HomeMy WebLinkAboutApplications, WC and Licenses i
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TOWN OF YARMOUTH BOARD OF HEA� ���
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� � APPLICATION FOR LICENSE�FP���1�- ��t �
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* Please complete form and attach all necessary�o�s y cem ,r�oZ0�8? 2008
Failure to do so will result in the returri`�fyour application pac �EALTH 6E�'T.
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"NAME OF ESTABLISHMENT: TEL. # Sl��'���'�CoS�- t
rLOCATION ADDRESS: � � Gt..�'� ll�� � �� `
MAILING ADD SS: D � � �
OWNER NAME: TAX ID FEIN or SSN :��-
CORROR.ATION NAME (IF APPL�ABLE):
MANAGER'S NAME: -e `I e�Z � TEL. # ;�?)f�-3 5��-Lo���-
MAILING ADDRESS: 2-C� v fi, � . �l fY�iCJ
POOL CERTIFICATIONS:
The poal 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.
},��¢._� ��� - �� ��,. ��
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Pool operators must list a minimum of two employees ctu-�ently certified in basic water safety,standard First Aid and
Community Caldiopulmo�uy Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a �le at your piRce of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are requued to have at Ieast one full-time employee who is cei-tified as a Food
Protection Manager, as defined in the State Sanitary CodE for Food Service Establishments, 145 CMR 590.000.
Please attach capies 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.
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PERSON IN CHARGE:
Each food establishment must have at least ane Person In Charge (PIC) on site during hours of operation.
1. 2�
HEIMLICH CERTIFICATIONS:
All food service establisfiments with 25 seats or more must have at least one employee trained in the Heunlich
Maneuver on the premises at all times. Please list your einployees 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 �le at your place of business.
l. 2-
3. 4•
RESTAURANT SEATING: TOTAL#
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OFFICE USE ONLY
LODGI�tG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B S55 _CABIN �SS l MOTEL �55 �05—G�D�'
INN S55 _CAMP $55 �SWIMMING POOL S80ea. �7
LODGE S55 ,TRAILER PARK $105 I WHIIZLPOOL �80ea. �_G CL3
FOOD SERVICE: _
_ _ _— —_- ___ __
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� 0-100 SEATS S85 O —OZY _CONTINENTAL �35 NON-PROFIT �30
>100 SEATS �160 �COMMON VIC. $60 ��� WHOLESALE �80
RETAIL SERVICE: —RESID.KITCFiEN $80
LICENSE REQUIRED FEE PERIVIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� _<50 sq.i�. �50 _>25,000 sq.ft. �225 VENDING-FOOD �25
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_<25,000 sq.i�. S80 _FROZEN DESSERT �40 _TOBACCO 5�5
�a�7E c�,�cE: sio AMOUNT DUE = S 3���00
**"�**PLEASE TUR�T OVER Ai�`D CO.'VIPLETE OTHER SIDE OF FORIVI"'****
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker'$
: Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ,�
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES 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 ofresidence elsewhere. I
' 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 s�(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.
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POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected '
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days �
; pnor to opemng.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been mspected I
j a.nd opened.
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! POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter. k
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of `
closing. �
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FOOD SERVICE
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CATERING POLICY:
E
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required"
Temporary Food Service Applica.tion form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
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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 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 fromthe Boa.rd ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. ;
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE:1�-�-��/ SIGNATLI�tI�-��(�-�l
PRINT NAME&TITLE: f� Y�'Yt^ �S C �T�y' ;
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� The Commonwealth of Massachusetts
Deparhnent of Industrial Accidents
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600 Washington Street, 7`"'Floor
' Baston,Mass. 0211�
� Worlcers'Compeasation Iffiurance A�idavih Baildiag/PlambieglElectrical Contractors
�►_., �r�srm�tlst•: P�e 1'RINT k�b1v
name:
address:
cih+ state• zio• phone#
work site location(fnll addressl_ `
Q I am a homeawner performing all work myself. Project Type: ❑New Construc.Kion QRemodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
�am an einplo er providing workers'compensation f�my�ployees wo�cing an this job.
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❑ I am a sole proprietor,geeersl coatractor,or bomeo�raer(cirde owe)and have hired tbe contractars listed below who have
tbe following workers'compensation polices:
�mu�v�ms•
address:
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, � Pe�aNk� 1,3M-00
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$ne st 10aY9 a da
P�� S y agaimt me. 1 aedmla�d ti�t a
dpy�f tlds sfa�nay be fonrardcd 6o Ne Omoe of lwe�atl�s ot the DfA for cavsnge vd'iACalie�.
!do IYer�tby ceruffy xn�er tlbe enl penelties of perJrnq that tlie Iwforinallo�provided aboae Es trae axd con�ect
�8� a Date __1� �"�Y
� Print name �.° Phone# �I�" �J) -���/ �_
o�dai ase oaly d�not write ia this area tA 6e mml�ktal bY.citF or i�wa e�cFal
eity ar tawn• �� ������n�
❑check iE imme�aEe rcspeme is re9�� �s O�oe
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coatact pelsBn: Pti�g; �
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' � A oRta CERTIFiCATE QF LlABIL1TY 1NSURANCE oP�� °"���� i
� P� DAV�N-1 02 14 08 i
j THtS CERTIFICATE IS iSSUED AS A MATTER OF 1NFORMA770N .
�.'he Addis Group, Inc, Ot�LY AND CONFERS NO RIGHi'3 UPON 7HE CERTIFlCATE `
HO�DER.THIS CERTiFtCAtE DOES NOT AME1rD,EXTENd OR "
� 2500 Reasa.isgaace Blvd. Ste 10� ALTEf�THE COVERA6EAFFORDED BYTFfE POL1C1E3 BELQW.
Kiag of Prusai,a PA 19406-2772
Fhone: 610-279-8550 Fax:610-279-8543 IN3URERSAFFORDFNG COVERAGE
nasurt�o NAIC�
Dane�p�rt Realty �s�a ,�rsaan znrsm inonr�.co. 40142'
B],u� Rock Mator � i�e: z,us�n,�s�z�,�,�.�. 16535
c o Daves3port Rea].ty Trust
S��� ASChettinQ ursu�R C:
� 20 Ror-th Main St.
Sonth Yarmouth, MA 02664 n�u�o:
INStJRER E:
COYERAGES
7'F1E POLIGES OF NISURJWCE LISTED BELOW HAVE SEEN ISSUED TO TFi�INSt)RED NNNED ABOVE FOR THE POLICY PERIOD�1DIG1i'ED.MOTYYITHSTANDING
ANY 1�E4UIf�MENT.7'ERM OR CONDI170N OF ANY CQNTRACT OR OTh�R DOCUA�NT WRH RESPECT TO WHICt17MS CERi1FICATE MAY BE ISSUEQ 0t2 �
MAY PERTAq�/,iHE�NSINtANCE AFFORDED BY T'H8 PQLICIES DESCRIHED F�iEiN S SUBJECT TO ALL THE 7'ERMS�EXCLl3S10NS AND CONdR10NS l�St1CH
P�ICE3.AGGREGATE llhtlTS SHOIMV N64Y HA�B�1 REQUCED BY PND CEAtluS.
L� TYPE OF lNSURANCE PW.�1f NUI�ER pA
M U�yryTg
GENERAL LIABk.ITY
8 X co��c�,��we�m �cr�accur�c� a1 Q00 �00
GL08196255 � 03/O1/08 03j01/09 ��S � s500,000 �
� cwAs eu,� Q occ� ,
. MEoocPW+yonspenonl s10,000 .
Pe�saavwauRr s I 000 000 s
r�n�.ac�rz�cnrE�r nr�i�s a�R:
c�x�acc,rt�cn� s 2 000 000 ;
e�c� _-- ,�� - toe _ _____-- -- _- --- _. aRonucrs-co�a��c_ s 2,Q00 400— -.. �
auroMo�ua�unr
8 aravauro BAPB196256 co�x�sn�.e�uar ;
-03/O1j08 Q3/O7/09 {e°'x�} s1,000,000
$ ALLOWNEDAttT03
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; ��uros {���Y a i
X rdREo auros
8 �ow-own,r�auros t���� • �
; X 250 Comp �
X 500 Coll �oa�nvaueac� s
(Per ax+dent)
GJIRAQE L418L1TY
I ANY AtJTO
AUTOONLY-EAACqDENT t I
oni�trww �as:c s i
AUTO O►�Y: AGG i
E7C�I�JMBRE�.1A t,IM1BLL11y
❑CIAQAS MADE EACH OCGURRENGE t �
OCCUR .
AC3GREGATE s -
dE0t1CTIBLE _
REIFNTION s =
wow�s cow�Nsnno��o s
I EIIq+LOYERS'LABILRY $
TORY �11i5 ER
� �°' EwvP�z�rowPa�� wC8196024 03/01/48 Q3j01/09 E�.�ncc»�wr t 1 000,000 �
I ���C��ER EXCLUDED?
' s a�r�e�,de� e�.o�nse-�,a�.o s 1,000 000
�cu��xrnnswHs ooww
orH�c E.�.asease-Poucr�ur s 1,000 000 ;
DESCPoP710Ft OF OPERA7i0Fi5!LOCA'1'�NS!VEWCI.ES/EXCLUSIONS ADpEED BY�ORSENENT/SpEC:IAI.PtiOVt3101�t3
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CERTIFIGATE HdLDER CANCELLATION
y�0_3 �o�n.a a�nr oF n�aeovE oEscr�s�Pouc�s se cnacEu.�a e�ot�n�ou�earro�
Toma Of Y$7�OII'�1 DATE TNEREOF,THE�SSWNG INSIJRER WN.L EIiDEAVOR TO MfA1L 30 oavs w�rrraa
ATTN- Permit Dept. �ce ro rt�c�rn��►re Ha��a wueeo ro n��r,eur Fan.uae�ro 0o so s►�au.
R+Qute 28 �ose No o�.�anoin oa w�en_rrv oF aen�n�Po�a n+e n��ae�,ns n��Errrs aR �
8. Yarmouth, MA 02664 xeP�rrra
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ACORp 25{2041/08)
�ACORd CORPORATION 1988
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMUUTH
BUARD OF HEALTH
PERMIT NUMBER: #09-OQ6 FEE: $55.00
1This is to cercify that Daven�.rt Realty d/b/a Blue Rock Clu�, Inc
39 Todd Raad, South Yarmauth,MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confarmity with the authority granted to the Board of HealtU,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amende�i,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2009 unless sooner suspended or revoked.
Navember 20.20U8 BOARD OF HEALTH: .`��¢ft S�IL�,�..lV., �tlnatt
(',�wr!'ee �.�CexG'hex 21ice�%Eai�rtaa
*4a u�i�;4a Bea�oo� ��t�.�wucua, C'���
1 Cottage; 1 Bedraom(over pro shop) �,,,/,,,, �+��-
�!'�.'l��.��.��I�,¢0
e G.Murphy, , .5.,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-024 FEE: 85.00
In accorciance with re�ations promulgated under authority of Chapter 94,Secrion 305A and Chapter
111,Section 5 of the enerat Laws,a permit is hereby granted to:
Davenport Realty, 39 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Club Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31,2009 BOARD OF HEALTH: .`�E�t S�, J`1'..N., C'Ra�marn
SEATIIVG:83 �Q11f�84 .`�. �r,C�l�tJ�' �tCC �RlX�I1t�fL
ttEs'rx[c�r[oxs: Packaged clups,candy,chewing gum only. � �.J�ItOUltt��
�'"'y''y�.`�• �"'''''7/'�'
November 20.2008
ruce G.M y,MP . .,CHO
Director of Health
I
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #09-014 FEE: $50.00
This is to Certify that Davenport Realtv d/b/a Blue Rock Club, Inc.
39 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place anly and expires December thirty-first 2009 unless
soaner suspended or revoked for violahon of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensmg authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affi�ced their official signatures.
BOARD OF HEALTH: .��len S�'�`.J�►��.'.I�V., C'�nu'vrxru�t��t_����
SEATING: 83 �������`� �y����`����V��� �"���'
.�itibvglviL.!..�i�Q�tlffZ� \:LQJ[�
Q�ttt(�' ee�tl�atunt, `J2..N.
�u�tt:1".�'fary�'
November 20 2Q08
Bruce C. urphy, , .5.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD 4F HEALTH
PERMIT NITMBER: #04-007 FEE: $80.00
This is to eertify that D v R ! Blu Roek lub In .
39 T h Y aut�,1VLA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Blue Rock Club,Inc -OUTDOOR POOL
39 Tadd Road
South Yarmout�, NLA
This permit is granted in conformity with Article VI af the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2009 unless saoner suspended or revoked.
November 20.2W8 BOARD OF HEALTH: .�E�¢ri S�� ✓�..ly., 'C.�ainenan
C!l�axlea .�.�`(elliR��ac `tJice Cl�aiacnuut
J�o.6�xt�:�xawn, e�
���` �-
Bruce . wp y, . .,
Director of Health
1
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; THE COMMONWEALTH OF MASSACHUSETTS
{ TOWN OF YARMOUTH
' BUARD OF HEALTH
' PERMIT NLTMBER: #09-003 FEE: $80.00
l
� 1This is to certi�y that__ Davent�ort Realtv d!b/a Blue Rock Club, Inc.
; 39 Todd Road, South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE BUSINESS OR PRACTICE OF
-GIVING OF VAPOR BATHS
This License is issued in conformity with the authority granted to the Board of HeaIth,by Chapter 140,Sections 51,of the
General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions, and to the niles and regulations in regard to the carrying on of the
occupation so licensed as adopted by the Board of Health,and expires December 31,2009 unless soaner revoked.
� November 2d.2008 BOARD OF HEALTH: ��¢fL S���..1{�.� ��tXftUxtL
� ���C'�c�e U'#�n�rxninn
' � � ��a�ee��
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Bruce G, hy, , .S.,CHO
Director of Health
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( * ` ��a� uE �2oc.�-Cc,v�
r`�t.�-�k� TOWN OF YARMOUTH BOARD OF HEALTH 6a ���
� � ' APPLICATION FOR L�CENSE/PER1VjIT-2 ��� 2`� `
r '? * � � ' ��: C�%°- �a ( �
, Plea.se complete form and attach all n�ces�s.�Oc�ments by�ecember� 2007.
1 Fa�lure to do so will result in therreturn of your application packet.
_ ,
NAME OF ESTABLISHMENT: , � �� �1 L_ TEL. #�k-��i�-(o S(��1
L,OCATIUN ADDRESS: �' d a �r1� 0 �
MAILiNG ADDRESS: p � "
�WN�R NAM�: r f �P oe� IN r N : -�- �/��
CORPORATION NAME IF APPLI ABLE):
MANAGER'S NAME: P I Z.i Z v�C� TEL. #Sv�-3 j fr-(a���
MAILING ADDRESS: � CJ , �c�� _S 1�_, , � C�r rn0� � �h b� C��-���f
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POOL CERTIFICATIQNS:
The pool supervisor must be certified�s 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.
.. ..
i� _ .�.�_ . . 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
eertifications to this form. T#�e �ealth Departfnent will not use past years' reeords. �'o� tr��s� prQvide new
copies and maintain a file at your place of business.
i 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 attaeh copies of certification to this appfication. 3'he�ie�lth Department�vitl not use past years'recards.
You must provide new copies and maintain a file at your establishment.
T. 2.
PERS9I�1_IN�I�AR�`iE:
Each food establishment must have at least one Person In Charge(PIC) 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 times. Please list your employees trained in anti-chokmg pr�cedures below and
attach copies of employe�e 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.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
I LODGING:
LICENSE REQUIRED FEE PER'�iIT# LICENSE REQL?IRED FEE PER'b11T* LICEh'SE REQL`IItED FEE PERVIIT�
_BBcB 550 _CABIN SSO / MOTEL S50 �G�'OI
II �
_INN �50 _CA1�4P S�0 � SV4'I1�LYIING POOL S75ea. $-(}��ja-
_LODGE �50 _TRAILER PARK S100 / V6'HIRLPOOL S75ea. -p I (�'
FOOD SERVICE:
�� _ __ —-------—--- ----_ _— — _ _
LIC£I�TSE REQUIRED FEE PERMIT� LICE1�iS£REQLTII�ED FEE PER,'�ZIT* LICENSE REQLIRED FEE PER'�iIT=
�0-100 SEATS 575 � _CONTINENTAL S30 _lv'ON-PROFIT S25
_>100 SEATS S150 � CO�fON VIC. S50 �Og�O� _Vi%HOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERVIIT# LICENSE REQLTIRED FEE PER'MT�
_<50 sq.ft. �45 _>25,000 sq.8. S200 VEl�'DI1vG-FOOD S20
<25,000 sq.ft. 575 _FROZEN DESSERT S35 TOBACCO SSO
NAi�IE CHANGE: S10 AMOUI`'T DUE _ $ 325,a0
'�****PLEASE TL'R\OVER�\D CO�IPLETE OTHER SIDE OF FOR�i*•*R*
_ ,. F
,� ► �
ADNiINISTRATION +
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
OR - /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TItANSIENT 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 us�: ;
Transient occupants must have and be able to demonstrate thax they maintain a principal place of residence elsewhere. '
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any s�(6)manth period. Use of a guest unit as a residence or �
dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amend�, shall generally be considered Transient.
* NOTE: Enclosed Motel Census must be completed and returned with this appiication.
POOLS
PUOL OPENIl�TG:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days
prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and c�uarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of�armouth must notify the Yarmouth Health Departme�t 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.
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 result in the suspension or revocation of your Frozen Dessert Pennit until the
above terms have been met.
UUTSIDE CAFES:
Outside cafes(i.e.,outdoor seaxing with waiter/waitress service),must have prior approval from the Board of Heatth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. �
�
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN
THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER,3�, 2007.
t�{
ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIVIEENT', MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COMME:VCEME:VT. RE:VOVATIONS MAY REQUIRE A SITE PLAN. !
4
�
DATE: ������ SIGNATURE:� C,C��,� � ��, � � y� � �
PRINT NAME&TITLE: � �S� �
io�o o%
i
4
s
�
� The Commonwealth of Massachusetts
' Departinent of Industrial Accidents
> �Nrw�fM�
600 WashiRgtoR Street, 7'f"'Floor
Boston,Mass. OZlll
Workers'Compeesatioa laseranee A�davit:BaildiHg/Plambieg/Electrical Coatnctors
� ��,�
name:
address:
�h' state: zin• nhone#
work site location ffull address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction�Remodel
�❑ I a sole pro�ietor and have no one working in�y capacity. ❑Build'mg Addition
an employer providing worke.rs'cflmpensati�for my employ�s wo�lcing an t�is job.
comu�v�me: l�J� L�`� �-�(�1,� �.��l.L.��, �'1 C-, � � � � �
addras: ; �C f 1,�(`�1 C+ C� (C'1_
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❑ I am a sole proprietor,ge�erat costractor,or�omeaw�aer(circle ont)and have hired the cornracto:s listed below who have�
tl�following w�kers'compensation polices:
��l�v�me• '
add�s:
cih�: uka�e�-
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, ,_w � �
�Ywue.
�:
s�iv- �#-
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Failere M secee orvera�e a�req�nd�Satlei�1�f MGL 152 ean la�d b I�e i�ps�a�f cririat pnaNies�f a�ue�b i1,SN.M aaN�r '
one yeaes'Impri�ea�mt as we8 as dvY peBaNia in t6e fer�eta 3TOt WORK ORDER aed a AAe af S1AS.is a day�t de. 1 o�denhad that a
dpy of tLia�a�eme�t m�q 6e forwarded Ie the O�ce o[l�af fl�DIA tor eoveragt verqkatle�.
1 do her+eby certr;J'y xnder NYe pal awd peneltlea of pt�}r�ry tJirat dYe urfarerelton provided abov�e ly due ard corr�
. /y,
Signature C�.'�' �.,.�,r(.''t����� — :� C-+c.� �YL ��' I�te ��'�L��� �
P�� ��. t.;�►- � Pbo�# .�`z�— 3��—a�--�3
•fficial ase only de aot wrih f�t6ia are,a to be esmpldcd 6Y eil�'or�wa�cid
city er tewn: per�f�oe�e# �ga�E��
O1Joea�Board
❑check if iess�e�ale nypene is n�n�u�ed �Sdeclaea's O�ce
����
coatact person: p4eee#; QOther
t�sm�-��
i
�
ACORD CERTIFICATE C)F LIABILtTY INSURANCE oP�d Q DATE(MMIDWYYYY) ;
� DAVEN-1 02 21 07 i
p��R THt3 CERTIFICA7E tS ISSUED AS A MATTER OF tNFORMATION j
� ONLY AND CONFERS NO RIGHTS UPON THE CERTIF[CATE j
The Addis Group, Iac., HOLDER.THIS CERTIF(CATE DOES NOT AMEND,EXTEND OR �
2500 Reaaissanca Blvd. $te 100 ALTER 7HE COYERAGE AFFORDED BY THE POLICIES BELOW.
Ring of �Prussia PA 19406-2772 +
Phane: 610-279-8550 Fax:610-279-8543 lNSURERSAFFORDINGCOVERAGE NAiC# ;
Mt3tlRED MISURERA: aa�ar�can zursah insux�nc�co. 40142
Daven�ort Realty�
B ti@ Ck MOtOr nII INSURERe: zuxic�.�wsriaan snsurana� co. �.GS35
c o Daveaport Realty Trust �R� �
3 eAhen Aachettino
2 North Main St. �ERa ;
South Yarmouth, 1�► 02664
MISURER E
COVERAGES •
TNE POLICtES OF INSURANCE LtSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PER�D INDICATED.NOTWITHSSANDINO
ANY REQU�2EMENT,TERM OR CpNDfT10N QF ANY CONTRACT OR OTHER dOCUNENT WITH RESPECT TO WHiCH THlS CERTIFICATE MAY BE ISSUED OR
MAY PERTAflV,THE 1NSURANCE AFFORDED BY THE POLIGES DESCRIBED HERBN IS SUB�CT TO ALL TF�TERMS IXCLUSIONS AND CONDITIONS OF SUCH
PCN.ICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CIAMAS.
LTR TVPEOFINSURANCE PO���� DATE MIND DATE MMID ��M�
GENERAI LIAB1lITY EACH OCCURRENCE s I,00 0,0 0 0 J
B % con�aeRcuucen�wLL�ws��mr Gvo8ig6255 03/Ol/07 03/Ol/08 PREMISES_(Eaaauronea) s500�d00 j
CLAIMS MADE X�OCCUR MED EXP(Any one pereon) S 1 O�O O O
�asowu.sanvn�uuFzv a 1 000,000
oEr�wu.�Ec�+re S 2,000,000 #
i GENLAGGREGATELiMITAPPLIESPER: PRODUCTS-COMPfOPAGG S 2 OOO OOO
POLJCY jECT LOC '
AV70MOBILE LASLLITY ,
B arrrauro BAP8196256 03/Ol/07 03/Ol/OB E°�'�'"t������� S i r 000,000 {
$ ALL OIMNED AUTOS BODILY INJl�2Y i
� . SCFIEDULED AUTOS � (Per parson) i
X HIRED AUFOS BODILY IN.II�tY a �
X NOM-OWNED AUTOS (Per acdOeM) 1
X ZSO COII1p PROPERTYDMAAGE �
X �J 0 0 �."OI.l. (Per acadeM) $
GARAOELIABRRY AUTOONLY-EAACCIOENT $ i
�
ANY AUTO OTHER THAN EA AC� S j
AUTO ONLY: AC�G S r
DCCESS1U�lBRELLA LtABILITY PACH OCCURRENCE i `
OCCUR �CWMSMADE AGTaREGATE S
� , E
I, DEDUCTIBLE S
RETENTION $ 8
�
� WORKERS COMPENSATlON AHD X TORY LIMITS ER I
A �P���� WC8196024 03/Ol/07 03/01/OB EL EACHACCmENT s 1 000 000
I, ANY PROPRIETOR/PARTNERIE7fECUTNE
� OFFICERAdEMBER EXCLUDED9
yae, E.L.(3ISEA5E-E4 EMPLOYE f 1�OOO OOO
SPECIAL�PR��OV�IOP►Sbelow E.L.DISEASE-POLICYLIMIT S� OOO OOO
OTHER
DESCREPTION OF OPERA't1�tS/LOCATIONS 1 VEMICLES/EXCLUSIONS ADDED BY ENDORSEMENT t SPECfAL PROVISIONS
i
1
I
CERTIFICATE HQLDER CAMCELLATI�N
Y��_Z SHOULD ANY OF TF�ABOVE DESCR[BED POLK:IES BE CANCELLED BEFORE THE EXMRATfON
DATE THEREOF 7HE 1SSUIN(�INSURER WILL ENOEAVOR TO AAAIt. 30 navs w�N
TOiPll Og YS]�O11tZ1 NOTICE TO THE CERTIFICATE HOL�ER MAAAED TO 7HE LEFT.BUT FAILURE TO DO SO St#ALL
ATTN: P@Z1n].'t D�pt 1MppgE WO OBLIGATION OR tJA61lITY OF ANY IaND UPON THE INSURER,I7S AGENTS OR �
1146 Route 28 i
S. Yarmouth, I�► 02664 r�rn�s�NTaTnr�s.
nur s�arn
4 i
ACORD 25(2001/08) �ACORD CORPORATION 9 988
TOV�N OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IMENT
PERMIT NLTMBER: #08-057 FEE: $75.00
In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted ta
Davenport Realty, 39 Todd Road, Sauth Yarmouth, MA.
Whose place of business is: Blue Rock Club Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth ` �
Pernut expires: December 31, 2008 Bot�tD oF HE�.'rH: �fe�e,ri SR�a�, J`�.JV., C�uxnuuz
SEAITNG:83 ���1�¢4 .�.��C��'G� v�lCe��IXIX��Llrtt
xEs1'x[Clzoxs: Packaged chips,candy,chewing gum only. J►�QJY�3.��YlltU�t, �X,QXI�
Qttlt , `.l�..11r.
December 6_2007
Bruce G.Murphy, ,RS.,CHO
Director of Health
THE CONIMONWEALTH OF MASSACHUSETTS
TOWN OF 3�ARMOUTH '
PERMIT NUMBER: #08-443 FEE: $50.00
This is to Certify that Davenport Realty d/b/a Blue Rock Club, Inc.
39 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
COMA�ION VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2048 unless
sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the hcensing authorities.by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .���e_ee��rt�t_S� Rt��af�, `J�..N�., �'l��a1vrnuut
SEATING: 83 �.(su�sr.� .7L..�,�1�R1lG V[CC��l1Y.iN�ICfL
� 5�a�ct�.J`3acotun, C'�cP�
C�iu� , J�t..N
December 6.2007
Bruce G.Murphy, ;R.S.,CHO
Director of Health
� • '
� THE COMMONWEALTH OF MASSACHUSETTS
;
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #08-032 t FEE: $75.00
� This is to Certify that Daven ort Rea1 dlbla Biue Rock Club Inc.
39 Todd Road, outh Yarmouth MA
IS HEREBY GRANT'ED A PERMIT
To Operate a Public, 5erni-Public Swimming or Wading Pool
At Blue Rock Club, Lnc_ - OLTTDOOR POOL
39 Todd Road
Sq��h Y�rmouth,.MA
This permit isgranted in conformity with Article VI of the Sanitary Code of The Commouwealth of Massachusetts,and
expires December 31_2008 unless sooner suspended or revoked.
December 6_2007 BOARD OF HEALTH: `.�E�i►Z$�(t� �..lV., �p.l�Ylfi�tt
('Igcrxl'¢� `.�'�.�eP.�i�r.e�c 21ice('f�avYritlXtt
I ����r�.cwa,�
�
;
�
Bruce G-MmP Y� , • •,
- Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARM4UTH
BOARD OF HEALTFI
PERMIT NUMBER: #08-0i2 FEE: $75.00
This is to Certify that Davenport Rea1ri d/b/a Blue Rock Club, Inc.
39 Todd Road, South Yarmouth. MA
. HAS BEEN GRANTED A LICENSE TO
ENGAGE 1N THE BUSINESS OR PRACTICE OF
-GIVING OF vAPOR BATHS
This�.icense is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Secrions 51,of the
General Laws,and amendments thereto,and is subject to the proyisions of the Laws of the Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the
occupation so licensed as adoptetl by the Board of Health,and expires December 31,2008 unless sooner revoked
December 6.2007 $OARD OF HEALTH: `.�E¢�¢ft S�� �.Jv.� (��y�tltLut
. (',/r.ac�cee� .�.9'f.eP�fl�ex `1�ice(.f�c�uurntan
J��ct�.�cawrri, C'�ex�
Qrzrt C��ceert�atcfn,J2..N'.
B ce G.Murphy, , .5.,CHO
' Directar of Health
�
a og r
� 1 1J VY � V F � 1� � � 1J V � .C3. Health
_
Division
E 1 l46 R4UTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 "
� 'a"'"°"°� Telephone(508)398-2231 Fax{508) 760-3472 Building
l ' Division
�
November 8, 2407
i'
iDavenport Realty Trust
� ci/b!a Blue Rock Club Inc_
� 20 North Main Street
j South Yarmouth,MA 02664
Re: 2008 Motel Licenses
Dear Motel Owner:
As you aze aware, the Town of Yarmouth is working to facilitate the motel license process to
encowage the appropriate utilization of motel properties. To that end, the licensing procedure
has been reworked, and additional materials developed.
Enclosed please find the following materials relating to your 2008 Motel License:
• Application for License/Permit
• 2008 Motel Census
� Mrrt�l Li��se G�i�lelines;/Process Flavvchart
• Motel Use Inquiry Fonn
Please complete the application and census according to the instructions provided. Please note
�h�t�pplication materials�re-to be f�led with the Health Division by December 14.2007.
The Motel Inquiry Form is being provided for yow convenience, should you have a question
regarding the curr�nt u�ilization of your property for non-transient use.
Questions regarding non-transient use or the Motel Inquiry Form should be directed to the
Building Division, 508-398-2231, e�rt. 26I. All other questions should be directed to the Health
Division, 508-398-2231, ext. 24L
Thank you in advance for your cooperation.
Si ely,
�
Bru G. Murphy, Director of Health
� c,�-s...� � ����r-��
_ mes Brandolini, Building Commissioner
fi ti,_�
� aw
�°�_Yaa � , C UD
.-__�o TOWN OF YARMOUTH BOARD OF HEAL�$�� �$�
o �'y APPLICATION FOR LICENSE/PERI�IIT-Z00���� Z�DEC 0 7 2006
F � . ./? "
* Please complete form and attach all necessa�-y'd �''m�t�=�y=D mbe .H
• Failure to do so will result in the returr�of�our application packet. �ErT.
NAME OF ESTABLISFIlViENT: ��� ��I� L TEL. # 52��3 i�'-G�i��-
LOCATION ADDRESS: �� T� � � Q � Q „� ��� � -�� �
��; MAILING ADDRESS: C� �c. ���� L �GC�,������ �'y , � '> ��
OWNER NAME: v f � � 0 r ' � . ��� ���u T r � � ���
CORPORATION NAME APPLICABLE): �
�' MANAGER'S NAME: ���1 S✓�'� i �'l� � TEL. # Sp�-�i�-�i��
�a.a,rNG a��xEss:� ��ro�11d �'� � ���-- ������ f�.. Y�'I�, n� ����
POOL CERTIFICATIONS:
1fie pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s)and attach a copy of the certifica,tion 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 Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
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 aze 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 establishmen�
1. 2
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
I
� HEIMLICH CERT'IFICATIONS:
! 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.
� �
� RESTAUR.ANT SEATING: TOTAL#
1
Lonc�rrG: OFFICE USE ONLY
, LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE pFRMIT# LICENSE REQUIIZED FEE PERMIT#
; _B&B �50 _CABIN S50 MOTEL $50 -�0 7—(1 Z/
' _� $50 `CAMI'
$50 / S G PooL$75ea. �Q7—U 3 7
{ _LODGE $50 _TRAII,gRpqRT{ $100
---__—------- � POOL $75ea.�d7'4l�o
----------------------- - _ --
FOOD SERVICE: —— ______
LICENSE REQUII2ED FEE PERMTf# LICENSE REQUlRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
� �0-100 SEATS $75 ���06� _CONTINENrAL $30
NON-PROFIT $25
_>I00 SEATS $150 / COMMON VIC. $50
U7—�.� WHOLESALE $75
RETAIL SERVICE: —
—RESID.KTTCHEN $75
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
,<50 sq.ft. $45 _>25,000 sq.ft. $200
VENDIlJG-FOOD $20
_45,OOOsq.ft. $75 _FROZENDESSERT �35
TOBACCO $50
NAME CHANGE: $10 AMOITNT DUE _ $ 3 ZJ'�•OO
""�"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
..... ;
�
I
_ --�. �__— _ __ _.---�--_1
__
_ ,
E..
,
ADMIlVISTRATION
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
OR ' /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V
Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID:
YES� 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 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 u�it 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 amended, sha.11 generally be considered Transient.
�
PUOLS
POOL OPENING:All swimnting,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to ogening. Contact the Health Department to schedule the inspection five(5�days
pnor to opening. �
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground svvimming pool Fnust be drained or covered within seven(7)days of
. _ -- -
_ _ --- _
_ _---
closin�. __ _ _ _ r
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filin�the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ob#ained at the f
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 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 approvai from the Board ofHealth.
i
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 RESPONSIBIIITY TO RETURN
'TI�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY POOD ESTABLISFIlViE PTR, M�OD Y�,� OARD O HE�.I.H P OR
E Q U Il'ME N T,E T C.),M U S T B E R E P O R T E D T O A N D A P �
TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
;
;
DATE: II ��G ' ��� SIGNATURE: Gc� ���c�c�-�� '� � � � �
PRINT NAME&TTTLE:_ C�r�c� !�u�✓� �� /� s 5 fi � Cn��/(�,� '
;
ion�io6
R
+ �
�
` � Feb. 24. 2006_ 4:04PM No. 8554 P, 3
ACORD. C�RTIFICATE 4F LIABI.LITY INSURANCE �°EN 1 �'oz a4 06'
PRpDt10ER TH18 CERTIFICATE IS ISSUED AS A MATTER QF INFCRMATlON
• ONLY AND CONFERS NO RIGHTS UPON THE CERTIFtCATE
The Add.is Group, Iac. HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXy'�ND OR
i
2500 Reaaissance Blvd. Ste lOp ALTEIeTHECOVERAc�E,4PFORDEDBYTWEPOLICIESBEI,OW.
Iiing of Prussia �A 19406-2772
Phone: 5Z0-279-8550 F'ax:610-279-8543 INSURERSAFFORDINGCOVERAG� NA1G�
���� INSURERA: Amnrsmn zurid�xa.ursnao oo. 401d2
8 Lte ROCk C111b o�esu�Re: s�iob�ionn Sasararic!CO. 1$535
c�o Daveaporb R�alty Trua� �u�Ra
3 hera Aschettiao _ �
3o��t1z��Ya��ouiths� 02664 . �s�Ro- !
' INSURER E:
COVERAGES
THE POUGES OF 1NSUFiANCE USTED eSt,pw f1AVE emv�ssuE�YO Tr�e naSUREo raMED,aBOVE FOR THE POLICY PERIOD INQICATEo,ntp�wm�srnMOING
ANY REQUIREMEKT,TERM OR CONDRION OF M�`G9Ni'RACT oR OTHER DOCUMEN7 WITH RE3PECT TD WHICH THIS CEft ilFICATE MAY BE ISSUEo oR
MAY PERTAIN,T►1E 1NSURANCE AFFOROED BY7tiE POLiCIE3 DESCRIBED HER@IN i6 SUBJECT7'0 RLL'IHE TERNIS,EXCCCigloNs ANO CONORIONS OF SUCH
PDUCIEs.AGGREGATE LIMITS 91i0WN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS.
L7R INSR TYPE OF INSUAANCE POLICY NIIYBER p,p E YI DATE M uM�
G�NERAL L1l1BILiTY EACH OCCURRENCE s 1 0 0 Q,Q 00
a g COMNERCYLLGENERALLIABILI7Y GL0819625504 03/01/05 03/Ol/07 pR9rIlSES�Eaawrcnre s 500 000
CWMBMADE x�occuR ��c��a��, a so,o00
PER$ONK 8 ADV INJE�lY S 1�O OO t OO O
GENERALAGGREOATE i Q �QQ QQO
GEN'tAGGREGA7ELIM�TAPPUE6PHft PRODUCTS-COMP/OPAGG S1�OOO,000
POLICY JECT LOC
atrro�o��uAeairr
B nNrAuro SAF81962560� 03/OZ/06 03/Ql/07 �e'��'�LEL@AIT g 1,000,000
X ALL OWNED AUTOS � BOOILY INJURY
SCHEDULEDAUTQS (p�pef°0^J S .
X HIRED AUTOS + ,
BODILY 1N.IURY § �
X NON-0WNEDAUTOS (P°��
x 250 ca� ;
, 8 500 Coll
P�d�a�E a j
�
j C.ARAOE LNBILITY AklTO ONLY•EA ACCtOENT S . �
'�A�fl , OTHERTHAN �ACC !
AUTO ONLY: AGG S
IXCE65NMBRELLA LIA911TTv EACH OCCURR�NCE S ;
OCCUR �Ct.A�LA5 MADE AGGREC,ATE 5 I
S �
DEDUCTIBLE • $ i
RET�KTION S S !
I
YYORKER3 CONP�NSATION AND X 70RY LIM R �
ElIPLOYER$LWBIf.ITY
A ANYPROPRIEfOR/PAitiNEwFxECUTNE �g19602409� 03/01./06 03/OX/07 E,�,�ncN�nerrr s1,000,000 °
OFFICERIMEMBERF�CCLUDFA? E.LD13EA3E-FAEMPLO S 1 OOO OOO , f
,'' 1fy�ciescribe u�der
I SPEC1At PROVISION3 below EL�IfiEASE-POLIGY LIM17 S 1�OO O�O O fl i
' OTNBR �
� �
i
. �
� OESGAIPTION OF OPenqnqNs��ocanoNs�va�KxES r IXCl.usi0t�ADDED BY ENDORSEMEN7!&PECu1L PRDv�SIONB i
. i
i
i
I
CERTIFICATE HOLDER CANCELLATION I
��2 SHOULD ANY OF 7'Fi�1►80�DESCR�ED POLICIE9 BE CANCEL�ED BEFORE THE EXPIRA7ICN I
� DATE 7MEREOF.THE 13SUINQ IN9l1RER 1Mi1.ENDEAVOR TO AWl 3O OJ1Y$WF�ITTEN
TOiOl1 Of YBSmouth NOTx�TO 7'HE CERSlPfGATE HOLDER NAMED 7'017�1E t.EiT,BUT FAILURE TO Do 30 SHALL
ATTN: Pesmi t D�pt. �MPOSE NO OBUGA7IQN OR VAHIUTY oF ANY qNo uPON THE W9l1RER,1T5 AGENTS CR !
� Route 28 reEartEs�nrranves. '
� S. YAXm01�fih r MA 02 664
�R�E�yREPR NTA
��
ACORD 25(2001/08} �1ACORD CQRPORATION 1988
,� ,
� The Commonwealth of Massachuset�s
, Depairirre�t of Industrial Accidentc
����
� 6(16 R'ashington SYree� f"`Floor
= Bnsto�,Mass. 02111
- — _-------- Workas'Com Uoa Ias�asce Affid�vih Ba� ' ' lectrieal Co�tract�ors
.
.. . w___ W . , �. � ,. ...-_ .,�._ . � , v , ._ ,;�,
n, . �
name:
address-
� s�te: zin_ ehoae#
work site locatim�(fnli addressl:
❑ I am a homeownet performing all wo�lc my�elf. Project Type: ❑New Ca�ructi��Reanodel
I sole and have��e w in an ca Buil ' Additian
I am an employer providing wo�ers'compen�i�fa�r my e.mployees working a�this job.
t,�'� �C:'�--- (�-l�� �—
j � �� �
. ���`,y,.ld ' �3���f . ��" '3`1 -��'f�
�` � ► � (�D �
❑ I am a sole praprietor,g�ral ca�tracter,or Lameewter(�arde o�re)amd have hired the co�ractois listed below who have
the follow'in8 w'orke,rs'co�ation Polices:
��: �
� �'a. , ��..
, �
�� w
ad�: :
�r: ,�
FaYtrc M aee�e crMera�e as reqieet uder Seetln 2SA d11lGL 1S2 eu Ind N tlie 6rp��f ai�ial pnallia�[a fe�b�f1,3M.N a�dl�r
e�e yeaes'isprhw�t as wd as cM pwpin ia tde fa�ota 31�01'WORK OBDER a�d a Ane�f S1N.M a day��e. I adas�a�d tluKK a '�
dpy�f tl�fh�my 6e firward�b He 018ce otlm��f t6e DIA fir av�a�e veriaeatlw. ,
I�fo Ard+tby cer(rfy xnder tlYe paF�s aed pe►�ndt�es ojper�rary tlYet tJie iufor�aado�pro�ed aboue ia lrue ahd on�
Sirtna�v�i��G7�?�//:��2C-�%,�� Date //c�O��Ca
Print name Ct�'l� / � i"'/ �L�!'� Phone# � ��'�l�`��,� ��
e�t me only de a•t�rrlte i�th�atsa fe be oe�plaed by dt9 Ar irws e�cLl
cky or tewn: perm�ce�e# Depatrest
❑eYedc if�dia�e re.�pene ie reqQed �'s O�ce
QNealtl�D�u�t
c�et Pet'seo: Ph�ae#1; QOmer
cn.�.m s�p-zoa+�
THE COMMONW�EALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-016 FEE: $75.00
�
; This is to Certify that Davenport Realtv Trust dibJa Blue Rock Club, Inc.
39 Tadd Road, South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE BUSINESS OR PRACTICE OF
-GIVING OF VAPOR BATHS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the
General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the canying on of the
occupation so licensed as adopted by the Board of Health,and expires December 31,2007 unless sooner revoked.
' January 31.2007 BOAI2D OF HEALTH: B �. ,/��., "
d�e&�e��t��'lr�, �sc��viinu-�
Rod�tt�Bnar�un, C�
� ������
ruce G.Murphy, .S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-037 FEE: $75.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club_ Inc. .
39 Todd Road_ South Yarmouth,MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Rock Club, nc. - O _ OOR OOT
39 Todd Road
_ South Yarmouth, MA
This peimit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2007 unless sooner saspended or revoked.
Januaty 3 L 2007 BOARD OF HEAI,TH: B �. ,/��.���
���s�, ��v.�, v�
. R�d�t� B�, Gl�
A�f��l�s�,tt .
�!�� ,R.N.
Director of H�ealhtyh� '
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #Q7-046 FEE: $50.00
This is to Certify that Davenport Realty Trust d/bla Blue Rock Club, Inc.
39 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALI�ER'S LICENSE
In said Town of Yarmouth and at that place only and e�ires December thirty-first 2007 unless
sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendrnents thereto.
In Testimony Whereof,the undersigned have hereunto a.ff�ed their oflicial signatures.
SEATINCr. g3 B4ARD OF HEALTH: �e���_`n. �o�ii�s, �l$., .
�r� .�., v�e�.�
Q�t� a�, �►�
� A�ht��ott
� � �!�Cj�teerrd�r�r�c, R.N.
January 31.2007
. _ _ __ Bruce G.Murphy S.,CHO
Director of Hea1 � �
___ _ _
_ __
. . . _
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #07-066 FEE: 75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Davenport Realty Trust, 39 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Club Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2007 BOARD oF HEAI,TH: B �y�y`}S. ,/l�l.$., '
SEATING:83 �e���c�, �''�`y, v�e���
1zESTTue'rtoNs: Packaged ctups,candy,chewing gum only. /�o�iwlr�� Bfi�iuwt, ��
� nc�ltcla/�la.�` �
�!����, R.N.
_ January 31.2007
Bruce G.Murphy, ,RS.,GHO
� Director of Health
�
� - , . , • �
' THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
� BOARD OF HEALTH
PERNIIT NUMBER: #Q7-021 FEE: $SQ.QO
This is to Certify that Daven�ort�Trust dlbla Blue Rock Club Inc
39 Todd Road, South Yarmouth,MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MC?TELS
Tlus License is issued in cc55nformity with the authority granted to the Board ofHealth,by Chapter 140,S�tions 32A,32B,
32C,32D and 32E as amended,and is subj�t to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and�nditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and e�ires December 31,2007 unless sooner suspendecl or revoked.
J��y 3 i.Zoo� Bo.4uD oF��.�rx: � ��5. , A9.�., .
��s�, ��e��
R�t� B�, et�
A��t��t
�4.�l�n��,R./Y.
ce G.Murph H,R S.,CHO
Director of Health
a
' . y : C�1�'°", ,; ���BW�Rock G,�$���.
�°`,s R� TOWN OF YARMOUTH BOA. O��E�I�TH
o: -� APPLICATION FOR LICENS�E/�`E � '200`6 � � � � � 1Yl C �
� , ,�? �,-
� * Please complete form and att�ch all necessary documents by Dece ber��2�0�.2005 �
Failure to do so will result in the return of your application p ck�. +
� HEALTH D PT. �
' NAME OF ESTABLISF�VIEEN'T: �j'U.IF �('a� Ct� P� I�JG �L. # 5�8�3�18����Z
� LOCATION ADDRESS: '
�u.rlvG avD�Ss: �i xl � . � D
OWNER NAME: 1 D T T T ID E r -
CORPORATION NAME (IF APPLICABLE): -----
MANAGER'S NAME: �C�/� �/j �-(�� TEL. #
MAII.ING ADDRESS:�°! TD�L`� �OA�-i7 � �P.M O 1 lvl�r �2(0 �-
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool f the certificatian to tlus form.
G/ � /y!yl.Qcr�G�,¢c.Y� j�y �S'�i�'`
; 1. -�. -�r �.�E- �r���� 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 o£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
1. J fLS'�`R�Gt ��D/f 2. �if �M/T�Y'
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 oot use past years' records.
You must pravide new copies and maintain a file at your establishment.
' 1. ��' ���ivE(� 2.
_ PERSQ�T Il�GHAR�'iE; _ - -- --___ _ _ _ _. _
- _ _
Each food establishment must have at least one Person In Charge(PIC} on site during hours of operation.
,
l. �'�55� ��r��T 2.
i
� HEIl't��H 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
� attae�i enpies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fite at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
.
OFFICE USE ONLY
LODGING:
i
i LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 _CABIN $SO �MOTEL $50 OG-��3
_INN �50 CAMP $50 I SWIlvgVv1Il�TG POOL$75ea. �(��'OZQ
_LODGE $50 _TRAII,ER PARK $50 �WHCRLpOpL $75ea.�rrrc,l_�o�(� '
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
( 0-100 SEATS $75 �Oto'D�o� CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 � COMMON VIG. $50 �d�0^D�q _WHOLESALE $75
RETAIL SERVICE:
LICENSfi REQUIItED FEE PERMTI'# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# '
_<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20
_QS,OOU sq.ft. $75 _FRQZENDESSERT $35 _TOBACCO $25 '
NAME CHANGE: �10 AMOUNT DUE _ $ 3 25.QQ
iY R R R RpLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM*"""" ���
�.� r. ,�
� ., _�;. I
• W= �
ADMINISTRATION
Under Chapter 152, Se�tion 25C, Subsection 6,the Town of�armo�tth 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 4
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
�
i
CERT. OF INSURANCE ATTACHED �
4R
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�_ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETL7RN
TI-�COMPLETED APPLICATION(S)AND REQUIKED FEE(S)BY DECEMBER 31, 2005. �
SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- `
10 DAYS PRIOR TO OPENING FOR THE SEASON. �
f
. �
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMN�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. '
ADDITIONAL REGULATIONS '
;
�
POOLS �
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspecte�
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSUMER ADVISORY: �
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
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. �
FROZEN DESSERTS: ,
- ---�c�gss�s�st-�-t�st�-s�� m�t�ly basis hy-�St�te�rtified-lab�-�es�results�nusibe sent�a-the�Iealth_ ._ �
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut 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 ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food roduct b a ail or food service establishme�t is prohibited.
DATE: �2�5 Z00� SIGNATURE: �
i
PRINT NAME&TI E: �U �
09/28105
I
�
� �
l +�..^.
� , R ,
� ` �
_--==_� The Commomvealth of Massachusetts
==�- Deparrir�ent of Indrts�inial Accidents
__ _ _ ���i
- -= 60e R'ashi�gtoa Stree� f"`Floor
-_-�,.,°'` Bo�ori,Mas� OZIII
,..., _
� Workus'C��aatio�I�s�aace Affi�vit:B'il ' bi��lectricat Co�tnctors
,..,�..., ,
� . �,. _ . � � .,:._ _. ... .,
, ,�,: �� _ � „ .. ., .
, °�. ;, ���
name:
address-
citv_ �s. zio• r�#
work site loc�ti�ffnll address):
p I am a nomoo„m�perf�g au Wo�m,�elf rro;ecc T,�pe: ❑xew ca��rucaa�px�naaea
I am a sole 'etar and have no one w in an Buil ' Addition
('�I am an employer�oviding wa�s'cflmpensatio�fa�r my�nployees warking an this job.
__ �,`_'�-- — ------ ----
�o�: �e.,� t7.�C�— �u�� lN�. _
�: �t Ta7� �Z.(a�
�. �, `/��2u1 o tl�"� � I✓1�- l>?1�,�� �� 5U� -�'g l�l�2.
� INS .Cp C bZ.�I-O
❑ I am a sole praprietor,geaeral co�tractor,or�omeewae�(crrde o,�)and have hinad the contzacstais listsd below wla have
the following wo�lc�s'comp�n polices:
a�v: �
�
�tr m�a:
�:
ettr: �s�h
Failm�e r seem a+�e a�reqai�ed nder 3eclba ZS�A�f MGL LS2 ea�Ind b tYe irpilMr�tcrf�ial pnal�e�a�se�b S1,3N�M a�/�r
e�e years'isptiwaeat as wd as civ/pmkies ia trc fira�ota 31�D!'WORK OBDER aad a A�e df10l.N s day s�aair��e. 1 odets�d tlut a
c�py ef tY6�tt1m�my be foiwardcd ts He flAlee o[Isratlptl�e�t lre DIA hr aven�e ver�atlw.
I do IYenby c r Nie polies on/perur![�of perjrrry tlYat tlie ixforw�ton prov�ded eboae ia dus awd aom�
�s� nm Z ! ��"
P' name c�� ` Phone# '%��ZsZ�I
effi�ia1 ase o�ly ao aoc.rrlcc is t6i.area a ne aapiaed by dly er 1n.a o�al
dly ar ts�vn: p�� ��
❑c�edic if�t1e mpsase is req�ime.vl �
�dect�n's�oe
�lfaMk De�ar�t
(��• P�we#t, �
�
; •
AcoRo, CERTIFICATE OF LIABILITY INSURANCE oP,o �l DATE(MM/DD/YVYY)
DAVEN-1 03 02/05
pRooucea THIS CERTIFICATE IS ISSUED AS A MATTER 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 COVERAGE AFFORDED BY THE POLICIES BELOW.
; King of Prussia PA 19406-2772
Phone: 610-279-8550 Fax:610-279-8543 INSURERSAFFORDWGCOVERAGE NAIC#
� INSURED � � INSURERA: American zurich insurance co. 4�142
Blue Rock Club INSURER B: zurich 7unerican Inaurance co. 16535
c/o Davenport Realty Trust wsuRea c:
' Stephen Aschettino
� 20 North Main St.. INSURERD:
5outh Yarmouth, MA 02664
INSURER E: � � �
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOFi THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM Ofl CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W�TH RESPECT TO W HICH 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � �
LTR NSR �� TYPE OF INSURANCE POLICY NUMBER DATE MM/DDN DATE(MMlDDN� ��UMITS
GENERALLIABILITY . EACHOCCURRENCE $l�OOO�OOO �
� B X COMMERCIALGENERALLIABILITY� GLOSZ9E)2�3r'JO3 � Q3�O1f OS O3f O�.�OS PREMISES Eaoccurence) � �J00�0�� �
� CLAIMS MADE ��OCCUR � . MED EXP(Any one person) $1 O�OOO
PERSONAL&ADV INJURY $1�OOO�OOO �
� - � GENEflALAGGREGATE� $2�OOO�OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 1�OOO�OOO
POLICY Pp0• LOC
JECT
AUTOMOBILE LIABILITY
B ANvnuro BAP819625603 03/01/05 03/01/06 COMB�NEDSINGLELIMIT §1 QOQ O��
(Ea accident) � �
X ALL OWNED AUTOS
BODILY INJURY $
. SCNEDULED AUTOS� � � (Per person) �
X HIRED AUTOS �
BODILY WJURY �
}( NON-OWNED AUTOS . (Per accident) �
X ZSO CO[Rj� PROPERTYDAMAGE $
X J��� C011 (Peraccident)
GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $
ANY AUTO EA ACC $
� OTHERTHAN
AUTOONLY: pGG $
EXCESS/UMBRELLA LIABILITY � �EACH OCCURRENCE $.. �
OCCUR �CLAIMS MADE AGGREGATE $ ��.
8
DEDUCTIBLE . � � a �
RETENTION $ a
WORKER5 COMPENSATION AND X TORY LIMITS fR '
A EMPLOYERS'LIABIUTY WC819602408 03/O1/05 03/O1/06 E.LEACHACCIDENT $1 QQQ QQQ
ANY PROPRIETOR/PARTNER/EXECUTIVE � �
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1�OOO�OOO
If yes,describe undei $�'O Q O'o 0 0
SPECIAL PROVISIONS below E.L.DISEASE-POLIGY LIMIT
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
� YARMO-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEHEOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAVS WRITTEN �
Town Of YdY'IC►OL1tI1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
ATTN: Permit D@P't. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
1146 Route 28
S. Yarmouth� MA 02664 REPRESENTATIVES.
AUTH SENTATIV
4
ACORD 25(2001/08) �ACORD CORPORATION 1988
,
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
; BOARD OF HEALTH
PERMIT NLJMBER: #06-013 FEE: $50.00
�
This is to Certify that Davenport Realtv Trust d/b/a Blue Rock C1ub�Inc
� 39 Todd Road, South Yarmouth MA
� ,
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the pmvisions of the Laws of the CommQnwealth of Massachusetts relaling
thereto,and upon such terms and canditions,and to the rules and regulations in regard to said Motels so licensed as adapted
by the Board of Health,and e�ires D�ember 31,2006 unless sooner suspended or revoked.
December 30 2005 BOARD OF HEALTH: Be�t�twa�. �o?�iist,//��. '
/��//N�$�taro�`, �lsu��sc�vusuts
R�it 4 B�, G'l�
����, R.N.
i � � � �4.�g���,R.N. �
�
1
ruce G. M hy, ,RS.,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERA,TE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: #06-065 FEE: $75.00
In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a gemut is hereby granted to:
i
� Davenport Realty Trust, 39 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Club Inc.
Type of business: Food Service �
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 20Q6 BOARD OF HEALTH: Best�ruis�. (�'�S,�19.`7S.
SEATING:83 p��r�� v�e���
RESTRICTIONS: PaCkBged Chips,candy,chewing gum only. /2ti�ltt�. ��tow�ss, �
- �s� Rrv.
��r���, R.�v.
December 30.2005
ruce G.Murphy, H,RS.,CHO
Director of Hea1
}
THE COMMONW�ALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
�
PERMIT NUMBER: #06-049 FEE: $50.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club, Inc.
39 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: Berr�r�s�s `�. �'r�+xd,as,/I��5,.� � '
SEnTnvG: 83 ��/blc`.?SPJu�u�, ?/lce C:fs�i�t��rt
R�r�t�. 8��, Gl�
� �1�, R.M.
�l�(�'�ieersdr�, R./V.
December 30,2005
Bruce G.Murphy R S.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #06-029 FEE: $75.00
This is to certify that Davenport Realty Trust dlb/a Blue Rock Club, Inc.
39 Todd Road, South Yarmoutl�MA
; IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
� At Blue Rock Club,Inc. -OUTDOOR POOI,
i 39 Todd Road �
South Yarmouth,MA
This pemut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2Q06 unless sooner suspended or revoked.
n�t�so.Zoos BoauD oF�.�: ����S. �'o�.�,�$. '
p��x���t, v�e�.��
� R��e� �
� sr�, R.�v.
�4.� ,R.N.
Director of H 1th�� •�
,
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-011 FEE: $75.OQ
This is to C�tify that Davenport Realtv Trust d/b/a Blue Rock Club Inc.
' 39 Todd Road South Yarmouth MA
� HAS BEEN GRANTED A LICENSE TO
' ENGAGE IN TI�BUSINESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued in confomuty with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the
Genei`al Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachus�.ts
� relating thereto, and upon such terms and conditions,and to the rules and regulations in regard to the canying on of the
� occupation so licensed as adopted by the Board of Health,and e�ires December 31,2�6 unless sooner revoked.
December 30.2005 BOARD OF HEALTH: B �. �j�,/��. e�h�tws
n�����, v��t��
R�t� e�, et�
� �'d�k, R.N.
�I�g��,R.N.
ruce G.Murphy, ,R S.,CHO
� Director of Hea1
;
i
�
R��� '.
�°��YA�� T O �U" N O F Y A R M O U T H
� _ ; °
0N � '� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451
" MATTACFIEES �
� ��AVppATtO��� Telephone (508) 398-2231, Ext. 241 — F� (508) 760-3472
��-
B OARD OF HEAL 'I' H
To: Yarmouth Board of Health Permit Holders !� � <<^ '� i-� '��7 (� r��
F::' n �) �� <� �v:.��
From: David D. Flaherty Jr., R S. ��� " -
Health Inspector H�AL�H D�pT,
Town of Yarmouth
Re: Federal Ta�c ID Number
Date: March 22,2005
The Massachusetts I3epartment of Revenue is now requiring that we furnish detailed information
to them regarding all permits and licenses that we issue. One of the details that they require we
send to them is every establishment's Federal Employer ldentification Number(FEIlrT)ott�rwise
known as your"Ta�c ID Nwnber". This is purely for administrative purposes only.
So� businesses use tl� owner's Social Security Number (SSI� for this purpose. If this is the
case for your establishment, be assured that we will not allow this information to be public
record
Please fill out the fields below and return this letter to
Yarmouth Health Departmerrt
114fi Route 28
South Yarmouth, MA 02664
'Thank you for your anticipated compliance. If you have any questions regazding this matter,
�lease do nvt 3nesitate to cati. �'h�offce h�urs are 11rlonday to Friday, 8:34 a.m. �0 4:3G�p.�. '�d'he
telephone number is(508)398-2231,eart.241.
Establishment�c.0� ���C �y�5 �u� FEIN or SSN: � ����
Location Address: �� �� ���
�_ �
Signature:
/ � �
Print: �� �/�✓ �� Title: ���
�� Printed on
( Recycled
� 3 PaPer
r
; oppq9� fl�.. _
` ' : ''',,Gl�'� � 2
I � °f:AR�c TOWN OF YARMOUTH B .�AL � , � �G'
I 2 � _ _
, �,_ ,s APPLICATION FOR�� , -2005
.,
� •�•'� ��' ° N 0 V 1 5 2004
i * Please complete form and attach a11 nec�ary documents by Decem er 3�A2�4•DEPT.
� Failure to do so will result in the return of your applica.tion pa I.TH
;
�
NAME OF ESTABLIS�IlVIENT-i�� I�,K C� �NC, TEL # -��6�Z
' LOCATION ADDRESS: 9 D � M
� �r.nvG a�Dx�ss:2O 0�2T1-1 A�r� M MA
� OWNER/CORPORATION NAME: DAV N {�1_
� MANAGER'S NAME: K 1� SM 1�1-! T�, # -.�,- Z
; MAa.ING ADDRESS:�9 TZ�DD ROA[� Sd�TN Y�I2MOU�-1 NtA �2664
l -
� 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.
1.7b @F PpU��@ d�i�t�{ 1N�� 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). 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.
I
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 o�certification to this applicaxion. The Health Department will not use p�st years' records.
' Yoa must provide new copies and m$intain a fde at your establishment.
i
1. 2.
PERSON Il�E�-IAIZGE: _______-- _ _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2
HEIlVILICH CERTIFICATIONS: , �
All food service establishments with 25 seats or more must have at least one employee tra.ined in the Hennlich
Maneuver on the premises at a11 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.
�
RESTAUR�NT SEATING: TOTAL#
LODGWG:
OFFICE USE ONLY
LICENSE REQUIIZED FEE p�ItMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEItMIT#
_B� $50 _CABIN $50 J MOTEL $50 ��
I1VN $50 _CAMP $50 I SWII��IIVIIlIGPOOL$75es. �Q��6� :
_LODGE $50 _TRAII,ER PARK $50 �WHIIZLpppL �75ea. O ••OOa-'
FOOD SERVICE: '
LICENSE REQUIlZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT#
�0-100 SEATS $75 �05-�7 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 �COMMON VICT. $50 S��OO7 _WI-iOL$SALE $75
RETAIL SERVICE:
LICENSE REQiI1REU FEE PERM[T# LICENSE REQUIItED FEE PERMI'P# LICENSE REQiJII2ED FEE PERMIT#
_<50 sq.R $45 _>25,OOQ sq.ft. �Z00 �VENDING-FOOD $20 i
_Q5,000 sq.ft. $75 _FROZEN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ ��,$,OO '
"'•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
f11!*RR
/•, �1'
_ . __ .. � . _ �. . �. __�
ADMINISTRATION
Under Chapter 152, 5ection 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 �TATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR '
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�_ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONS�.BILITY TO RETURN ;
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2004. �
�
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPART'MENT FOR INSPECTION 7-10 �
DAYS PRIOR TO OPENING FOR THE SEASQN.
i
�
ALL REN4VATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR P40L (i.e., PAINTING, NEW !
EQUIPMENT, ETC.}, MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
;
ADDITIONAL REGULATIONS
�
POOLS
POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
i
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ;
closing. �
FOOD SERVICE
CQNSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POI.YCY•
Anyone w o 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. Thses forms can be
obtained at the Health Department.
F�20�EN 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 result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
' OUTSIDE CAFES:
' Outside cafes(i.e.,outdo�r seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by retail or food service establishment is prnhibited.
DATE: /� �S 0 SIGNA
PRINT NAME&TITLE: � � SC�{o/'77� �v�
10/22/04
�_ � • _
� .
�
, .
�
=_—--___- The Commonwealth of Massachusetxs
- Depart�rtent of Industria!Accidents
� -_- - -� N�'INi��
` _ - 600 WashiAgto�e Stree� 7`�`Floor
<
�,,,. Boston,Mass. 02111
Work�s'Com aaba�I'sora�ce Affidav�:Bail leedrical Co,haet+ars
�
name:
a�dress-
�' �• zio• nhme#
work site locatia�(fnll a�ressA
❑ I am a homoownea performing all wo�lc my�eif. Projed Type: ❑New C�ac��Rennodel
I am a sole 'etor and have no a�e w in an g� ' A��
I am an emPbY�P���S�'�'��'compea�ti�fa�r my employ�s working ar►tbis job.
_�t_.t.�F �C� � CL�,1�3 t�C
�: �9 `�D i�_1� O,�i�
�: ��� YA I�1Jbi.xT�-1 ��,�-.�9f3-6962
�
❑ I am a sole praprietor,�i cestracMr,or homeawaer(cude oue)and have hined�e cantractors listed below who v
ha e
the following workers'compensation pofices;
�_
� -
�__,
c�v' ��.
�
l�v�see
—��_
�Y: ��.
FaY�rce r see�+e c�+�era�e a�req�+ed udv Seci�2SA�f MGL L�cn lad t�lie��[cr4�in1 pnd�es�f a�e�p b t1,SM,M a�r
sse ye�rs 6ePtha��eat as wd aa dv�pau�les io tie ferai eti 3T0!WORK ORDER ud a�ne eiS1N.M a day a�aiet�e. I asdezahad tYat a
apy�f Wa�a1e�t my be firwarded M the Omoe�1mMi�tl�ns of tl�D!A ta�ava�a=e ra'Nintla.
/�o heneby ce�ify xnde�Hie pa�f�rs mi/peeRhEes of prrjury tAut tNe iefo�rrtlloA prov�ded ebovie ia bzre awd c�omcx
��� � ll I�s/G �
P��_ Ann f�1� /�e� Pbo�# 5'vP'-3��-aa9�3
effidal ase.ely a.sot wrltc ia r�is arn te ne�pl�d bY�er tawa efficfai
cily or tawn: ��
���t
❑ttecic if immediale respeme is req�red �Bsard
❑Sd�e�'s o(6ce
ceetad petsea; �0—��,,_J ���
lTMvieod Sept IOai) �#' L.M1�ae� .
�
�
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i
�
CORD CERTIFICATE OF LIABILITY INSURANCE DAVEN 1 1 �o� 2��05
� THIS CERTIFICATE IS ISStlED AS A MATTER OF INFORMATiON
ONI.Y AND CONFERS NO RICiHT3 UPON THE CERTiFICATE
The Addis Group, Inc. HOLAER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
2500 Reaaissanae Blvd. Ste 100 AL'fER THE COVERAGE AFFORDED BY THE POUCfE3 BELOW.
King of Prussia PA 19406-2772
Phone: 610-279-8550 Fax:610-2'19-8543 INSURERSAFFORDINGCOYERAGE ��t
�Nsu�o
INSURERA: Awwripn 2urich �naurance co. QO1Q'1
B].ue Rock Club uvsua�R a: z,u� 16535
cJo Davenport Realty Trust RE i i
� Ste hen Asciaettino r�suReRc: ; I�, +`��- C� (� � M _
20 �orth Main St. INSURERO: '
South Yarmouth, MA 02664
INSURER E: ? �'
COVERAGES
THE POlIC1ES OF INSURANCE l.ISTED BELOW HAVE BEEN ISSUED TO THE INSUREQ NAh1ED ABOVE FOR THE POLICY P R 01 G
ANY REQUIREMENT,TERM OR CONDRION OF ANY CONTRACT OR dTHER DOCUMENT WIT►i RESPECT TO WHICH THtS A MAY BE iSSVEO OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRISED HEREIN IS SVBJECT TO ALL THE TERMS,EXCLUSIONS AND CONOITIONS OF SUCH
POLICIES.AGGREGATE LIM(TS SMOWM MAY HAVE gEEN REDUCED BY PAIO CLAIMS.
lTR TYPE OF INSURANGE POLaCY NUMBER pq GATE LIMITS
�'�� EACH OCCURRENCE i S�OOO�OOO
B X COMMERCIAI.GENERALLIABILITY GI,pg19625503 03/O1J05 03/O1/06 ���s ea�� s500,000
cuu�s NwnE �OCCUR MED EXP(My one person} a 7.0,00 0
PERSONAL&ADV INJURY S 1�(fO(� OOO
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GEN'L AGGREGATE LIMIT APPl1ES PER: PRODUCTS-COMP/OP AGG S],l OOO OOO
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B MIYAUTO BAP819625603 03/O1/05 03/O1/06 ���� s1,Q40,000
X ALL OWNED AUTOS -
� BODIIY INJURY
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X NON-OWNED AUTOS BOOIIY INJURY S
(P�acciderrt)
X 2�JO COIItj� pROPERTY DMAAGE
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(iARAGE LIA�f�l/ AUTO ONLY-EA ACCIOENT S
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AUTO ONI.Y: qCaG S
���M�u�� EACH OCCURRENCE S
OCCUR �CLAIMS MADE AGGREGATE _
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REFENTION E
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����N�D X TORY LIMITS ER
A �ov�s u�m
a�rPRo�ierowraRrNewExecurn� �$19602408 03J01/05 03/O1/06 E.I.EACHACCIDENT s 1,000,000
OFFICERMIEMBER EXCLUDFb9 --
If�s,desaibe w� E.L OiSEASE-EA EAAPLOYEE $1��OO�OOO
SPECIAL PROYISIONS balow E�.DISEASE-POLlCY LIMIT i�, OOO OOO
OTFIER
DE8CR�i10N QF OF�iAT10N9!IOCATIONli!Vd1K�,E$/EXCL1J310N3 ADDED BY�/SPE�f:IAL PRO�OIiS
CERTIFICATE HOLDER CANCELLATION
YARMO-2 �uw a�n oF TM��eovE o�o Poix�a se��or�rne�nar
aw�'rt�.n+e�wsu�wiu.�oeavoa m� 30 a►rs w�
To�vn of Yarmouth ����c�TE�����',BUT FARUt�TO DO SO SiU1LL i
Route 28 �aoa�No oeucnrioN ae u�unr�,�,��TM���������
South Yarmouth, MA 0266� �T�
A
I
ACORD 2S(2001N8) '
�ACORD CORPpRpTWN 1988 '
�
� a � ' `
� THE COMMQNWEALTH OF MASSA
CHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-003 FEE: $?S.OQ
This is to Certify that Daven ort Rea1 Trust d/b/a Blue Rock Club Inc.
39 Todd Road outh Yarmouth, MA
IS HEREBY GRANTED A P�RMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Rh3e Rock 1 b, Lnc -OL�OOR POOT
39 Todd Road
South Yarmouth,MA �
This peimit isgranted in confornuty with Ariicle VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires D�ber 31 2005 unless sooner suspended ar revoked.
n��i.Zoo4 Boax�oF�.�: B��$. �'auP,o.�,�t�l.�. •
P���� v�e��
�' Rad�t� B�, Gl�r�a
� � � s�, R.�
�l����,R.N.
B� .Nt� , , : .,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT IVUMBER: #OS-007 FEE: 50.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club Inc
39 Todd Road, South Yarmout MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornuty with the authonty granted to�
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto a�ed their o,fficial signatures.
BOARD OF HEALTH: Berrya�x�$�y. (`�''o������ ,�l.`�r�.f .- •
3EATING: H3 A��C.l�e�s�li(ii�� (/%tig�+�lGI�/Jl�fy
Rod��i�� B�ocva, G�le�i�a
.�ele� �S'l�, R./V.
�4�!�'�.�, R.1V.
December 1_2004 ,
Bruce .Murp , ,R S.,CHO �
Director of He
;
�
1
, ; � . �
t
� TOWN
OF YARMOUTH
� BOARD OF HEALTH
!
� PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
; PERMIT NUMBER: #OS-007
FEE: 75.00
�
� In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�eneral Laws,a pernrit is hereby granted to:
� Davenport Realty Trust, 39 Todd Road, South Yannouth, MA
i
Whose place of business'is: Blue Rack Club. Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit e�ires:_December 31, 2005 BOARD oF HEALTH: �esrya�rrsut�S. (�''d�rdorz,/yJ,�S, •
SEATING:83 P���� v�e��
xEsllucT�olvs: Packaged chips,candy,chewing gum only. Qti�wlt�`� Bnou�� (�eh�
�4��� R R.N
December 1_2004
Bruce G. Murp , S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-Q02 FEE: $50.00
This is to Certify that Davennort Realtv Trust d/b!a Blue Rock Club Inc
_ 39 Todd Road, South Yazmout MA
HAS BEEN GP:ANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confoxmity with the authority granted to the Board of Health,by Chapter 140,S�tions 32A,32B,
32C,32D and 32E as amended,ffid is subject to the provisians of the Laws of the Commonwealth of Massa�husetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2005 unless sooner suspended or revoked.
��i Zooa BoaxD oF�fu.�: Be.�$. ��M�. •
: A����, v����
Rod�t 4 B�, Gl�a
��� R R.N.
,
���
Bruce G.M hy,MP .,CHO
Director of Health
i
1
�
' ' � . .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YA�RMOUTH
BOARD OF HEALTH
� PERMIT NLJMBER: . #OS-002 FEE: $75.00
This is to Certify that_ Davenvort Realty Trust d/b/a Blue Rock Club Inc
39 Todd Road South Yarmout MA
' HAS BEEN GI�:AIVTED A LICENSE TO
i E�VGAGE IN THE BUSTNESS OR PRACTICE OF
' ' - GNING OF VAPOR BATHS
� Tlus License is issued in conformity with the suthority granted to the Board of Health,by Chapter 140,Sections 51,of the
General Laws,and amendments theretq and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the canying on of the
occupation so licensed as adopted by the Boazd of Health,and expires December 31,2005 unless sooner revoked.
� n��-i_aooa. Bor�oF�.�: ����$. �'o�,�1.�. G'l���
` �/l�l�$e�au��r ?lsoe��i��
� Ro�t�B� �
' i4���6ar�,R.N.
�
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Bruce G.Muq,hy, .,CHO
Director of Health
i
�
�
� cl�.�o00�7 r �WF� cu,Q �
� �f�AR W � � I 1�' �S L�/
• �- � TOWN OF YARMOUTH BOARD OF H L'�H..;; � �
a _ _,o
} "�� APPLICATION FOR LICENSE/� I'� 2 (t4 n� ,/
. �' �'. ������/� . s'..4 a � 1 Y O Y
0 4 2003
* Please complete form and attach all necessary d ',�e � �Decembe 3�..�����..H
Failure to do so will result in the return of y application packe . DEPT.
NAMF. OF EST Ri iS'NMFNT• 1 I � (Y !'1 1 1 �� �rrr u G i 1 l n
_ ____ .�y�� . _ _ 1 L.,_ �l V I� /C TI�J _
►�1 A 12
� L
�A�TAGER'S NAME• D�N 1 i> FI�OM 11/►F�l E 12 T i �
��.�vG ADD FS�• TDDD OA D SOU yA!'1�/I �f�il-� --
POOL CERTIFICATIONS•
; The pool supervisor must be certified as a Pool Operator,as required_by�tate law. Please list the designated
+ PooT6perator(s and attach a copy of the certification to this form.
1.sU P�F C,�11 ��Ll f� @ D�N 1 N�- 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 MANA ERS - �ERTIFICATIONS•
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. 2.
-- __ _-
PERS�N IN CILARr:_ -- -- _ _— _ _ _ _ -
� Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
1. 2,
;
I�EIMLICH CERTLFICATIONS•
j All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
� 1Vlaneuver on the premises at all times. Please list your employees tra.ined in anti-choking procedures beIow and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
I You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4,
jZF.STAi1RANT RF.ATiNf�• TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERM[T#
' _B&B $50 CABIN $SO I MOTEL �50 ���0��
I —
_llvld $50 _CAMP �50 „j_SWIMMING POOL$7Sea. �oy D03
_LODGE $50 _TRAfLER PARK $50 �WHIRLPOOL S75ea. �01�-DOf
FOOD�FRVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $75 ���� _CONTINENTAL S30 _NON-PROFIT S25
>100 SEATS $150 I COMMON VICT. S50 �-(� _WHOLESALE $75
RETAIL SERVI .
LICENSE REQUIRED FEE PERMIT# LICENSE RGQUlRGD PEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_<25,000 sq.ft. �75 _ , DI:SSf;R'I' S35 _TOBACCO S25
,NAM�C ANGF.� $�o AMOUNT DUE _ $�2.5.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****"
_ _ __ _� _ ;�.-
♦ r
ADMINISTR.ATION '
�
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR '
�
4
�
CERT. OF INSURANCE ATTACHED �
Q$ �
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� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN �
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. �
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 �
DAYS PRIOR TO OPENING FOR THE SEASON.
�
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORT�D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
�
s
ADDITIONAL REGULATIONS �
,
POOLS _ :
POOL OPEI�iING:All swimming,wading and whirlpools which have been closed for the season must be inspected '
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CO�,�UMER ADVISQRY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING PO,�,,IeY•
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. Thses forms can be �
obtained at the Health Department. '
F _ _ _ __ __ _ �
• --- -
- —
_ -- -- _
�rozen esserts 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 result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUT�IDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOO�.�OO.I�NG:
Outdoor cooking,preparation,or display of any food product by a r il or food service establishment is prohibited.
I
�
�
i
DATE: // � � SIGNATURE: �
PRINT NAME&TITLE: S• • TT NU �
�
�
10/22/03
�
�- __
�
` , . �
The Commonwealth of Mossachusetts
� � Department ojlndustrial.-�ccidents
� �" Olflceoll�sll�slliis
a
600 Washington Street
' ` Boston.Mass 02111
�~ ��y W'ori:ers' Compensation insurance Atfidavit
; Aonlicant information• pq�«pg -�
I namr�
Ls�cati�n:
CI[\
nitOflG I�
� ( am a homecwner pertorming all work myself.
� I am a sole proprieror �r.,a, ha�e no one��orkinc in am•capacin�
I am an e v��i�,iino_�nrl;ers' corn-pensatior��or mti��rsaplo;�ees�•arking on this job:
�___— .
, s9mnanv name� r�UF � � � �Iv�
address•� IV�� K�t1U
s,t,�:�bu11-� YARMOU 11-4 nhone p SI.U��U�(���U�
�sur�ncecoA��tl.1C�l.fiN �K��TI ���UI[t'tNI.0 olicy# �l�U�"II[J�2`T`�b
� I am a sole proprietor. general contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the follu��in_ ��orkzr.' �ompensation polices:
comoanv name•
address•
citr: zons q•
insur�occ co, policy!!
com�anv name:
--- - -- ---—
-
_ - _ --- _ __
address: _
citv: �ee If•
insurance co. �7�
�
Faiiure to sccure covengt as requ�red unde�Secnoo 2SA of MGL 1S2 ta�iad to t�t iepo�itioe oterisi�l pe�dtla o(a 6�e ap to 51.500.00 a�d/or
one years'imprisonment a�w•ell as ciril penddn io tAe form of a STOP WORK ORDER asd a lfee o�S100.00�dar a=aiost ma I a�dersta�d t6at a
copy of thh statement may be fonvarded to the 011iee of Inve�tigadom of the DIA tor eoven�e verifibtio�.
/do hrreby certif}•under the peins and prnalties ojperjury that 1he injormotion provided abovt is true and eorrtet
Signature�.Lii.,..�–�.�/(,<.,t'Y Dsr� lI/�/U.-3
Print name _ �h�1 �I1 i II-eff' �+one� �U p-3��–aa�
., o(Ticiat use only do no�w rite in this tres to be completed by citp or town oAleial
ciry or town: Y�M�IITQ _ permidlieenu q n8uilding Departmeot
�Liceosieg Board
�cheek if immediate response i�required 261 �Seieetmenb Oflice
QHeaItA Departmeot
coot�ct person: p6oneM;_ �508� 398�2231 eat. nOthcr
.. ..� .< ��,.
�
� -
� -
� THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #04-003 FEE: $50.00
�
a �is is to Certity mat Davennort Realtv Trust d1b/a Blae Rock Club Inc
�
_ 39 Todd Road South Yarmout MA
j HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions ofthe Laws oft�e Commonwealth ofMassachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and e�ires Deoember 31,2004 unless sooner suspended or revoked.
� _ November 5.2003 BOARD OF HEALTH: �e�C�j>, l��,a,l, 'f�f),, ��
� �a�utk�D�cat�C. ?IdcC �
,�ad�t�. �naaa�, e�ik
'��c .SiEak, ��l.
i -� { ''
�� ��,Xg_ �
��-.
trttce G.Murphy,MPH,R. .,g
IIi�e�tor of Health
TOWN OF YARMOUTH
BOARD OF HEALTIi
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLTMBER: #04-008 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter
1 i l,Section 5 ofthe General Laws,a permit is hereby granted to:
Davenport Realty Trust, 39 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Club, Inc.
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: De�ember 31, 2004 Bo�oF��.TH: �e.c�D. C�,onda,c. 7�D., �alnara.�
SEATING:83 j�q,�'�j)� �� ��
ttEs'r�c'rtorrs: Packaged chips,candy,chewing gum only. �o�ent jt, �na�, ��
`s�efe�c SiFa�(c .�
�_ � �
�- �_ .
November 5 �. r.� �'"� " "
.2003 �.r
ruce G.Murphy,MPH, .S., O
Director of Health �
1
i �..
a
a •
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�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLJMBER: #04-004 FEE: $50.00
� This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club. Inc.
39 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
; COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that pla.ce only and expires December thirty-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
� licensing of common victualler's. This license is issued in conformity with the authority granted to
� the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
� BOARD OF HEALTH: �e.tJa«�t.i D. C�mrdo�c, �D., (,fkavr.�a.�
SEATING: 83 �ae�Y�Ck�CDP11Mt4tt`, �1CC ��ACQK
�OO�W�, �70QW1, �1�
, l�P�IG .��, ��G. y�
�°� �/ `/
N' l i i� ��1.:-
� November 5,2003 � � `-'��``
ruce - wP Y, �
Director of Health `-°
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-003 FEE: $75.00
1'his is to certify that Daven rt Real Trust d/b/a Blue Rock Club Inc.
39 To d Road. South Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At ' Blue Rock Club, Inc. - OUTDOOR POOL
39 Todd Road
South Yarmouth. MA
T'his permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2004 unless sooner suspended or revoked.
November 5.2003 BOARD OF HEALTH: fi'eoc��. (�%ardowc, �j>., ��
�a�iiek�1fcrD�xo�, 2lice ���
,�o�ezt�, b`'�, Gfar�
� �
,/ s��
� ;
,, �� ��.�5
'.�_�_i ,;
ruce G.Murphy,MPH, .,
Director of Health
,
,
t
i
�
� V
d
� THE COMMONWEALTH OF MASSACHUSETTS
,
� TOWN OF YARMOUTH
� BOARD OF HEALTH
i
� PERMIT NUMBER: #04-001 FEE: $'75.00
�
' This is to Certify that Davennort Realtv Trust d/b/a Blue Rock Club Inc
;
_ 39 Todd Road South Yarmout _ MA
�
? HAS BEEN GRANTED A LICENSE TO
� ENGAGE IN THE BUSINESS OR PRACTICE OF
� - GIVING OF VAPOR BATHS
� This License is issued in confnrmity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the
General Laws,and amendmerrts thereto,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts
� relating thereto,and upon such terms azid conditions,and to the rules and regulations in regard to the carrying on of the
occupadon so licensed as adopted by the Board of Health,and expires December 31,2004 unless sooner revoked.
November 5.2003 BOARD OF HEALTH: �e�rjaMct�c�. C%acde�c, �D,, �a��
,aa�&71leZ�ar.xot�, 2/tec ekavro�ra�c
j �o�e�ct�. �ro�c, el�rk
� � � ��, ��I
�� �;
--,�,
ce G.Murphy,MPH, . O
Director of Health `
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� ar .20, 2002-11 :42AM_ THE ADDIS GROUP No .8837 P , 8/14
�vRv� �;Et� � �rl�� i t c�r� ��A�ILITY tNSURANC �~�����°°�
��'° o��a��o�
PRoouCeFt - TMIS CERTI�I�ATE IS ISSUED A8 4 MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHT$UpQN THE CERTIFICATE �
The Add#.8 Group, Ts3C. . Ht�l.DER.THIS CERTIFtCATE DOES NOT AMEND,�X't'END OR ; �
�300 Re2�$�s�uCe 8oulavard pLTER TH�CpVERAGEAFFOflDED BY THE POLICIES BELOW. '
Riag o� Pz'ussia PA 194d6-2972
P1wne: 61Q-279-8550 Fax:610-Z79-8543 INSURERSAFFOEIDINOCOVERA�E
INSUR6D INSURER A A:e�,riaaa zurich 7.�a.sura�ad Cb�
Slu� Roa]s CZub INSURER B: • �
a/o D ve rt Realty Trust ,ncsuR�o:
20 bto��h�ia St. !
' 3outh Ya=mouth, MA 02664 iws�aeRo:
iNsu�A e
CQVERAGES
THE PaL1ClES OF INSURqNCE L1ST£O 8EW W HaVE gEEN I55UED TO THE iNSURECE NAMED A80VE FOq THE PQLiCY P��pp�NDICATED.NOlWRHSTANDING
ANY REQUIREMENT,TERM pp CONOITION OF ANY COMTRACT OR OTHER DOCUMENT WRH R�S?ECT TO WMICH TFIi3 CERTIFlCATE MAY BE 19SUED OR
MAY PERTAM�'i'lie INSURANCE RFFORDED BV TH�POIICIES DESCflIBED HEflEIN 13 SUBJECT TO ALL THE TERMS,E]CCWS�ONS ANC1 CONOtTlONS OF SUCH
POUCIE$.Ap�qE6ATE UMY7S SHOWN MAY HAVE 6EEN REDUi�D BY PAID CLAlMS.
i
LTfl 7YPE OF INSLIRANCE PpL(CY NUM6ER DA7'E M1D dATE A�l� I.IAAITS
GENERpL LIABILI'TY EACH QCCURAENCE $ (
COMMERCIAI QENERAL LIA8ILITY FIRE DA1Hat�e(My one nre7 $ -^r`
CLA1M3 MADE �oCCUR MBD ExP(Any one pavson) 9 -�� �
PERSONJAL&AOV INJURV S
i
GENER�.AGGR�pATE $
GBJ'4 AGGREGAT�41MIT App�lE3 PER: PROQt1C79-CdMP/OP AGG $ I
POLICY PRO•
JECT �� �
AITTOMO8ILE I.IA811.iYY
COMBINEO SINGI.�IIMIT
ANY RUrO (Ea aaid.nt) � I
ALl OWNED AUT06 i
SCHEDUIED AU't'08 BOOiIv INJUFtY $
(�ue�an)
HIREO AUT03
BODtLY INJURY �
NON-OWNED AUTOS (Par acoidan)
PROPER7Y OPMAdE �
(Peracdden�
6/IRAGE LIAHILITY AUTO ONIY-EA ACCIDENT �
ANY AUTO
OTHER THAN �ACC � '
AUTO ONI.Y: A� S
E7LCE�LIA91U1"� '
EACH OCCURHENC6 S
OCCUF �CWMSMADE AGGFtEGATE g
_ $
DEDUCTIeLE s
RETENTfON $ $ �
WbRKER3 COMPENSATlON AND X tORY UMRS ER
A EMPLOYLR3'uns�unr pq�819602405 03/41/Oa 03/01/08 �.I..EACtiACCIDEKf s1,00Q.pp0
E.L DISEASE-6A EMPLOYE �1�OOO�OQO
6.L DISEASE,P041CY L�MR �1,04Q,000
QTHER
DESCliiPT10N OF dPERATIONfIlOCA7�ONS/VEHICLE9/EXbLt131ONS ADOED 6Y ENDOqSEM£NT/9P�C�AL PROVISIONS
C�RTIFICATE HdLDER N AOPIT10NAl INSURED:INSURER LE7TER: CANCELLATI�N
YA�S��a SMOULD AI'4Y Of TtIE ABOVE tlESCRIBEO POtlCIE3 BE CANCELLED 9EFpqp Y'pE p�p�p,�7�
DATE THEpEOF,TNE[SSI,NNQ INSUNER WILL ENDEAVOR Tp Mai. _��DAYS WRITfEN
TC7NTl1 of Yn.�rivytttli NOTICE TQ THE C£pT1EICATE HOLDER NAMED TQ TNE LEFf,��IT FAlLURE TO DO 30 SXp1.L
ATTN: Pera�it TaA��".. �MPOSE N�OBLIC�UqT10N OR WABILRY OF ANY IpND Up4N THE UQSURER,tT3 AGENTS OR
1146 Route 2B
S. YAiICO\lth� Y$A O2GG� REPRESENTA7IVES.
AUTNORIZED REpq�9ENTATiVE �
St$v'e�x S. C01 '
ACORD 25-S(7/977 �RCORD CORPORATIbN 1988
MAR 14 2003`6 29�I�F�C�N� `DD��GR�O������.� �NSURANCE NU. �33 N. 1�,��,,,�o,,,,,,,,r, '
� v�ID
vEN—i 03 la o3
PR�� TN13 GERTIFlCA7E 1315SUED AS A IMATTER OF INfORMA ON
�
OI�.Y AND CONFER3 NO WGHT3 UPON THE CBRTIFICpTE
The Addis Group, Iac. H�L.DER THIS CERTiFlCATE pOES NOT AMEND,EXYEND OR
2300 RenaissanCe Soulevard ALTER THE COVERAGE AFFORD6D BY TFI�POLIGES BLI,OW. f
Kittg of Prussia PA 19406-2772 I
Phone: 610,279-6550 Fax:610-279-8543 INSURERSAFFOR�NGCOVERAG�s NAIG# !
�
�� iNsu�Ra Am,ericaa Zurich Isssurance C .40142 i
DaveAport Realty
B ue 1�ock Motor an iNsu�e: Am.�sican C�uazantea 6 Liabi�' 62�47
c o Da�aport Rea].ty Txust
sou� ar�uths,2� 02664 G�3 C C LK � ' ',
�s+��:
cav�►c�s
Tt�E PL7iJCtES 0F fNSt�lANCE LISTED BEIOW tY4YE B�N ISSLIED TO INBURED IVMAW A80VE FCR ICY PERl�ll�lCA7ED.N07WrIHSTANDW6 '
�RE4UIR�AEMT,TERM oR Ct�roR�hl�ANY GOrrTRA�T OR 7HI3 CERTIF�A'IE idAY BE ISSUW OR
MAY PERTAIN,TNE 1NSURANL'E AF�ORD�BY'filE P01:1C�S �EXCW810NS A!�C01�1710N6 OF BUCH
PC3UCIES.AGGREGAT$L�MMTS SHOWNlU4Y 11AV£6EEN R�UCED BY P,�CWMS.
,L'FR 7YPE�U�ISUNANCE ���R DATE OATE ��
c,�1�pa,uaeRmr �i►cH occu�ENOE S 1,000,000
A X ���Rcu�c�►ERAtuABN.+ri GL0919625501 03/Ol/03 03/O1j04 ises oeeuror,w s50o,000
ca:�� 0 o��,R �o�u�«��� 5�a o00
��so�.s.���uu�r $i o00,o00
�,E�nc��oa� s 2,o00,o00
i GEML AGGthEGA'fE LMMT APPLIES PEJ� PROWCTS-COMPIOP ACrG a 1,0 0 0.0 0 0
POLICY jE�, LOC
` 'AUTOMOBlLE LIABIUTY ���sMK7.E IA�T
B i adv�►uro F3AP819625601 03/Ol/03 03/01/0� :1,000,m00
X au.own►�o Avros eoa�r iNavrtr
s
scrieoui�o,au�ros �v�'r�'? �
X h��o Auros �u����
�[ �N0IWOWNED AIlTOS S
X 250 Comp ���o�� _
X 50a Coll '
ca�e un� n�rro oTux.rw nccioEH'r a
IWY AUTO OTi�R TW1N EA ACC 8
AUTO Of�.Y: q�, s
E7CCE.'SS/WM6REI.LA uABlulv FJ►CN OCCURREIVCE s
OCCUR �G.AIAAs MADfc AGGREGATE S
i
DEOUCTI@LE s '
RETENTWN S s
YyORICERS COI�eb18A710N AMD X �
E116PI.d1►ERS'LJA81lf71f
A �,P�R��.��,.���yE �C819S02406 03/Ol/03 03/�1/04 E�,EncHnr.c�Ewr s1,000 000
����eFx�cwD�r �.L,Dta�nse-�+ 51 OOO OOO
{�fy����°'�e1g1°� • E.�.p�s�se•aoucr�x�ttr sl 000 000
SPECIAL PROVISIONS below
OTt�
f
�TION OF OpERAATlONS/LOCATIONS!V'�E91�CI.tIS10NS ADDLO 6Y ENDOR8E61ENT/SPECI4L.PROVISION9
FPsX: 508-39B—OB36
MAR 1 4 2003
LICENSES & PERMITS
CERTIFiCAT�HOLDER �C���
YAMOII-1 stiotlto�wv oF-n+E neo++E oF.S�ISEo valc�s eE GwcE1.I.Eo sEFox�n+e�IRI►no
GA�E THEf�OF,TNE 1&S1�W,URER vWl.L[NDEAVOR TO MAN. 3� pAYS WRfTiEN
Towa of Yarmeuth No-rrce m�r►�e cr�cAre Ka.u��t�o ro tt�E�r�Bur Fw�.ur�m oo�sw►u
ATTN: LiC�SS53.a J D�i'"' IdIPOSE NO OBLIOAt10N OR LIA8IU11/�{WY N�ID UPON TNE INSURER 178 A6ENT3 OR
1166 Route 28
S. Yarmouth, I�a 02664 R���ATM�
Atl7'tw�¢ED R�RESENTA7Ne �
.��
S E. Coll' s
ACORD 25(7A01/08) �ACaI�CORPORATION 198
I
♦ • �
f
THE COMMONWEALTH OF MASSACHUSETTS ;
TOWN OF YARMOUTH j
BOARD OF HEALTH '
PERNIIT NUMBER: #03-017
FEE: $50.00 �
�
't7�is is to Certify that Davenport Reatty Trust d/b/a Blue Rock Club Inc. :
39 Todd Road South Yarmouth_ NIA ;
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issuetl in conformih+with tt►e audiority ganted to 1�e Board ofHeatth,by Chapt�i40,Secti�s 32A,32B,
32C,32D and 32E as�mended,��is subject W the provisions ofthe Laws ofthe CommonwealW ofMassachusetta relating ';i
thereto,and upon such�erms md�nditions,and to the rules and regulations in regard:�o said Cabips so licensed`as adopted ;
by tlie Board of H�a1th,and expires December 3:1,2003 un�ess sooner suspendecl oc�evokec�� :-� � ~ '
-'� � ���December 18��- ,2002� ° BOA�tD OF HEALTH: �le�t�'r�,: �tf�tar (��a �� �� f
a'e�ic�ni�e 2J.. G�wna�,c. 7JlG.D.. �l/iee
,�a��> �roaeaac. ��
�a�ek 7�D�
�ele.�Skak, �7Z
, �G.M�hy, .s.,c,�o :,
� Director of Health 1
� � � . �
,. _� ,, � _ _...a�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT � '
PERMIT NUMBER: #03-065 : FEE: $75.00
In accflrdance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter �
111,Section S of the General Laws,a peimrt is hereby granted to: _
Dave�ort Realty Trust,39 Todd Road, South Yarmouth,MA
Whose place ofbusiness is: Blue Rock Club Inc.
', Type of business: Food Service '
;i To operate a food establishment in: Town of Yazmouth
;
� Permit expires: December 31,2003 Bo�oF xEAL't�: �kanlea?� �ef�i. ��x�
s��rn�rG:g3 �u�cfa�ct�c�. C�azdar. 71lC.D.. ?l�cc
� ttEs'rx�Crtol�ls ��: Packaged clups,candy,chewing gum only. �o�art�• �aaaac• (�ack
;
�a�rlck�'Dattirot�
��s�. ��
December 18 ,2002
ruce G.Murphy, RS.,CHO
Director of Health
! �
�
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLIMBER: #03-041 FEE: $50.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club. Inc.
39 Todd Road, South Yazmouth,MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that plaee only and e�pires December thirty-first 2003 u�iless
sooner�spended or revoked for viola.tio�of the la.ws:o�the Commonwealth r�specting t�e ,
licensing of common victualler's. This license is.issued in�onformity with the authority gratated to
�.. the kc�ns�g authorities by General Laws, Chap�er 140, and amendments thereto. < : , . ; .. ,
y 4 � 'gn a.�ced their oi�icial signatures.
In Testimon Whereo the undersi ed have hereunta
t: . , �
BOARD QF�ALTH: �a�?f. ��. Lkavur�a+�
: ..- SEaTING: 83 �'urc1a«ru�c'D, G�iozalo�, 7K 9., ?/�te '
�o�e�ct�. �, (,Jl�tk
�a�r�ek'yll.c'D�rr�xott
S �72.
December 18 ,2002
_ � y, . .,
' Director of Health
.. .. � �_ : � �. . �
�., � �
THE COMMONWEALTH OF MASSACHU�ET�'S,
TOW1�I OF YARMOUTH . :
BOARD OF HEALTH
PERMIT NUMBER: #03-033 < FEE; $75.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club Inc.
39 Todd Road South Yarmouth,MA '
IS HEREBY GRANTED A PERIV�I'r ' , ;. -
To Dper�te a PubGc, Se�ni-Public Swimming or Wading Pool
At Blue Rock Club Inc. -OUTDOOR POOL -
39 Todd Road __ ___ .
South Yarmouth MA .
� This permit is granted in confarmity with Article VI of the Sanitary Code of The Gommonwealth of Massachusetts,and
expires December 31.2003 unless sooner suspended or revoked. _
� December 18 ,2002 BOARD OF HEALTH: �a�d�f; i�e1�, �a.vc�raa
� $'e.,c1a.xi�,c?>. G��da�c. 711G.�.. `�/1ce
j � � � ��3. �. �
�a�ck�D�
' � .S .?Z.
ruce G.MurP Y�MP -,
Director of Health
I
i
THE COMMONWEALTH OF MASSACHUSETT5
! TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-013 FEE: $75.00
'rhis is to certify that Davenport Realty Trust d/b/a Blue Rock Club. Inc.
39 Todd Road, South Yannouth. MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN TI�BUSINESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued i�ronformity with the authority granted to the Board of Hea�th,�y Chapter:14¢,Section�51,of the
General Laws,and amendments thereta,aztd is subject to the provisions ofthe Laws;ofthe Common�v�alth ofMass�husetts
relating thereto,and upon such terms and�conditions;and to the rules and regulafitons�in;regard:to�the:cany�n�-on of the
. occupation so licensed as adapted by the-Boazd ofHealth,and exp.ires Decembex 31,:2�Q�,unless:sczQner revoked,
`` December 18 ,2002 BOAitD DF HEAI,TH' (�!�. �elli�Cac; �ai�rmu�c'
. b�e�,cfaNrf,��. �[�tdo�c. '��.. 2/iCe
,�o�art�, �tndr�c, (�
�a�rte�?1ldDar�xott
�Felu�Ska�. ,�.72.
ruce G,Murphy, . .,CHO
Director af Health
_ _
�
� ' t
QW6 ROCK C(.UB�INC.
� ' ,*�q.� � "'� OF YARMOUTH BOARD OF HEALTH
' � �l3 w #��`��� APPLICATION FOR LICENSE/PERMIT -2002
oa.��.�o�-t ,�a o a�� �'i a.� �v G3 � Cc� C� Q U L� Cp
� * P'1`ease complete form and attach all necessary documents by December 31, 2001. Failur to do so will resu�t m
the return of your application packet. N�4+ 2 7 2pp1
� AME F ESTABLI ENT: u e a
; lo S. 3 Tot� o�d .
MAILING ADDRE S: ZD I'1 p .'(Y)Guv� S�-• S�v�°ti► a,v'vnaU f�-�
C IO I � ►�f' 1-
MANA R'S N v TEL. #
LING D SS: ��?. �0 0. ouf'1�
POOL CERTIFICATIONS:
i 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. � �u r(?�.i-t d � n Defn t�� 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 atta.ch 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•
�
FOt'�D'F�OTECTIflN�€A�A��R.S-C�I�.TI��,�:TI�T�:
� 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 atta.ch 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.
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
��. _ 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 a11 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 REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 L,MOTEL $50 6a—(f/p�
_INN $50 _CAMP $50 L,SWIMMING POOL$SOea.� ��'"Ol7
_LODGE $50 _'I`RAILER PARK $50 LWHIRLPOOL $25ea.�6 �00
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $75 �O�''��6 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $I50 / COMMON VICT. $50 �E'0�-OSZ� WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.R. $75 _TOBACCO $20
<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ �5'a,QQ �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�. �, r
� � ,. �
...
� ADMINISTRATION
Under Chapter 152, Se�tion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any licens� or perrriit to operate a business if a person or company does not have a Certificate of Worker's
Cor�p�nsation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE i
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED '�
�
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� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN
THE COMPLETED APPLICATION(S)AND REQtTIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 ;
P
DAYS PRIOR TO OPENING FOR THE SEASON. ;
i
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 MAY REQUIRE A SITE PLAN.
E
ADDITIONAL REGULATIONS ;
POOLS
POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CQNSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
('ATERING 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. Thses 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 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. j
i
DAT'E: ��' Y 3� �� SIGNATURE: �!
PRINT NAME&TITLE: �- �. U.
09/11/O1
' .�.-,""'"�' n'"w� �i Ilw!1�A
� a�o CERTIFICATE OF LIABILITY INSURANC�;� PK DATE(MM/DD/YY)
° � VEN-1 03/Ol/O1
i PRouuce; � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
! ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The Addis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
23Q0`Renaissance Boulevard ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
King of Prussia PA 19406-2772 INSURERS AFFORDING COVERAGE
Phone: 610-279-8550 Fax:610-279-8543
INSURED INSURERA: AmeZ'iC811 Zurich
Bl.ue Rock Club INSURER B:
C�o Daven ort Realty Trust
K@Try Bllr�@ INSURER C:
20 l�orth Main St. INSURERD:
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.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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN R TypE OF INSURANCE POLICY NUMBER POLI Y EFFECTIVE POLICY EXPIRATI N LIMITS
LTR DATE MM/DD/YY DATE MM/DD
' GENERAL LIABIUTY EACH OCCURRENCE i
i
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) S
� CLAIMS MADE � OCCUR MED EXP(Any one person) S
PERSONAL&ADV INJURY i
GENERALAGGREGATE S
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS•COMP/OP AGG S
POUCY PRO• LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident� E
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AU70S (Per person)
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTYDAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN �AC� E
AUTO ONLY: ,4GG S
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR �CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE j
RETENTION S j
WORKERS COMPENSATION AND X TORY LIMITS ER.
A EMPLOYERS'LIABILITY WC819602404 03�0�.�01 O3�OZ�O2 E.L.EACHACCIDENT S 1�OOO�OOO
E.L.DISEASE•EA EMPIOYE S 1�OOO�OOO
E.L.DISEASE-POIICYLIMIT S 1�OOO�OOO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER N ADDITIONAL INSURED;iNsuReR�erreR: CANCELLATION
YARM�_2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFf,BUT FAILURE TO DO SO SHALL
Town of Yarmouth
ATTN• Permi t D@j�t. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
1146 Route 28 REPRESENTATIVES.
S. Yarmouth, MA 02664 �
Pamela � � �y �
ACORD 25-5(7/97) OACORD CORPORATtON 1988
,
i
` THE COMMONWEALTH OF MASSACHUSETTS
i TOWN OF YARMOUTH
SOARD OF HEALTH
PERNIIT NLJMBER: #02-012 FEE: $50.00
;
" 'rhis is to Certify that Davenuort Realtv Trust d/b/a Blue Rock Club Inc
39 Todd Road. 5outh Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or
revoked.
March 13 ,2002 BOARD OF HEALTH: ;� i�dll�z,
�. C�ldrdou. .I�lee
,�o�Ct� �toaeart. ��
�a�riek'I�auacat�'
.Slcak .72.
ruce G.Murphy, . .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-017 FEE: $50.00
This is to Certify thar Davennort Realtv Trust d/bta Blue Rock Club Inc
39 Todd Road. South Yarmouth,MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Blue Rock Club Inc - O TDOOR POOL
_ 39 Todd Road
South Yatmouth_ MA
T�S P�t������ty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cpires December 31.2002 unless sooner suspended or revoked.
March 13 ,2002 BOARD OF HEALTH: ,��, ���y,
��D. �a�rdohc, .�1ee
,�o�ert� b�7oa�c. L�
�aDrtek�Dar.xot�
s ��t
ruce .
Director of Healy� �
l
�
THE COMMONWEALTH OF MASSACAUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-008 FEE: $25.00
This is to Certify that Davenport Realty Trust dlb/a Blue Rock Club,Inc.
39 Todd Road. South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN TI�BUSINESS OR PRACTICE OF
-GIVING OF VAPOR BATHS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of
the General Laws, and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of
( Massachusetts relating thereto,and upon such terms�d conditions,and to�e rules and regulations in regard to the
carrying on of the occupation so licensed as adopted by the Boazd of Health,and e�ires December 31,2002 unless
sooner revoked.
March 13 ,2002 BOARD OF HEALTH: ;{� xa�.
�2�. Cjardo�c, .�iee
,�oder�� �ioaa�ec, elerk
�a�iek��uxa�
'�i� S .?2
Bruce G.Murph ,MP HO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #02-050 FEE: $50.00
This is to Certify that Daven�tort Realtv Trust d/b/a Blue Rock Club,Inc
39 Todd Rnad, 40�th Y rrno� h,l��s
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity wrth the authority granted
to the hcensing authorities by General Laws, Chapter 140,and amenc�ments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: (�kanlea s� zell�i. ��a�c
SE,4TiNG: 83 �aNr�c�. G�iarda�c �D.. I�/ie:e
f�G�Ort`� �. �,`�
�a�rlek�erurot�
� . �Z??Z.
March S ,2002
Bruce G.Murphy RS.,CHO
Director of Heal
, , ,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IlVIENT
� PERMIT NUMBER:_ #02-076 FEE: $75.00
� In accordance with regulations prom under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General�ws,a peimit is hereby granted to:
�
Whose place of business is: Blue Rock Club_In_c.
� Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
� Permit expires: December 31,2002 BOARD OF HEALTH: �cul�a ,� , x'�, ���
; sEnTnvG:s3 �'�cfa.,�c D. C��laMc, 7JfC.D.. ?/r��;ce
�S�rtucTtoxs �artY: Packaged chips,candy,chewing gum only. ,�o�etZ'�l, �, �rk
�a�t�c���cot�.'
`�ef�c S .?Z.
March 8 ,2002
Bruce G.Murp y, S.,CHO
Director of Health
� � `!� : �- �,,,��.
� "*� �j�U.� KvC�- C�U b
F T� . i�...- '1�tJ� .
• TOWN OF YARMOUTH BOARD OF HEALTH p � � � � M � �
�_•" � A�PPLICATION FO�.ICENSE/PERMIT-2000 N 0 V 2 9 1999
` - ' oU,����',�°�'��$��'
* Please complete form and attach all necessary docun�s by December 31, 1�99. Failur��b��� � 1 n
the return of your application packet.
--------------------------------------------------------------------------------------------------------------------
---------------�---Y----•
F s � lue R ck U,c,�� (mc # 34 � �'�
LOCATIQN ADDRESSi 3� Tadd' o�ccf 5. o�meur'�►
MAILING ADDRE�S: '?-t� �14�'I� lYla.t.►n Sfi• S�U c�R.cm�r�{'I�
O\�VN�R/CORPORATION NAME�,.�Q,U�,v��ori-_� T�fi
MANAG�R'S N��VIF: "fYto� I�Ue,v�+l�.r/ TEL. # .���� 4�GI(�)i
MAIL�TG AUDRES S: �n.�a u $�q S a t,1�crn cu(1�
�'OOL CERTIFICATI�NS:
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tlus form.
L 2.
Poo1 operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Cammunity Cazdiopulmonary Resuscitation (CPR). Plea.se list these employees below and attach copies of
employce 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. -ia b�e. �r� a i�n .�. 2
3. �� <
ICH E�TIF�CAT�ONS:
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 empioyees trained in anti-choking procedures below and
attach copies of employee c+�rtifications to this form. The Health Department will not use past years' records.
You must provide ne�v copies and maintain �fde at yaur place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOT�L,# NC�P�-SiViOI�dG��ATS: TQTAL# _ ---- -_ _-
--------------------------------------------------------------- -----------_•.___-------------------------------------__---------------------
OFFICE USE O,NLY
LODGING•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 TRAILER PARK $50
�MOTEL $50 Y21C-9 � SWIlVIlV�TG P �o� $SOea. yZK-13
�VVHIRL L $25ea. y21L—S
FOOD SERVICE: �^0''��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $75 Z.K� �CONTTNENTAL $30
>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 k,�� WHOLESALE $75
I RETAIL �ERVICE:
; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $45 _TOBACCO $20
<25,000 sq.ft. $75 FROZEN DESSERT $35 �
>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE = $ Z�D-"
"""`•PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM""""
t
�
�_ ...._». _ .___,.. `:� �
1 , _ _
� ADMINISTRATION ` .
tINDER CHAPTER 152; SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIR'ED'
TO HOLD ISSUANCE;OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A �'
P��Ol�`,'C,�R. CQ1VIl'ANY 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
�
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 AP ROPRIATELY IF PAID:
YES� NO
NOTICE: PERMITS RUN ANNU,ALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT TF�HE.ALTH DEFARTMENT FOR INSPECTION 7-10
DAYS PRIOR TQ OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMI��NCEMENT. RENOVATIONS Mt�Y REQUIRE A SITE PLAN.
ADDITIONAL REGLT[JATIONS
POOLS
POOL OPEMNG: ALL SVVIlVIlVIING, WADING AND WHIItLPCfOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR
-- PSEUDOMONAS, TQTAL COLIFflRM AND 5TANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING:EVERY OUTDOOR IN GROUND SWIN[MING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
�ATERING POLICY:
ANYONE WHO CATERS WITHIN'THE TOWN OF YARMOUTH MUST NOTIF'Y TI-�YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TQ 'TI� CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT THE HEALTH
DEPARTMENT.
FROZEN�E S�RTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN TI-�E
SUSPENSION OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTII,TI-�ABOVE TERMS HAVE
BEEN MET. - _ _
OI]TSIDE CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLT5T HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
�UTDOOR COQKING: �
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD �
SERVICE ESTABLISHMENT IS PROHIBITED.
�
�
DATE: 1/�1�.q� SIGNATURE:
PRINT NAME& TITLE: �'C. �gLD�;;r.l Tr. �yy�f� �,�.-
11/12/99
!
-,R,�„�:.. ,
ACORD� CERTIFICATE OF LIABILITY INSURANCE�,, DATE(MMJDD/W) j
CSR�+1 03 04 99
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Addis Ciroup, Iac. ONLY AND CONFERS NO RIOHTS UPON THE CERTIFICATE '
Sui��e`'2 00 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
3lDO Fons Falls Cozporate Ctr. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
West Coashohockea PA 19428-2976 INSURERS AFFORDING COVERAGE
Phoae: 610-832-aiao Fax:610-825-9136
1NSUR� }NSURER A: a�iII1Er'1C8I1 Z13rj.Cl'1
8],ue Rock Club u�suR�e: ;
c/o Daveaport Re lty Truat �NsuR�c:
Mr. Oeorge Saldar�a
2 0 North Maia S t. iNsuReR o: '
South Yarmouth, MA 02664
INSURER E:
COVERAGES
THE POLIqES OF iNSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.IVOTWITHSTANDINO
A1dY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WliICH TNIS CERTIFlCATE MAY BE ISSUEO OR
NWY PERTAIN,TNE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSfONS AND CONDITIONS OF SUCH
POLICIES.AC30REGATE lINATS SFiOWN MAY HAVE 6EEN REDUCED BY PAID CLAIMS.
�� TYPE OF INSURANCE POLICY NUMBER ATE DA D LIMITS
GENERAL LIABiLIT! �ACH OCCURRFJVCE S
CDMMERCIAL OENERAL LIABILITY FIRE DAMADE(Any ona flre) S
CCAIMS MADE �OCCIIR MED IXP(Any one peison) S
PERSONAL 8 ADV INJURY S
OENERALACiGREGATE S
OEN'L AQGREOATE LIMff APPL�ES PER; PRaDUCTS-COMP/OP AGG S
POLICY �a LOC
AUTOMOBILE LfABfUTY COMBINED SINOLE LIMIT $
ANY AUTO (Ea acddenq
ALl OWNED AUTOS 60D1LY INJURY $
SCHEDl1LED AUTOS (Per person)
HIRED AUTOS BODILY INJURV
NON•OWtVEDAUT03 (Peraccidenfl 5
PROPERTVDAMAGE �
(Per aecident)
GARAGE I.IABILIN AUTD ONLY-EA ACCIDENT $
ANY AUTO EA qCC ;
OT11ER THAN
AUTO ONLY: A0� S
IXCESS LIABILIiY EACH�«1RREfVCE S
OCCUR �CLAIMS MADE AGCiREGATE $
S
DEDLICTIBLE
S
RETEN710N S s
WORKERS COMPENSAl10N AN� X TORY LIMITS ER�
A dum�ov�suneiurv yQC819602402 d3/OI/99 03/O1/00 E,�,�ACHACqOENT s1,000,000
�.LDISEASE•EAEMPLOY SZ�OOO�OOO
e�.ofstase-PoucvuMrr s 1,000,000
OTHER I
OESCRIPTION OF OPERATION3fLOCATI�lS/VEHICLES/D(CLU�ONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
�
�
�
i
CERTIFICATE HOLDER y noornoru��iNsuRW;iNsuR���R: CANCELLATI�N
YARMO—a SHOULD ANY OF THE ABOVE OESCRIBED POL ES BE CANCELLED BEFORE THE DCPIRATION
DATE THEREOF,THE ISSUING INSURER WtLL EAVOR TO MAIL 3 O DAYS WRITTEN
N017CE To THE CERTIFICATE HOLDER NAMED THE LEFT,BUT FAILl1RE TO DO SO SHALL
TOWl1 o f Yarmouth IMPOSE NO 08LKiATION OR LfAB�C1TPaF�A1'�1'1'� i D UP E INStJRER,ITS qGEM'S OR
ATTN: Permit Dept.
1146 Route 28 REPRESEM'ATIVES,
$. Y8=31011t$� MA O26(¢ AUTHORIZEDREPRESEr1 TIVE
Amie M. MeHa �
ACORD 25-S(7/97) ' " ACO ORPORA 1
I
I
i
�
f
. THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH '
PERMIT NUMBER: Y2K-5 FEE: $25.00
This is to Certify that Davenport Realtv Trust dlb/a Blue Rock Club Inc ;,
39 Todd Road South Y�rmouth MA '
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE BUSTNESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 51,of the
General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the carrying on of the
occupation so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner revoked.
December 3 , 1999 BOARD OF HEALTH: �c� �r/. �et.�e�, C�jxaBrman
�oan G. �ullivan, �/l., Vice (_.�irmarc
Ko�ert..t. a�rocun
a�rie�le�a�oG���-,�tooPea
'chael � ou�h[i�.
�r
ruce G.Murphy, MP , .S., CHO
Director of Health
�
�
. THE COMMONWEALTH OF MASSACHUSETTS
' TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-15 FEE: $50.00
This is to Certify that Davenport RealtXTrust d/b/a Blue Rock Club. Inc.
'�9 Todd Road,lSo � h Yarmouth, MA
IS I�REBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in confomut�vv�th the authonty granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto �xed their official signatures.
BOARD OF HEALTH: �� `�ett�, C'�aairman
SEATING: 83 �oan� �u[livan, �//., Vice C,�irman
/'Cobert�`. 9�rotun, C,larh
a�ris[[e�a�ol.��i�-✓dooPe�
' hael oCo hlin
�
December 3 , 1929 �-
ruce G. Murphy, M , R. .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-13 FEE: $50.00
This is to Certify that Dav eal Tru / 1 C
39 Tod Road South Yarmouth.MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Rock Club Inc -OUTDOOR POOL
39 Todd Road
South Yarmouth MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
December 3 , 19QQ BOARD OF HEALTH: �c` ii/. �elf,e�, C�iairman
�oaa� �u[�an� �//., Vice l.hairman
�o�ert� /�rou�n
a�rie[[e�a�ol���-�tooPe�
6 � o �6in.
PlICB . 111'p }r, , •,
Director of Health .
THE COMMONWEALTH OF MASSACHUS�TTS
' TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-9 FEE: $50.00
This is to Certify that Davenport Realtv Trust d/b/a Blue Rock Club. Inc.
39 Todd Road. South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonweaith of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked.
December 3 , t999 BOARD OF HEALTH: �c`� �ette�, ��i,ai�marc
�oa�x G. �ullivarc, K.I'/., Vice (..hairman
�oberE� �rown
a�ria[le�a�Zol��c�-�ooPe�
• �� �ou��l n
�
Bruce G.Murphy, H,R ., CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-26 FEE: $75.00
In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
l�aven�ort Realt�v Trust, 39 Todd R�ad, South Yarm�uth, MA
Whose place of business is: Blue Rock Club. Inc.
Type of business: Food Service
To operate a food establishment in: Toum of Yarmouth
Permit expires: December 3 l. 2000 BOARD OF HEALTH:��� ��tt�, C'�tr��.
SEATING:83 �oan G. �ul�ivan, K.//., Vice C,�irma
ttEs'['1t[c'['[orrs tF AtvY: Packaged chips,candy,chewing gum only. /�o�e�t� �iown, C�er�
a6rie�le�a�o(.��y-./�tooPe�
����o����
December 3 , 19 99
Bruce G.Murphy,MP ,R. ., CHO
Director of Health
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,� TOWN OF YARMOUTH BO��I��IE�LTH
APPLICATION�OR LICEN _� � � �� � 19�9 �' Q E� � 6 1998
�_v .
* Please complete form and attach a11 necessary documents by December 31, 1998. Fai
the return of your application packet.
------------------------------------------------------------------------------------------------------------�--
NAME OF ESTABLISHMFNT� Blu� Rock C.t,tl� Iv�C TET # 5�K 3�j�3 e,q�y
O A ION ADDRFSS. 3�1 TOG1d �oud Sa.�/�t,vmo��
MAILINC ADDRFSS: � f10 �(icu n � So Ya,rmoui'l�
nRATION N�1vtF� C�u�-v�A o rf 2� .. Tr� ;
ER� N ' en i,�' L. # 5 K � �- � �z
IN P� ,S 5o mo�I'l�
POOLCERmI�ICATIONS.------------------------------------------------------------------------------------------------------
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tl�us form.
i�.��������� .�� � _
.s�-� _ -- 2. —
Pool operators must list a minimum of two employees cwrently certified in basic water safety, standard First Aid and
Commuruty Cardio�ulmonary Resuscitation(CPR). Please li�t 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. amu VU�n c/ 2
3. r�� �Yia..v �dq�5 a.
HEIMI,ICH rERTTFICATICIN •
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
atta.ch copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fite at your ptace of business.
1. �. 2.
3. ��.`� � 4. �
RESTAURANT SEATING: TOTAL# �3 � NON-SMOKING SEATS: TOTAL# ��
------------------- ----- -----
- - -
_ ------ ------ ------------------------
_ __ _ _ __� --
--$����E�Ni�-_ — - -- - - _ _ __
LOD nvcT•
LICENSE REQL7IRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
B&B $50 CABIN
------ — $50
—� $50 CAMP
--- — $50
LODGE $50 _TRAII,,ER pARg $50
-----______
�MOTEL $50 ��� . ( SV�VA�IlI�IING POOL
;
— SOea ..2,
�'OOI� �F.R�(`F• �WHIR�LPOOL $25ea. 99—��
LICENSE REQi,TIRED FEE PERMIT#
LICENSE REQUIlZgD FEE pERMIT#
�_0-100 SEATS $75 �� _CO��NT� $30
�>100 SEATS $150 —"—
---_____ N�N-PROFIT $25
; I COMMON VICT. $5 � ------
i —�� _WHOLESALE $75
------___._
RFTAIL. ERVI('F•
�
LICENSE REQUIRED FEE pE�T#
; LICENSE REQUIlZED FEE pE�T#
�; —<50 �.ft. $45 �TOBACCO
_<25,000 s .ft. $20
q $75 ----
------- FROZEN DESSERT $2g
_>25,000 sq.ft. $200 `-----
�—
NE1MF CAA N :F• $10
---------
AMOUNT DUE _ $ � �,d _
"'""""PLEASE T[TRN p�,rg A�C��,LETE OTHER SIDE OF FORM
•w.��
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ADMINISTRATION
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED
Tb �TOL�'�TSSUANCE DR RENEWAI. 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 STA'�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SiGNED, OR
CERT. OF INSURANCE ATTACHED �
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAI.OR ISSUANCE OF ;
YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: k
yBS�_ NO
;
NOTICE: FERMITS RUN ANNUA�.,�,� FROM J�4NUARY 2 TO DECEMBER 31. IT IS YOUR '
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 3 i, 1998.
SEASONAL ESTABLIS��VVIEN'I'S ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR TI� SEASON.
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 CONIlVtENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SV�G, WADING AND wHIRI�POOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEAI-'TH DEPARTMEI''IT,AND T�w`�TER TESTED FOR ;
PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STA'�E CERT�F�ED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVavIlVIING POOL MUST BE DRAtNED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
�
FOUD SERVICE '
C a�R�TC'7 POLI�Y:
ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST D�E VICEE�L�ICATIDN :
HEALTH DEPARTMENT BY FILING � D Q�D T�E ORM O AN BE OBTAINED AT THE j
FORM 72 HOURS PRIOR TO THE CA �
HEALTH DEPARTNIENT.
FUC�7FN DE� E TS:
u
OZEN DESSERTS NNST BE TESTED ON A MONTHI.Y BASIS BY�TO DO SO WII,L RESUI-T 1N
FR
RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII.. �ABOVE TERMS
THE SUSPENSION OR REVOCATION OF YOUR FROZEN DE55ERT PERMIT UNTII- -
---HA '� ----------- ,
nr rrCIDE�AFES: HAVE PRIOR
OUTSIDE CAF�S(i.e.,OUTDOOR SEATING WI'TH WA�TE��T�SS 5ERVICE),N�.�
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR �'�0�� �
�G pRF,pARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RET�-OR FOO k
pUTDOOR COO ,
SERVICE ESTABLISHMENT IS pROHIBITED•
�
DATE: I�'j S -j� 5IGNATLTRE: --� ',,
i.v �� � U''� ����. '�
� ���. ,-�,., , .
Pg�NT N?,IviE&TITLE: �
�
, , - -
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. �a �
� The Commonwealth of Massachusetts
� � W Department ojlndustrial.accidents
' � o Ofllceol/�s�los�li�s
� " 600 Washington Street
:
•` Boston, Mass 02111
V
N v•
W'orkers' Compensation Insurance Atfidavit
Aoolicant information• p►eas�pRiNTT�,-i�r
n�mr:
loca[ion: '
�it� phone�
� ( am a homeowner pertorming ali work myself.
� I am a sole proprietor��� ha�e no one��orking in am�capacin�
� I am an emplo�er pro�idin�workers' compensation for my employees working on this job.
_-----__ _ -- ----- --_ .
m n �
ddress:
in urance o. �• �
� I am a sole proprietor. general contract r. or homeowner(circle onel and have hired the contractors listed below ��ho ha�e
the follu�sin� ��orker_� ;ompensation olices:
sQmoanv name•
address:
citv• phone#•
i�surance ca A��.�
s2moanv name:
___ _
__--
a��ss:- ----
ciri: nhon�i�.
insurance co. ��Y�
Failure to secu�e covenge as required under Seetioo 25A of MCL 1S2 ea�lad to tbt i�positloa of uisiwl pt�altles of a O�t op to S1rS00.00 a�d/or
one yean'imprisonment aa w�ell a�civil penalde�io the form of a STOP WORK ORDER aed a flot of f100.00 i day apiost ma I a�denn�d tlat a
eopy of thu sutement may be forrvarded to the ORiee of Invatigatiow of tbe DIA for eoven�t ve�i6utiw. ;
/do hrreby cerrij}�under�he peins and penalties of perjury that 1/�e injorniotion providtd abovt is trut and eonect '
Signaturc nAt�
Print name Phone N '
.. olTicial use onh do not w rite in this area to be tompleted by city or town offlcia) !
ciry or town: YA��D� _ permitAicense M �Buildiog Departmeot ;
pLiceasiog Board
�eheck if immediate response is required �Selectmen's ORiee
261 �Health Department
contact person: phone p;_ �508� 398�?231 egt. nOther
_ i
i
Ire.-�ised 3,9t P1A1 . I
(
� � .. �
� , , DATE(MNUDD/YY)
AcoRo ���Tl�l�#�►T� �F Lf��IL.[�"� ��t��J��l���
;; � ;.; A�iT. 1 ; 04 17/98
; PRoauc�iF THIS�ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
' The Addis Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Suite 200 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
100 Four Falls Corporate Ctr. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
West Conshohocken PA 19428-2976 COMPANIESAFFORDINGCOVERAGE
Gaxy PP. Warren. CPCU� ARM COMPANY
Pno�erw. 610-832-2100 F�No.610-825-9136 A American Zurich
INSURED
COMPANY
B
Blue Rock Club
c/o Davenport Realty Trust COMPANY
D�r. George Baldwin �
2� North Main $t. CAMPANY
South Yarmouth, MA 02664 p
� ;�E���� ; ,, ;
; _ _ _.
;. ;
,.:: _ ,. ; ;::.
_ _... _.. __ _.. , ;:. ;.
THIS IS TO CERTIFY THAT THE POL�CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAAAED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREN�NT,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 REDUCEO BY PAID CLAMAS.
�TR TVPE OF INSURANCE POLICY NUMBER �ET M�AMppm) OA�E(MIDD/Y1�N LIMITS
6ENERAL LIABILITV GENERA�AGGREGATE S
COMMERCIAL GENERAL LIABILIIY PRODUCTS-COMP�P AGG $
CLAIMS MADE �OCCUR PERSONAL$ADV INJURY S
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE S
' FlRE OAMAGE(Any one fire) S
MED DCP(Any one person) S
AUTOMOBILE IIABILITY
COMBINED SINGLE LiMR y
ANY AUTO ,
ALL OWNED AUTOS
BODILY INJURY a
SCHEDULED AUTOS (Pe�Pe��)
HIRED AUTOS
BODILV INJURY a
NON-OWNED AUTOS (Per eccidenq
PROPERTY DAMAGE $
iARAGE LUIBILITY AUTO ONLV-EA ACCIDENT E
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACGDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE S '
UMBRELLAFORM AGGREGATE s
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND g TORY l MNfTS �ER '
_......:;
EMPLOYERS LIABILITY _........::::::::::::::..:.........
' �-�+c�+Acc�oErJr s 1,OOO,OOO
A P,u�n��Rs�x�cunvE X �"�x �C819602401 03/O1/98 03/Ol/99 �DISEASE-POLICI'IIMfT s 1,000,000
OFFlCERS ARE: IXCL EL DISEASE-EA EMpLOVEE S 1�O O O r O O O
OTHER
DESCRIPTION Of OPERATIONS/LOCATIONSNEHICLES/SPECU'1L ITEMS
.fi����"����� ::: �- ` ;: ::: ��; .
, ��'r.s� ■�a�z
,
-..:,-: _.,:: :<. `: '.: . .:::i �i/R1�{iL����lVi�l ::i :
:._.;:. ._ ..
_._ _ .::.:. .. . ....: . ::::.: . _...: ... ..: ,
YARMO-a �OULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE TNEREOF,THE ISSUINO COMPANY WILL ENOEAVOR TO MAII
TOF1i1 Of Y3T'�t011til �_DAYS WRITTEN NOTICE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT,
ATTN: Permi t Dep t. BUT FAILURE TO MAIL SUCFI NOTICE SHALL IMPOSE NO OBUGATION OR LIABILITY
114 6 ROLLte 2 8 OF ANY KIND UPON THE COMPANY,ITS AOENTS OR REPRESENTATIVES.
S. Yarmouth, MA 02664 AUTH RIZEDREPRESENTATIVE
Gar�r W Warre�8� �J� C�„>�s,,,e�_
i0.t';R3RE�Z��'►�'F�S�: . ` ;:
, c�
' A��Rt'��t�"Rt#Ak�E t�8$�, ;
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: 99-56 FEE: $50.00
This is to Certify that Daven�ort Realty Trust d/b/a Blue Rock Club Inc
39 Todd Rn dF SoLth Y rmo� h, 11�A
IS HEREBY GRANTED A
COMMON VICTUALLER'5 LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in confornuty with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures.
BOARD OF HEALTH: �d�/. `�Bltee, C'�cr,��
SEATTNG: 83 �oan � �u6[ivar�� K,f/.� Vice (�hairinan
�o�e�E JD'. 9�i�owQic� l..le/r�
a�rieG[e�al�o(��cj-.�dooPed
- 6�0' ����.
Januaty 28 , 19 99
ruce .Murphy,MPH,RS CHO
Director of Health
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� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-13 FEE: $25.00
`rhis is to ce�vfy that Davennort Realtv Trust d�/a Blue Rock Club, Inc
39 Todd Road South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN TI�BU5INESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issuecl in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the
General Lat'vs,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts
relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the
occupation so licensed as adopted by the Board of Health,and eacpires December 31, 19�9 unless sooner revoked.
Janua�,�3 28 , 1999 BOARD O�HEALTH: �c�� �atfe�, l.�eairmaR
�oa�.(�. �u�Livan,/C.//., Vice C�hairmari
/C o�erE.}. /�roruic
� abrie�Ja�of���-J�too�oee
'i/��aL O' u hf�n.
�
Bruce G.Murphy,MpH, S.,C
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: 99-92 FEE: $75.00
In accordance with regulations promulgated under a�hority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
v nno�t R�lty Tms , 39 Todd R� cl,So �th Y rm�� h,_��s
Whose place of business is: Blue Rock lub,Lnc
Type of business:_ Food ervice
To operate a food establishmerrt in: Town of Yarmou
Permit expires: December 31, 1999 BOARD OF HEALTH:�'d�f. �et�,, C'�,��n
SEATING:83 • oan� �u�an�K.�, Vice (..�irmaa
REs�ticTtotvs �Atvx: Packaged chips,candy,chewin8 gom only �o�ert� /�,ow►� ����
/ e, /,
a�via��akolal��-�tooPed
�� �o���. ;'
_Januarv 28 , 19 99
Bruce G.Muiphy,MPH, S., O
Director af Health ;
i
�
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: 99-17
FEE: $50.00
This is to certify rhat__ Davenport Realtv Trust d/b/a Blue Rock lub, Inc
39 Todd Road South Yarm th MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conf-ormit�,���e auWority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to We rules and regulations in regard to said Cabins so licensed as adopted
by thc Boazd of I�ea1W,and expires Dccember 31, 1999 unless sooner suspended or revoked.
Januar�8 , 1999 BOARD OF HEALTH: �d
� �8��, c��,��
�oar�G. JuGlivan�/�,�� �ice C.hairmarc
/C o�erE,}, ��w�
a�rielle�a�Zol��i[f-�tooPed
' hael O� u�hli'rc
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Bruce G.Murphy,MPH,R .,C
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
- TOWN OFYARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-27 FEE: $50.00
This is to certify thac Davennort Rea1_tv Truct �/h�a �lue Rock('lub Inc
39 To R o th Y th MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Bl R ck 1 Inc - R PO L
39 o R
— o�th Yarmouth_ 1VLq
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31 1999 unless sooner suspended or revoked.
Januarv�_, 1999 BOARD OF HEALTH:
�d� .�e��, c��,�,�
, " �oaie.� su��aR� K.�� �ice C.hairman
KoberE.}, �rown
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hae6 0� ou�hliit
Director of Health� '
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� . The Commonwealth of Mossachusetts
M W Department ojlndustrial.-�ccidents
T ; O/flceo/%►es�►�s�liis
� � 600 Washington Street
, •� Boston,Mass. 02111
(� SV•r
W'orkers' Compensation Insurance Affidavit
Aoolicant information: P(eesePR�
- __ �
n�mr:
location:
���� �hone#
� I am a homeowner pertorming all work myself.
� f am a sole proprietor��� ha�e no one ��orkine in am•capaciry
� I am an employer pro�idin� workers' compensation for my employees workine on this job.
- � n _ i - _ _ , _ __ _ _
compan?� name: ��UC iSCX� mP�O�/ 1 11Y1
address: �� J�C�C� �QG�'
si �: �b. IGtI/YYl(7(�'I�'� /� !'�- ��L�-- nhone Il:
�
insur�nce co. ��V�l�'1 I n5_ I wtn C�.� �'��� Aolicy# �� w �PJx ���
� I am a sole proprietor. ;enera)contractor, or homeowner(circle one/ and ha�•e hired the contractors listed belov►� �cho ha�e
the follo��in� ��orker�' ,ompensation polices:
gompanv name:
address•
Si.tk: Ahone#•
insurance ca Aoli�y#
• compan�name•
- --- -
-- ---- -— -__-- --- _
address• '
c�; Rhoee i�•
insurance co. o�ti ,y#
Failure to secure coverage as required under Secaoo 25A of MGL lS2 a�lad to the iopaitioo of erisi�l peadtie�ota ti�e op to S1,S00.00 a�d/or
one years'imprisonment a�w�efl aa civil penaldea io the to�m of a STOP WORK ORDER aed a lioe of SI00.00 a day apiost ma I a�dersta�d t6st a
copy of thy statement may be forwarded to the Oflice of Investigadon�of the DU tor eoven=e veri6atio�.
!do•hrreby cerriJ}• parns and penahr�o perj ry that t t injornwtion provid�d above is true and corrret
� � Signature ate i Z.-(�L�(o �
Print name 1 • Phone� ��' 3�� -Z'Z� 3
., otTicial use onh do not r►rite in this area to be completed by city or town otfleial
ciry or town: yA�DIITQ _ permiUlitee�e p nBuilding Department
�Liceasiog Board
�check if immediate respoese is required 261 QSelectmen's Offiee
pHealt6 Departmeat
contact person: phone p;_ �508� 398�2231 egt. nOtder
Irecised i;9t P1A1 �'.
NUMBER FEE
97_7 THE COMMONWEALTH OF MASSACHUSETTS $SO.00
� ..__. of .Y��v�H
Board of Health
This ia to Certify that ..�V��RT REALITY TRUST D/B/A BLUE ROQ� MO2'OR II�i
.................••-----.._._.._......._.._..------••--••-•-----._...---•---•--...------....---•---------..
-------------------------------•--34.'1'ODD._ROAD.�_.SOUTH-.YARlyI0U1'H,•--MA------......------------------•--•--..._...._._.._...----•..
HAS BEEN GRANTED A LICENSE TO
OPERATE
� MOTELS
Thia License is issued in conformity with the authority granted to the Board of Healtli, by
Chapter 140, Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions
of the Laws of the Commonwealth of Massachusetts relating thereto, and upon auch terms and
conditiona, and to the rulee and regulations in regard to said Camp s or Cabins so licensed as
adopted by the Board of Flealth, and expires December 31st, 19..9-r.. unles sooner suspended
or revoked. . �
••••-••� •��M+-�-- - • - -•--•... Board
..__DECIIv]BER-•18-'-----------.19._96 ._.... �. . -
-
. . . .- --•-f� -- -- - -- --- ----- - ••,�--•
......-�---- -
-- - -----� �-- �- --- ....---• of
- -.. .
- -�--� -- --- - - - -- -- --
�------.... - -----
---------=----- - • •-- ------- ------ - - - -- -------� Health
• /La3�L�'H;..
Original License Fee
RenewalFee BY---•-•.............•-------•--•----•--•-.....---....--------•---..........-•--•----••-••••
FORM S 525 A.M.SULKIN,INC.-BOSTON (617)542-5858
PERMIT FEE
THE COMMONWEALTH OF MASSACHUSETTS
97-10 $50.00
•-•...----•--T�NdV-..--••--- of ..YAR1vI0UTH----------------------•---------•-•--•--•-
Board of Health
Thie is to Certify that _.DAVII�IPORT REALITY TRUS"T D/B/A
.............................................._......_.w---...._....._......_...-----•-•-----....
NAME
...BLUE ROCx MO'TOR INN,�--39_TODD_.ROAD�..SOUT'H..YARrROUTH,..MA.......................................
-------•-------•..................... .._.. ------
ADDHESS
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Publie Swimming or Wading Pool
At ...__:.Rt��IJ.�._R(�K.b%7.tOR--IL�I--•------•--------•------•-----------..QIJTIX�QB..PAOL----....--•...............................
---••-------..�Q..'I'fl�?D..K�.AD.-----•-•-------•------------------------•-----------•-----.._._._._..---......-----------------••---•----...-----------------•--
•----.....---�5?i.l'i'�[_.X�3MQIJ'�'H._..1�tA.......................•---......-------....-•---._.....---..._._......_...------••---•-----•---------------•-•----
This permit ie granted in conformity with Article VI of the Sanitary Code of The
Commonwealth of Masaachusetta, and expirea _._._......_D�._31 .19. ....................... unlese
aooner auspended or revoked. � ..
: ..._...... -i���- _ ._. .............
..--•--•--• t���--t- -��-----
---DE�CII��ER 18, 19._96. ...._..---- .. _. _.. . .,�...._ Board
----•.....................•-•--•-•-------- of
. ...... - --'...--
-----
..----•---. ..M•-•-� •--.. Iiealth
---•.......... . . . !• i��i6'L-lJj:�„
• BY ---------------------------------------------------------
PORM S 1712 A.M.SULKIN ......-�-----•�---••- �,A
�r_
�
_ - ---- - _ _ _ _ _ - _-- -------- — ---- -------- i
NUMBER FEE �
9?-6 THE COMMONWEALTH OF MASSACHUSETTS $25.00 � �
— •--.....TUN1i�T............: of _.....YARMOUTH I
-------�--------�------------------------�-�--�- .
� Board of Health �
� This is to Certifv that _�V�'�RT..RF�LITY TRUST D/B/A �
- - �-�-------------------------------�----�-------------------...-------...--- -- � I
; BLUE ROCx MOrTOR� INN, 39 TODD ROAD, SOLTTH YARMOUTH, MA
� ..................•-•••••-••••••-•••-•••-•-•.........----••-••.........-•---•---•---..._......_..............•••-...•--•-..._._._....._.._._....-•--•-••......•-•••........ �
�i HAS BEEN GRANTED ,4 LICENSE TO �
' ENGAGE IN THE BUSINESS OR PRACTICE OF i
I ��- GIVING OF VAPOR BATHS
AT-----�z.�U�..Rtx�..t�taz'QA__.z�..................�---�-----•--..........._......:--...._..........._..---------------�---....---------�---------- I
! This license is issued in conformity with the autliority granted to tlie Board of Health,
ib� Chapter 140, Section S1, of the General Laws, an�l amendments thereto, ancl is subject to the �
provisions of tlie Laws of tlie Commonwealth of 1'Iassachusetts relatin�_ tl►ereto, and i�pon such �'
� terms and conditions, and to the rules and regulations in regard to t}��� 31 of the I
I occupation so licensed as adopted by the Board of Healtli, and expire _L ...............:..._.._._...
-------- ---
� 19_.QZ-., unless sooner revoked.
� CHAPTER 140, GENERAL LA�VS �' �
� Sec. 52. riembers of the police department of �_f ' �"�
I any town may enter and inspect any premises in "'��"�'-'�'� "�"'�����" �"' " ��� ' �� �� � � � �
- -• • --
' that town, used for manicuring or massage or the � • __ y� Board
giving of vapor baths. ---'�""' ' " ' ' " " ' ";F.�
Sec. 53. \t'hoe��er violates any provision of Seo- .-� '
� tion 51, or any rule or regulation made under •_......_... Of
authority thereof, or prevents or hinders any mem•
I her of a police force from exercising the authority ,.__.___.__.��:::._i.r.�c�.�.-_�..____._�` _._ _ Health
conferred upon him by Section 52, shall be punis6ed
}ry a fine of not more than one hundred dollars, or
by imprisonmmc for not more than six months, or ""' ' ����R�--- ----•- ���/'��
both. ��� �
---••--DECFIvlBER..18�..-----19-96_. By..---•--•--•-•----•-•--•.....................•--•-••---......-------...._.__...---......._.
( FORM S 107 A.M.SULKIN.INC.-BOSTON (617)542-5858 - �
� ��
�
a
NUMBER FEE
9?-31 THE COMMONWEALTH OF MASSACHUSETTS
$75.00
.......T.�...... of ....YARMOUI'H.....................
Board of Health of
PERMIT TO OPERATE A FOOD ESTABLISHMENT
Permit No. C:V• #97-26 D�ER 18 96
.........'.. 19.....
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A
and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to:
DAVIIVL'ORT REAI�'TY TRUST, 39 TODD ROAD, SOUT'H YARMOIJTH,..MA ..................
Whose place of business is .BLUE ROC� MOTOR INN . . . . .. . .... .
Type of business and any restrictions .�D SEIZVICE 0-100 SEATS,.. ... .. .. ..
..
To operate a food establishment in .:.Y��,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
(City or Town)
Permit Expires ..DF�CE1vfBER,31 x.....19..97. -�- ----- - __.___... ,�
:.��,:-�.�. .- � ..
.... .�j� Board
.... ... v of
.... /� .�..�,. ....... Health
FORM 738 A.M. BULKtN COMPANV ••••• O(��..�. �'//�.....
� ��
��
NUMBER FEE
97-26 THE COMMONWEALTH OF MASSACHUSETTS $5O.OO
..----'�'S�I-------...of-------.YARI1�QLiTH..............:.......................
DAVIIVPORT REAI,TY TRUST D/B/A BLUE ROCZ� I�TOR II�V
This is to Certify that.......................�----------..........----------�-�--�------------................................._.......--�--�-------------............----------........._
39 TODD ROAD, SOUT'H YARMOU`1'H, MA
------��---...-----�.....................................................�--��------..._.......---�------�--......---......................._........_............................._......_..........-----------------......
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
in said .-�---�.....................-YARMOUTH----------�---------.....------..........................---.....------------- and at that place only and expires ;
December thirty-first 19..9?..._..._unless sooner suspended or revoked for violation of the laws of the
Commonwealth respecting the licensing of common victuallers. This license is issued in conformity
with the authority granted to the licensing authorities by General Laws, Chapter 140, and amend-
ments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their uia �tures.
��--�-----.... .+��G.t�-+�.�.--- '
_ ----------- ------ �.........
' i
....------�-- � --- ----------- ---��� -- --- �-�-
���
-------------- --.............�'�''''�_ ... ..-- �-��---... Licensing '
--�--��--- -. _..�.'�.....::.1--=-------- -- -- Authorities
-- --- ��
. . .
-- -- ----�- -
............... ,bw 11`�'�^ ... ..._..: '�vy.I'`"
---�----DEG��R._.1$.,-�-- 19 .9�--- '
FORM S 348 A.M.SULKIN CO.-BOSTON,MA - �OVER�
����