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Home My WebLink AboutApplication and WC _ ; , r��B�uE Wa�. �� TOWN OF YARMOUTH BOARD OF HEALTH � , � APPLICATION FOR LICENSElPERMIT-29�r� �'�' �'� � �- �� .�� a� �,.,., �� ' �. ��.�bc�s .A., , �� * Please complete form and attach all necessary do� ts by Dece ber l��`°29I�U�-` �`' Failure to do so will result in the return of your application p etHEALTH D��"f. ESTABLISHMENT NAME: Blue Water TAX ID• LOCATION ADDRESS: 291 South Shore Drive, South Yarmouth TEL.#: 508-398-2288 MAILING ADDRESS: Same OWNER NAME: Dewitt Davenport � CORPORATION NAME (IF APPLICABLE): � � MANAGER'S NAME: John Verity TEL.#: 774-208-1305 MAILING ADDRESS: 291 South Shore Drive, South 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 cei-tificanon to this fornz. , 1. � �� ; 2. i { � Pool operators must list a minimum of two employees cumently certified in basic water safety,standard First Aid aud 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 3�ears' records. You must provide new copies and maintain a file at your place of business. 1. ?ohn Verity 2. Robert Thomas 3. Frank Pina 4. 1 FOOD PROTECTION MANAG�RS - CERTIFICATIONS: All food service establislunents a1e requued to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitaiy Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei-tification to this application. The Health Department�vill not use past years' records. You must provide new copies and maintain a fle at your establishment. 1. Robert Thomas 2. John Verity PERSON IN CHARGE: Each food establisiunent inust Ilave at teast one Person In Charge (PIC) on site duruig hours af operation. � 1. Robert Thomas 2 Christine Janson HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained 'ui the Hei�nlich Maneuver on the premises at all times. Please list your employees trauled in anti-chokuig procedures belo�v and . attach copies of employee certifications to this foini. The Health Department will not use past years' records. You must provide new copies and maintain a �te at your place of business. ' 1. John Verity 2 3. 4. RESTAURANT SEATING: TOTAL # 125 LODGI\G: OFFICE USE ONLY LICENSE REQUIRED FEE PERI�IIT# LICENSE REQUIRED FEE PER�fi7# LICENSE REQUIRED FEE PER�VIIT� _B&B S�5 _CABIN S�5 ( 1qOI'EL S» �''I�O(� 1NN S55 'd a — _CA1�n S;c 2. ctarr,�,r�TI?�r�pOn7 �gn�;, f1..cS�S _LODGE S5� `TRt1ILERPARK 510� �`�41-IIRI.pOOL S80ea. J�.f� FOOD SER�'ICE: LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERi��IIT� LICENSE REQUIRED FEE PER�vIIT� _0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 �>100 SEATS S160 �p(o( �CO'_VIMON VIC. S60 ��6=j� _��OLESALE S80 RETAIL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER.�III'# LICENSE REQUIRED FEE PER'�1IT# LICENSE REQUIRED FEE PER.�'�IIT� _<50 sq.ft. S50 >25,000 sq.t2. S225 VENDING-FOOD S25 _<2�,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S» �a`zE c�`cE: sis AMOUNT DUE _ $ 5(S .00 ***"�*PLEASE TtiR\O�ER A\D COITPLETE OTHER SIDE OF FOR�I***** � �-:> �,�;�.:;. � � _ I . , . ADMINISTRATION ` _ � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ; of any license or permit to operate a business if a person or company does not have a Certificate of Worker's E Compensation Insurance. 1'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ; � Town of Yarmouth t�es and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO �='�Q'�'E�S�ID ��.��T�'��„�.I��l'�I�N�'� . � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be � limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy 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 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 De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. i POOL WATER 1'ESTING: 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. YOOI.CLUSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of � closing. � FOOD 5ERVICE ' i SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the ; Health Department to schedule the inspechon three (3) days prior to opening. � CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department,Downloadable � Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State 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 I 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 ofHealth. ----- ------—---------__ __ _ - ; 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETiJRN E ; THE COMRLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. 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. n , DATE:�'�"//G� SIGNATURE: ,�iZ' �GC-1i� ; PRINT NAME&TITLE: /�(,( d'(� %u l'!'l eY /"/5 SZ�- C C"1'l_�'d�l�� ` � 10�06'10 I ; �� I i ( , � � , i . . � I _ The Comnionwealth of Massachusetxs ; . Department of Industrial Accidents � NKINrI� � ; = 600 Washington Street, 7`"'Floor Boston,Mas� 02111 I' Workers'Compensatios Iaaerante Aftidavih Bailding/Ptambi��/Ekctrical Contnctors � ffn: Pkaie irrr t.a�.h, . natne: address: ciri state• �P' Phone# work site location(full addressl: ❑ I am a homeowner performing all work myself. Project Type: �New Construction�Remodel ❑ I am a sole proprietor and have no one working tn any capacity. ❑Building Addition � �I am an employer providing workers'compensation f�my employees wodcing on t6is job. �mn�..��: Bl�e Water-LP . _ , : _ . ; ,� ..-.., Y .::-`: ! �aa�.- � 20 North Main Street �ic�: South Yarmouth, MA 02664 ��, 508-398-2293 in.Q,.�e�o. Zurich American Ins. Co �� WC8196036 ❑ [am a sole praprietor,geaeral coscractor,or homeo�vner(circle u»e)and have hired the contractocs listed below who have � the following worke�s•compensation polices: � CO�DSYY�!: � � I � �drqs' � citv p`�� iesara■ce eo. # � � eomouv oame: address: citv: olio�e S .._ ___, 4 _ __ i��ce co. _ __ __ _ ooLicv� _ ! A�e�M�d i��t r��r Failve 0�seeae a�era�e a required�ider See1M�tSA�I MGL 132 eu lad b tre t�polM��[al�iul peialtln�['a�e R b S1,SM.M aN/�r mrc ynn'i��..�.�„,�„a.��,�u�,m cre r.�r.r.s�ror wo�uc oxn�n..a a en�arsia.a a day a6aldt re. 1 nedenta�d that a i eM►y�t tYM�taleme�t may be forwarded os tAe OQke e[lavatl��t lie DIA for arera`e verMeaNw ' !do hertby ce weder Nre paiws awr ehler ojperjr�ry NYat tlie Fafonwoflon provlded oboae Ls tnre mrd comct � �,.' �, s►�n,n �� 11-19-2010 li � P�t� Mar� Purrier as agent onl,v Phone* 508-398-2293 ' ef'Acial ux oNy do oM wrke h�this area te be rnvpieted by dty or Mwo o�chl . dty or tewn• per�tlHeeme/ �Bolldins Department ❑ehed[ffimmedhle re�eex h reqoired , []Sdectmn Ofde�e ,I �� De�a��est i rnatact penoa: Ph�K' i tn�� r : � ACORD CERTIFICATE OF LIABILITY INSURANCE oP�o EE DATE(MNUDD/YYYY) DAVEN-1 03/02 10 vaooucea THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGMTS 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 INSURERS AFFORDING COVERAGE NAIC# ' � INSURED � � INSURERA: American zuriah In�urmca co. � � � � 40142 I B U2 Water LP INSURER'8: Zusich American Insurnnce co. 16535 � c�o Davenport Realty Trust iNsuRea c ' S�ephen Aschettino 20 Rorth Main St. INSURER D: South Yarmouth, MA 02664 ; INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR i MAY PERTAIN,TWE INSURANCE AFFORDED BV THE POUCIES DESCRIBED HEREIN IS SUB,IECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH � POLIGES.AGGREGATE LIMITS SHOW N MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY ��MfTS GENERAL LIABILITY � EACH OCCURRENCE � $1�OOO�OOO . . . $ }� COMMERCIALGENERALLIABIUTY GL08196255 03��.�1� �3��1��.1 PREMISES(Eaoecurence) S �JOO�Q0� . CLAIMS MADE �OCCUR � � MED EXP(Any one person) $�.O�OOO : PERSONAL&ADV INJURY S 1.�OOO�OOO GENEHALAGGREGATE $2�OOO�OOO GEN'L AGGHEGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2�OO O�O O O POLICY PRO- LOC � JECT , � AUTOMOBILE UABILRY � � � COMBINED SINGLE LIMIT � g nNvnuTo BAP8196256 03/O1/10 03/O1/11 (Eaacciden[) $lr 000,000 X ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS X .HIRED AUTOS . � � � BODILY INJURY � . (Per accident) $ X NON-OWNEDAUTOS X Z rJ O COMp PROPERTY DAMAGE $ X 50� C011 (Per accident) ; GARAOE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO � OTHER THAN EA ACC $ � AUTO ONLY: qGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE� � AGGREGATE � $ $ DEDUCTIBLE a RETENTION $ a WORKERS COMPENSATION AND X TORY LIMITS ER EMPLOYERS'LIABILITY A ANVPROPRIETOR/PARTNER/EXECUTIVE WC8196036 03/01/10 03/Ol/11 E.L.EACHACCIDENT $l.�OOO�OOO OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S 1�OOO�OOO If yes,describe under E.L.DISEASE-POLICY LIMIT $�,��0� SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICIES/EXCLUSIONS ADDED BY ENDOHSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION � YARMO—O SHOULD ANY OF THE ABOVE DESCRIBED POLIGES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAII 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOSaII Of YdI'RIOUtIl IMpOSE NO OBLIGATION OR LIABILRY OF ANY KIND UPON THE INSURER,RS AGENTS OR Route 28 � $OL1tZ1 YdTI1lOUtYl MA OZE>E4� REPRESENTATIVES. AUTH SENTATIV 4 ACORD 25(2001/08) �ACORD CORPORATION 1988 � :�—�•� OP ID: EE aco�zor CERTIFICATE OF LIABILITY INSURANCE °A,�,M�°"""`' � �►.-r~�� 01/18/11 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS � CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED � REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the 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 lieu of such endorsemen s. PRODUCER s�O-279�5�JO C�E CT The Addis Group,Inc. 610-279-8543 PHONE � No: 2500 Renaissance Blvd.Ste 100 e-ra� King of Prussia, PA 19406-2772 � RODRUCER Jeffrey A.Grebe c T M iu r:DAVEN-1 INSUR S AFFORDING COVERAGE NAIC A� INSURED glue Water LP INSURERA:M1enC117 ZUfICF)Ifl8U/'d�iC@ CO. 4O'I4T c/o Davenport Realty Trust �Nsur�a s:Zurich American Insurance Co. 16535 Stephen Aschettino 20 North Main St INSURER C: South Yarmouth„MA 02664 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 POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OF INSURANCE POLICY EFF POLJCY EXP UM� POLICY NUMBER M M GENERAL LU1&UTY EACH OCCURRENCE $ 'I�OOO,OO B X COMMERCWLGENERALLL481LITY GL08196255 03/01/11 �3/�1N2 pREMISE eeo�e� a 500�� CLAIMS-MADE �OCCUR MED EXP(My one person) $ �O�OO PERSONAL&ADV INJURY S 'I,OOO,OO GENERALAGGREGATE $ Z�OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Z�OOO�OO POLICY PRO- l� $ AUTOMOBILE WIBIIJTY COMBINED SINGLE LIMIT S ' 'I�OOO�OO (Ea accident) B ANY AUTO BAP8196256 03/01/17 �3/��/�2 gODILY INJURY(Per person) S X ALL OWNED AUTOS BODILY INJURY(Per axident) $ SCHEDULED AUTOS PROPERTY DAMAGE S X HIREDAUTOS (Peraccident) X NON-0WNEDAUTOS s X 250 Comp z UMBRELLA LU1B OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DEDUCTBLE $ RETENTION s WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS W481UTY A ANYPROPRIETOR/PARTNEWEXECUTIVE Y�N Ci$�96036 03/01/11 0$/0�/�Z E.L.EACHACCIDENT S �,��0�� OFFICER/MEMBER EXCLUDED? � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S �,OOO,OO H yes,desaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 'I�OOO�OO �.,a.n_ ... - DESCRIPTION OF OPERATION3/LOCATIONS/VEHICLES(Athch ACORD 101,AddHional Remarks ScAedul�,if moro spaee b nqWrod� � JAN �4 2011 � � rv�_� .. � CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE Town of Yarmouth 7NE EXPIRATION DATE THEREOF, NOTiCE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ROUte 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE T�� 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) TheACORD name and logo are regiatered marks of ACORD