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Home My WebLink AboutApplication and WC� � ��K -, • , ; ' TOWN OF YARMOUTH BOARD OF HEA�,'I'� �-yl ,�� r/(�D i APPLICATION F4R LTCENSE✓g�'�RMRMIT-2�i�c 6�� ; *Please complete form and attach all necessaryY�oc�nents by�ece er T3V2g�z�09 Faiawe to do so will result in the retur,�of your application pa e�EqL H utr��. ; • .�...�...�_.. _..._�. � NAME OF ESTA$LISHMENT: Blue Rock Club, Inc. TEL. # 508-398-6962 � . LOCATIONADDRESS: 39 Todd Road South Yarmouth MA 02664 MAILINGAUDRESS: 20 North Main StreetZ South Yarmouth, MA 0266 i OWNERNAME:_- naVP„�rr g�al ty � ID(FEINor,�SN)• I CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Diane Kingman TEL. #508-398-6962 ' MAILINGADDRESS:;. 20 North Main Street, South Yarmouth, MA 42� ��111��1��111I��I��I�I�I�I�u1��1 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. �- � 2, .. � . � .: ,. .. , Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiapulmonary Resuscitarion(CPR}. Please list these employees belaw 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. ; �. a. 3• 4. FOOD PROTECTION�VIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least ane full-time employee who is certified as a Food , Protection Manager, as defined in the State Sanitary Code for Faod Service Establishments, 105 CMR 590.000. � Please attach copies of certification ta this application. The Health DepArtment will not use past years'records. ; You must pravide new copies and maint�in a file at youx establishment. ! - ,� � � �. �p 7 f ��u��.._ .�,� Z. 1 _ _ , � PERSON IN CHARGE: � Each food establishment must have at least one person In�fiarge �PTC) on site during hours of operation. 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 rimes. Please list your employees trained in anti-chokin�procedures below and I 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 �ile at your place of business. �� 1. �. 3. 4. _ RESTAURA,NT SEATING: TOTAL# .�.� _ OFFICE USE ONLY LODGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# LICENS�REQUIRED FEE PERMIT# ,_B&B $55 _CAB1N $55 �MOTEL $55 v-�OD� 1NN $55 ��,�.A�' $55 �S`NL'!gll�NC'i P�O�; �8J2s. <O—OCL'� �LODGE $55 �TRAILER PA,ItK $105 _ �WHIItI,POOL $80ea. t6�4-00/ FOOD SERVICE: LICENSE REQUIRED FEE P$RMIT# LICENSE REQUIRED f�E PETtMIT# LICENSE REQUIRED FEE PERMIT# �0-100 S£ATS $$5 �o -p?�{ �GONTINENTAL $35 __,_NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $b0 ��-Q� �Wgp�,�g,�� $80 RETAII.SERVICE: —RESID.KITCHEN �80 T,ICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# ,_„<50 sq.R. $50 >25,000 sq.R. �225 �VENDIr1G-FOOD �25 ,,,r,Q5,000 sq.ft. $80 �FRQZEN DESSERT $40 �TOBACCO $55 NAME CHANGE: $ts AMOUNT DUE _ $_v�60. o0 "*""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**** . r. --:C' �'" ��. . ..._ f i .,: ADMINISTRATION � � Und�r Chapter 1 S2, Se�taon 25C, Subsection 6,the Tawn 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 WURKER'S COMPENSATI+DN INSURANCE ' , AFFIDAViT MUST BE COMPLEI"ED AND SIGNED,OR � ; CERT. OF INSURANCE ATTACHED � - . OR ; WORKER'S COMP. AFFIDAVIT SIGNED ANU ATTACHED � F E E Town of Yarmouth taxes and liens must be paid pri r to renewal or issuance af your pernuts. PLEASE CHECK � APPROPRI�TELY IF PAID: � YES NO MOTELS AND OTHER LQDGING ESTABLISHMENT5 TR.ANSIENT OCCUPANCY: For purposes of the limitations of MoteI or Hotel use,Transieirt 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 accupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an � � aggregate of not more than ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or � dwelling unit sha11 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�nnended, shall general�y be considered Transient. ` f � POOLS I POOL OPENING: All swimming,wading and whirlpools which ha.ve been closed for the season must be inspecteci by the Health Department��prior to opening. Contact the Health Departmerrt to schedule the inspection three(3)days pnor to opening.PLEASE N01'�:People are NOT allowed ta sit in the pool area until the pool has been inspected ; and opened. � p POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count E by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly thereafter. POOL CL4SING: Every outdoor in ground swimming pool must be drained or covered within seven(7)d�ys of i closing. ; � FOOD SERVICE , CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food 5ervice Application form 72 hours prior to the catered event. These forms can be obtained at the ; Health Department. � FROZEN DESSERTS: � Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will resu�t in the suspension or revocation of your Frozen Dessext Permit until�the above terms have been met. OUTSIDE CAFES: Uutside cafes(i.e.,outdoor sea.ting with w'aiter/waitress service),must have prior approval from the Board ofHealth. QUTDOOR COOKING: ; Outdoor caokin�preparationi or display of any food product by a reta�l or food seryice establishnnerit is�rohibited. ._ _ � N4TICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN � THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ; ALL RENOVATI4NS TO ANY FOOD ESTABLISHiv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. ', ; , � i { DATE: /�- ��—� �j SIGNATURE: ^ PRINT NAME&TITLE: �C Gc�r �� < �On �/ ,�r � 09125l09 �� _ _ � � �\ The Comm n o wealth o Massachusetts � Department of Indu 'al Accidents NA�raN 600 Washington Sh e� 7�"'Floor Boston,Mass. 02111 i � Woricers'Compeesation i�seraace Atfidavih 'Iding/Plamt►iag/Electrical Coatractors � � name- � address: � � ci shate- Zi ' hone � work site location full address: � ❑ I am a homeowaer perfornung all work myseif. Pr ject Type: ❑New Constcvction[�Remodel � ❑ I am a sole proprietor and have no one wocicing in any capacity. ❑Building Addition '�I am an employer p�oviding workeis'compe�ation f�my empb ees working�this job. com a�ume: $lue RoCk Club ' IrtC. _ _ __ - _ ��: 3a Toaa Roaa p : outh Yarmouth MAr 26 4 ��: 508-398-6962 '' �o. Zurich American Ins . Co. WC8196024 _ ,:: ,. �.: , ;:�, . ;. y, ,. : , . . ..—::.r_ .. ..,;. � ,>...N.?a� .�c, . ...,;�.s �::i:;c�rs.��.«�.,�c. ...�:.; � ❑ I am a sole propnefor,Seaeral co�tractor,or homeowwer(arde ne)and}�ve tric�ed tbe contractas listsd below who have the following workers'compensation polices: address•, d • �, �seatoe ca � • - �_ ��.� _ , �_ �-�:��;:: ad�ras: , : �. - — ------ -- -- _ — - _:_.. � ---- F�r seeae a�era�e as'reqa�+ed�a�drr Seelfo�2SA�f MGL 152 cu.lead t�� ;�� ;�i[,�.a�i�al.��s'��., �:-;��-�� , � Iwai�es da�e tip b f1,SM M ad/�r �e�nes i�prba�at as w�eY as dH pe�aldes ia tie 6x�eta 37'Ot WORIC ud�9ne dS1A1�.N a day aaat�st oe.1 adaslard t�at a e�pg�f lii�ah1��g.be tarwaMM M Ne Omce a[1�Mws�f the DIA e�d�e v�1�, /l014d�e3 ' rnder Nie pafws penwfdks of perj+w�'tbat�t l�tfetwr preelded oboae fs bare med onmr� �� nate //—L/-D�J � r�'°R� Cc �u . � e ��v�-3��r-a��3 .e6Ctal.x.sly ao sut w#e Ia t�area a a�o..ple4ea by.aey or a�.�.efieiai . dtp�r trwa: l�� f�Ln.�.p�t p��c��.��a ��''d �•:oe� ��as.o: �� t I I � I � • - ACORv CERTIFICATE OF LIABILITY IINSURANCE OPID J DATE(MMIDD/YYY� i DAVEN-1 03 06 09 i vRonuceR THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION � Ot�LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE The Addis Group, Inc. HqLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2500 Renaissance Blvd. Ste 100 AL�fER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. ' King of Prussia PA 19406-2772 � Phone: 610-279-8550 Fax:610-279-8543 INS RERS AFFORDING COVERAGE NAIC# INSURED INSU ERA: �ricaa snrich sasuranc� co. 40142 I Daven�ort Realty� � � B ile ock Motor nn wsu eR s: z,us�,�_�� u,.u��. co. 16535 c o Davenport Realty Trust INSUF�ER C: S ephen Aschettino 20 Aorth Main St. INSUqER 0: South Yarmouth, MA 02664 INSU ER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F R THE POLICY PERIOD INDICATED.NOTW ITHSTANDING ANY REQUIREMENT,TERM OR CANDITION OF ANY CONTRACT OR OTHEH DOCUAAENT WITH RESPECt TO WHICH THIS CERTIFICATE MAY BE ISSUED OR b1AY PERTAIN,THE INSURANCE AFFORDED BY THE POIICIES DESCHIBED HEREIN IS SUBJECT TO AU;THE TERMS,EXCLUSIONS AND CONDIT�ONS OF SUCH � POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLA�MS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE M DD/Y DATE MNVDD/Y LIMRS GENERALLIABILRY EACHOCCURRENCE S�.�OOO�OOO B }� COMMERCIALGENERALLIABILITY GL08196255 03/pl/09 �3�01�10 PREMISES Eaoccurence S 5��0� CLAIMS MADE �OCCUR MED DCP(Arry one person) S 1 O�OOO PERSONAL&ADV INJURY $1�OOO�OOO GENERALAGGREGATE $2�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/0P AGG $2�OOO�OOO POLICY �T LOC AUTOMOBILE LIABILITY $ ANYAUTO BAP8196256 03/pl/09 �3�01�10 COMBINEDSINGLELIMR $1 �QO 000 (ea accidenq . i X ALL OWNED AUTOS BODILYIWURY a SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY IWURY a X NON-0W NED AUTOS (Per axfdent) X 250 Comp X SOO C011 �ROPERTYDAMAGE a Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC 3 OTHEA THAN AUTO ONLY: A� a EXCE55/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ E DEDUCTIBLE y RETENTION y y WORKERS(�MPENSATION AND X TORY LIMITS ER A EMPLOYERS'UABILITY WC8196024 03/�1/09 O3�OZ�ZO E.L.EACHACCIDENT $1 0�0 ��Q ANY PROPRIETOR/PARTNERIEXECUTIVE r i OFFICER/MEMBER EXCLUDED7 E.L DISEASE-EA EMPLOYE $�.�OOO�OOO I(yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POUCY LIMIT S 1 OOO�OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SP CIAL PROVISIONS CERTIFICATE HOLDER CAN ELLATION YARMO�3 SHO LD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAT�THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O OAYS WRITTEN � TOtiPIl O P Y8PIt10t1t1Y NOTI�E TO THE CERTIFICATE HOLDER NAMED TO THE LEFf,BUT FAILURE TO DO SO SHALL ATTN: Permit Dept, g�pp�E NO OBLIC,ATION OR LIABILITY OF ANY KWD UPON THE INSURER,ITS AGENTS OR Route 28 S. Yarmouth, MA 02664 REP ESENTATIVES. AUT SENTATIV i 4 ; ACORD 25(2001/08) �ACORD CORPORATION 1988 ! � � � f �