � GENERAL LIABILRY EACH OCCURRENCE � $1�OOO�OOO � B X COMMERCIALGENERALLIABILITY GL08196255 03�O�.�LO 03�01��.�. PREMISES(Eaoccurence) $ �JOO�OOO� � � CLAIMS MADE ��OCCUR � � MED EXP(Any one pe�son) $1��0 PERSONAL&ADV IN,IURY $1�OOO�OOO . � . GENERALAGGREGATE $2�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2�OOO�OOO POLICY PR� LOC JECT . � AUTOMOBILE LIABILITY � COMBINED SINGLE IIMIT � g nNvnuTo BAP8196256 03/O1/10 03/O1/11 (Eaaccident) $1,000,000 X ALL OWNED AUTOS BODILY INJURY � SCHEDULED AUTOS (Per person) $ . X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) X ZSO COMP PROPERTYDAMAGE $ X 50� C011 (Peraccidenq � � GARAGE LIABILRY � � � AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: pGG $ EXCESS/UMBRELLA LIABILRY EACH OCCURRENCE $ OCCUR �CLAIMS MADE � � . AGGREGATE $ � $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X TOtiY LIMITS ER EMPLOYERS'LIABILITY A ANYPROPRIETOR/PARTNER/EXECUTIVE WC8196024 03/Ol/10 03�01�11 E.L.EACHACCIDENT $l�OOO�OOO OFFICER/MEMBER IXCLUDED? � E.L.DISEASE-EA EMPLOYEE $�.�O O O�OOO If yes,describe under SPECIAL PROVIStONS below E.L DISEASE-POLICY LIMIT $1�O O O�OOO � � OTHER � � � � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION YARMO—O SHOULD ANY OF THE ABOVE DESCRIBED POLIGES BE CANCELLED BEFORE THE EXP�RATION � DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN � � NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUT FAILURE TO DO SO SHAIL Town Of YdrMOUtYl IMPOSE NO OBLIGATION OR LIA8ILRY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Route 28 South Yarmouth MA 02664 REPRESENTATIV . nun+ s�rnnv 4 ACORD 25(2001/08) �ACORD CORPORATION 1988 ,�� OP ID: EE ACORD� DATE(MMfDD/YYYY) �,�� CERTIFICATE OF LIABILITY INSURANCE 01/78/11 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 IS WAIVED,subject to the tertns and conditions of the policy,ce�tain policies may require an endorsement A statement on this certificate does not confer rights to the certiflcate holder in tieu of such endorsemen s. PRODUCER s�O-279�5J�O NO�NEACT The Addis Group,Inc. 610-279-8543 PHONE FAX 2500 Renaissance Blvd.Ste 100 E-MNL � N�� King of Prussia,PA 19406-2772 PRODUCER Jeffrey A.Grebe c r M io r•DAVEN-1 INSUR S AFFORDING COVERAGE NAIC# INSURED Davenport Realty/ iNsuR�e n:American Zurich Insurance Co. 40142 Blue Rock Motor Inn �Nsueea e:Zurich American Insurance Co. 16535 c/o Davenport Realty Trust Stephen Aschettino INSURER C: 20 North Main St INSURERD: South Yarmouth„MA 02664 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 �ypE OF INSURANCE POLICY EPF POLICY EXP LIMITS L POLJCY NUMBER MM/D M GENERAL LUIBIUTY EACH OCCURRENCE $ 'I�OOO�OO B X COMMERCtAL GENERAL LIABILITY GL08196255 03/01/11 ��Z pREMISES Ea occurrence S S��r�� CLAIMS-MADE ❑X occuR MED EXP(My one petson) s 10,00 PERSONAL 8 ADV INJURY S 'I�OOO,OO GENERALAGGREGATE $ Z,OOO,OO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S Y,OOO,OO POLICY PRa LOC $ AUTOMO&LE W181LM `eMB�INdE�D`'INGLE IIMIT a 1,000,00 B ANY AUTO BAP8196256 03/01/71 0��/�2 gODILY INJURY(Per person) 3 X ALL OWNED AUTOS BOOILY INJURY(Per accidenq S SCHEDULED AUTOS PROPERTY DAMAGE S X HIRED AUTOS (P��) X NON-0WNEDAUTOS s X 250 Comp s UMBRELLA UAB OCCUR EACH OCCURRENCE i EXCESS W1B CLAIMS-MHDE AGGREGATE S DEDUCTIBLE $ RETENTION S S WORKERS CONPENSA770N X WC STATU- OTH- ANO EMPLOYERS'LW&LITY A ANYPROPRIETOR/PARTNEWEXECUTIVE Y� N�A C8196024 03/01/17 OS/O'I/'IY E.L.EACHACCIDENT $ 'I,OOO�OO OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ �,OOO,OO M yes,desaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OO � ,... v � � DESCRIPTION OF OPERATIONS/LOCAT10N3/VEHICLES(AKaeA ACORD 701.I4dditla�d Remarks ScheduN,it more apace is required� JA� 2� 2 011 CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yartnouth TF'�E EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE YYITH THE POLICY PROVISIONS. ROUte 28 South Yarmouth,MA 02664 AUTNORIZED REPRESENTATNE T�� m 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD