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Home My WebLink AboutApplication and WC _, . . �,..,�, � � TOWN OF YARMOUTH BOARD OF HEALT �� . M, APPLICATION FOR LIC�l'�T� � -3 1 ��j� 0 5 2D 13 � ✓ :: � * Please complete form and attach all�e� �cti �e�� December 13 20„r13. Failure to do so will result in aPet �i�-�ot�"'applic ion ESTABLISHMENTNAME: Blue Water TAXID: LOCATION ADDRESS: 291 South Shore Dr. , So . Yarmouth TEL.#: 508-398-2288 MAILINGADDRESS: 20 North �IE�in St. , South Yarmouth, MA 02664 E-MAIL ADDRESS: mpurrier@thedavenportcompanies .com OWNER NAME: Daven�or t CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: John Verity TEL.#: 774-208-1305 MAILINGADDRESS: 20 North Main Street So. Yarmouth MA 02664 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscita.tion(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection � Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach j 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. PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your establishment. . 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-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. I 1. 2. � 3. 4. RESTAURANT SEATING: TOTAL# 1 �5 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�FRMIT# _B&B $55 CABIN $55 lMOTEL $55 �i�t-ooy INN $55 CAMP $55 2.SWIMMING POOL $80ea.�k 1�k-�a: �07 LODGE $55 TRAILER PARK $105 �WHIRLPOOL $80ea. t�-tr FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $160 �i -c i� �COMMON VIC. $60 �V-cc�t WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 =TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ �1 S:�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � , � � � , � � ; , ADMINISTRATION - ' � �� Under Chapter 152, Sectio�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 XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' ; Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: ' YES�_ NO � MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be � lirnited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. ' i Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. � Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate o£ not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall ' not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in � M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. i POOLS i POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three(3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. f FOOD SERVICE � SEASONAL FOOD SERVICE OPENING: j All food service establishments must be inspected by the Health Department prior to opening. Please contact the i Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required ! Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ; Health Department, or from the Town's website at www..yarmouth.ma.us under Health Department, Downloadable � Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results ' submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert '' Permit until the above terrns have been met. ' OUTSIDE CAFES: �, Outside cafes (i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13, 2013. 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 AN. DATE: 11-1-13 SIGNATURE:�� ..�L�?��-C°U PRINTNAME&TITLE: Mary P rrier , Assistant Controller Rev. 10/08/13 The Commonwealth ofMassachusetts Department of Industrial Accidents � Office of Investigations ' 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Please Print Le ibl Auplicant Information � v Business/Or anizationName: Blue Water LP g Address: 20 North Main St . City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-2288 Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Esta.blishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]* 11.� Health Care 4.❑ We are a non-profit organization,sta.ffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other S e a s o n a 1 R e s o r t *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organizadon should check box#1. I am an employer that is providdng workers'compensation insurance for my employees Below is the policy information. Insurance CompanyName: Zurich American Ins . Co . Insurer's Address: a t tached City/State/Zip: Policy#or Self-ins.Lic. # WC 819 6 0 3 5 Expiration Date: 3-1-14 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ' ,under the pain nd penalties of perjury that the information provided above is true and correct. 12,� � Si ature. -'��-'L� Date: 11-1-13 ' Phone#: 508-398-2293 Official use only. Do not write in thds area,to be completed by city or town officia� City or Town: PermitJLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia , � ..i"'� OP ID: KD � '4`�..oRo� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/WW) 02/28/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATtON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. tf SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in tieu of such endorsement(s). PRODUCER CONTACT Phone:610-279-8550 NAME: The Addis Group,Ina Fax:610-279-8543 PHONE FAX 2500 Renaissance Bivd.Ste 100 n� N e : ac No: King of Prussia,PA 19406-2772 E-M^i� Jeffrey A.Grebe PRODUCER c T MER io#•DAVEN-1 INSURER S AFFORDING COVERAGE NAIC# INSURED Blue Water LP iNsuReRn:America�n Zurich Insurance Co�. 40142 ' c/o Davenport Realty Trust wsuReRe:Zurich American Insurance Ca 16535 Stephen Aschettino INSURER C: 20 North Main St. South Yarmouth„MA OZSG4 INSURER D: . � INSURER E: � � � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �LTR � TYPE OF INSURANCE ADDL SUBR pQ��CY NUMBER MM/D'DY EFF MMroD� LIMITS GENERAL LIABILITY EACH OCCURRENCE S 'I,OOO,OOO B X COMMERCIAL GENERAL LIABILITY GL08196255 03/01/13 03l01/14 pREMISES Ea occurzence $__ 500,00� CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 'I,OOO,OOO GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Z,OOO,OOO X POLICY PR� LOC $ AU70MOBILE LIABIUTY . � COMBINED SINGLE LIMIT (Eaaccidenq $ 1,000,000 B ANY AUTO BAP8196256 03/01/13 03/01/14 BODILY INJURY(Per person) 8 X ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accidenQ X NON-OWNEDAUTOS $ X 250 Comp g UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS L1A8 CLAIMS-MADE � AGGREGATE . $ DEDUCTIBLE g RETENTION $ $ WORKERS COMPEN5ATION � WC STATU- OTH- � AND EMPLOYERS'LIABILITY � X M T R A ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N WC8196035 03/01/73 03/01/14 E.L.EACHACC�DENT� $ ��0�0�000 OFFICERIMEMBER EXCLUDED? ❑ N/A � . . (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 3 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OOO , I � � � -DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additlonal Remarks Schedule,if more space is required) i iI CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth rHe EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth�MA OZBF)4 AUTHORIZEDREPRESENTATNE T�� O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD