HomeMy WebLinkAboutApplications, WC and Licenses�
�
' " . 8�u� wa�t 2�o�r
' - TOWN OF-Y� f` OF HEALTH
APPLICATI� : /PERMIT-2002
,�- �- Q � � � od � o
* Please complete form and attach all neces's��ocuments byryI3ece ber 31, 2001. Fai e ult in
the return of your application packet. � ���
�
� NAME OF ESTABLISHMENT: B�Le wa r R o - 288
�,OCATION ADDRFSS: 291 South Shore Drive South Yarmouth, MA
; MAILING ADDRESS: p_o_R�X �76, South Yarmoui-h MA 07664
j OWNER/CORPOR.ATION Nt�ME: Blue Water Limited Partnership
� MANAGER'S NAME: Richard v. Riley TEL # 508-477-1266
� MAILING ADDRESS• 2a Arnol d Road For dal e, A 0 644
�
� POOL CER'�IFICATIONS:
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, Oceanside Pools-Edward J. Moraan 2, ra�ncir7a Pnnla-Sj-avP F._ Simnn
� 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 fde at your place of business.
� 1, Richard V. Riley 2, Alan Lowe
� 3._Paul Rrau�c� 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 not use past years' records.
! You must provide new copies and maintain a file at your establishment.
I
1. Timc�th� l�_ M�C'arth� 2.
_ ---- —------
_ PERSON IN�HAR�E: -----______ --------- ----__— _ _ _ _
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1, Timothy D. McCarthy 2, Richard V. Rilev
��MLICH 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. Richard V. Riley 2. Alan Lowe
3. Paul Braude 4. C`hri Gt i nP r.QWe
RESTAURANT SEATING: TOTAL# 205
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 _,MOTEL $50
�
� INN $50 �a-oo6 _c�r �so �SWIMMING POOL$SOea. ��sr]-a�
_LODGE $50 TRAILERPARK $50 �WHIRLPOOL $25ea. ��--00q �
—
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25
�>100 SEATS $150 �� ) COMMON VICT. $50 �O��S7 _WHOLESALE $75 ,
RETAIL SERVICE: '
�
LICENS'"�-�,EQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO ��� $20 _<25,000 sq.ft. $75 _TOBACCO $20
�
_<50 sq.ft. �#3 _>25,000 sq.ft. $200 FROZEN DESSERT$35 �
�..„� —
NAMECHANGE: $io AMOUNTDUE _ $ 3?5.00 ✓ �
c « � ;
*****PLEASE TURN OVER AND COMPLETE OTH�C������
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' 4
ADMINISTRATION ' `
Under Chapter 152, Sectibn 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
�
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 t,/ NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. �
F
s
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�E HEALTH DEPART'MENT FOR INSPECTION 7-10 I
�
DAYS PRIOR TO OPENING FOR THE 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ,
�
ADDITIONAL REGULATIONS
POOLS
POOL OPEI�IING:All swimming,wading and whirlpools which have been closed for the season must be inspecfed
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 CLOSTNG: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing.
FOOD SERVICE
rnNSiTMER ADVISORv�
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze 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. Thses forms can be
obtasned 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 pro6ibited.
�
~� ' �� I
DATE:November 20, 2001 SIGNATURE: � /C-
PRINT NAME& TITLE: Richard v Ri �P�� [',PnPra_]__1�Jc-�ds�Pr
09/11/O1 �
_ .r _ �r
i ,
�` ACORD CERTIFICATE OF LIABILITY INSURANC�� PK DATE(MM/DD/YY)
VEN-1 03/O1/O1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The ?,ddis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
2300 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: Amer1C3I1 �,Ll=1Ct1
B ue Water LP INSURER B:
c o Davenp ort Realty Trust INSURERC:
Kerry Burxe
20 N-orth Main St. INSURERD:
South Yarmouth, MA 02664
INSURER E:
COVERAGES
THE POIICIES 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
POIICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN R TypE OF INSURANCE POLICY NUMBER P LICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE MM/DD/YY DATE MM/DDMI
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) S
CLAIMS MADE �OCCUR MED EXP(Any one person) S
PERSONAL 8 ADV INJURY E
GENERALAGGREGATE S
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S
POLICY PR�� LOC
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT s
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) a
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE 5
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN �`ACC S
AUTO ONLY: AGG S
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR �CLAIMS MADE AGGREGATE S :
S
DEDUCTIBLE y
RETENTION 5 S
WORKERS COMPENSATION AND X TORY LIMITS ER�
A EMPLOYERS'LIABILITY WC819603604 O3�OZ�O1 O3�OZ�O2 E.L.EACHACCIDENT S 1�OOO�OOO
E.L.DISEASE-EA EMPLOYE S 1�OOO�OOO
E.L.DISEASE-POLICYLIMIT S�. OOO OOO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIOWS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETfER: 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 LEFT,BUT FAILURE TO DO SO SHALL I
TOWIl Of Yarmouth IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
ATTN: Permit Dept. �, � �,
1146 Route 28 �C�� ,� ATIVES.
S. Yarmouth, MA 02664 y :
��
ACORD 25-5(7/97) c ACORD CORPORATION 1988
THE COMMONWEALTH OF MA�SSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #02-006 FEE: $50.00
THIS IS TO CERTIFY THAT AN
INNHOLDER'S LICENSE
is hereby granted to Blue Water Limited Partnershi�d/b/a Blue Water Resort
at 291 South Shore Drive.South Yarmouth MA
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 innholders. This license is issued in
conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto
and is subject to sections twenty-two to thirty two, inclusive, and of said chapter and sections twenty-five to twenty-
seven,inclusive,of Chapter 272.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Fifteenth day
of March A.D. 2002.
BOARD OF HEALTH: �a�rfea s'tf, xelli�ie�c. C�ct�c
��as�D. �io�cda.�, �'1l.D.. �I/iee
,�o�art� �acaw,c, (�
�a�ric,k��xa�
�f .S . �'f2.
.
ruce G.Murphy, .S.,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-084 FEE: $150.00
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:
RiLe Water L.imited Partnershi�, 291 Sc�Lth �hnrP 17riv�, Sc►nth Yarmnnth�MA
Whose place of business is: Blue Water Resort
Type of business: Food Service
To operate a food esta.blishment in: Town of Yarmouth
Pernut expires: December 31, 2002 BOARD OF HEALTH: �a�cfea�f, �d�ilez, ���
sEA'[vvG: 205 total (26,dining room 1; ��f�, G��, 'jft D, �f/� ���
26,dining room 2; 153,main dining room) �o�r�� �, ��
�a�tick�Der�r�otC
�efeu S�Cak, ,�72. '
March 15 ,2002 ���-��",,��� .
ruce G.Murphy, H . ., CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #02-057 FEE: $50.00
This is to Certify that Blue Water Limited Partnership d/b/a Blue Water Resort
291 South Sh�re T)rive, South Yarm�uth,MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirly-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 with the authonty granted
to the licensing authorities by General Laws, Chapter 140,and amenclments thereta
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �tle�'s�. �el�ac, (kauraccta�
SEA'rnvG: 205 total (26,dining room 1; b'ewc�a�xu�D. G�loza�°�. �D.. �Iit�
26,dining room 2; 153,main dining room) �o�e�rt� �cotoac, (,(�tk
�a�titk�anc�ot`t
`�fele� �72
March 15 ,2002
B ce G.Murphy . .,CHO
Director of Hea1
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-020 FEE: $50.00
This is to Certify that_ Blixe Water Limited Partnership d/b/a Blue Water Resort
291 South Shore Dnve South Yazmouth,MA
IS HEREBY GRANTED A PERNIIT
� To Operate a Pub6c,Semi-Public Swimming or Wading Pool
At Blue Water Resort - OUTDOOR POOL
291 South Shore Dnve
South Yazmo th. MA
This permit is graz�ted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2002 unless sooner suspended or revoked.
_ March 15 ,2002 BOARD OF HEALTH: �j1 x'��,y,
���Ja�xlu�. l�laadaic. �`j/Ece
,�ofiezt� �,�ik
�aririck�XcDauxott
� S�. ��l.
'a���' �`�i�i G� ruce u
Director of He ly �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-019 FEE: $50.00
This is to Certify that Blue Water Limited Partnershi�d1b/a Blue Water Resort
291 South Shore Drive South Yarmouth,MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Blue Water Resort -iNDOOR POOL
291 South Shore Drive
South Yarmouth_MA
This pennit is grananted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 3 l.2002 y unless sooner suspended or revoked.
March 15 ,2002 BOARD OF HEALTH: �� r��, i��ie�. ��
e�c�art�c D. �ia�do�c. D., 2/1ee
,�ade�rt� �+ioaart,(�
�aaciu���
'�f .S , .?Z
rue . , ,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-009 FEE: $25.00
This is to Certify that Blue Water Limited Partnership d/b/a Blue Water Resort
291 South Shore Drive, 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 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 regard to the
carrying on of the occupation so licensed as adopted by the Board of Health,and e�ires December 31,2002 unless
sooner revoked.
March 15 ,2002 BOARD OF HEALTH: ���1as�rlu'���, .��/lce '
�o�� �. (�
�a�r�ek�cDer,xo�
?� . .S , .
�'� ' ,���� ruce G.Murphy, H,R. O
� --;� �
Director of Health
t ,
j ,�;- `�WE l�l�A'T57'- �E'SOQ..T
. } � ` � . � � � � � Ob � �
. TOWN OF YARMOUTH BOA
APPLICATION FOR LICENSE � f 2 1 D E C Z $ ZOOO
�
j _ �
� H ALT �
* Please complete form and attach all necessary documents by December 31,2000. Failur
the return of your application packet.
-------------------------------------------------------------------------------------------------------------------------------------------
NAME OF ESTABLISHMENT: 1�i.ilF. WATF.R RF..S�RT �',�L #5o8-��s „2�usz
LOCATION AT,DRFSS: 291 SoLth Shore Dri ve o� h varmc�nth
��II..�TG ADD,�ESS: P.O.Box 276 South,�armouth, MA 02664
QWNER/CORPQRATION N.�E; Blue Water Limited Partnership
��AG�R'S N�E: Richard v. Riley TEL. #508-477-1266
M.A�LING ADDRESS: 24 Arnold Road Forestdale, MA 02644
---------------------------------------------------------------------------------------------------------------------------------------------
POQ�CERTIFICA�ONS:
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 this form.
l. Edward Mo,�gan - Oceanside Pools Z. Chris Colem�n - Oceanside Poo)s
Pool operators must list a minimum of two emplayees 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. Richard V� R11P„� 2• Paul Rraude
3. Alan Lowe 4. .TAR}1�-���i
HEIMLICH CERTIFI�ATIONS:
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 Departmeat will not u�e past years' records.
You must provide new copies and maintain a file at your place of business.
1, Richard V. Bilev 2. �ui F3raur7P
3. Alan T.owP 4. Josh Joel
RESTAURANT SEATING: TOTAL# 2Os NON-SMOKING SEATS: TOTAL# 205
______________ _________________W_____'�. _..�v_ ,._.� ..�__ _.��:_� s
_ _ _
OFFICE USE ONLY
LODGIP�TG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
�INN $50 �b 1-00(o TCAMP $50
LODGE $50 TRAILER PARK $50
— — 0 01-0(oZ
_MOTEL $50 2- SWIMMING POOL $SOea. Cs�#Of-OG 3
I WHIRLPOOL $25ea. o/-OZ ,
FOOD SERVI�;E:
NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for '
food protection manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
. 0-100 SEATS $75 CONTINENTAI., $30
! >100 SEATS $150 �01-/ NON-PROFIT $2S
I COMMON VICT. $50 �6/670 ,WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_�'15,000 sq.ft. $75 �FROZEN DESSERT $35
>25,000 sq.ft. $200
r
�AME CHANGE� ��O ' �
AMOUNT DUE _ $ 3 75.00
,� f-: � �
***"�*PLEASE TURN OVER AND COM���I��RM*.***
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� � ADMINISTRATION " • t
k
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itJnder Cl�a�t�r�1,�2,��Se tion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
�r.�. ; :
�a£;��i��s�"-or �' it 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 �
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be 'd prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ;
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON. �
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW k
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ;
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
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,and the water tested for pseudomonas,total coliform and standard plate count by a State
cemfied lab,prior to operung,and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)da.ys of '
closing.
FOOD SERVICE
NFW�TATE SANITARY CODE FOR FOOD ESTABLISHMENTS•
The effective date for food protection manager certification is October 1, 200L As stated in 105 CMR
Sg0.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection
manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As sta.ted in 105 CMR 590.000(K),enforcement
of Consumer advisory,Food Code 3-603.1 l,will be implemented Janutary 1,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yazmouth 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.
FR07F.N 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 C�FFS:
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 prnhibited.
� i
DATE: �C• 7 Z�� SIGNATURE: �'� ��
�-
PR1NT NAME&TITLE: i c �F V. ►I � �tv f
11/16/00 ;
� �.-- , � J4t1�V1- 6102198519 �VO� OJL4 f• `t�Gtmmi�.+ri.�
. ��ar .28 2000�s . . .:��,^ . � ,,,F LIABILITY INSURANC�,v�N-� 03,28,00
PRUDUCfiR THIS CERTIFICATE IS ISSUED AS A MATTER CF INFORMATION
ONLY AND CON�ERS NO RIGHTS UPON THE CERTIFICATE
Th.e Addia aroup, Iac. HOLDER.THIS CERTlFICATE DOES NOT AMEND,EXTEND oR
2300 Reasiaeaz►ae SOulav8r8 ALTERTHE COVERAc3E AFFORDED BY THE POIICIES BELOW.
Kiiig o£ Psv�aia QA 19406-�77Z INSURERSAFFORDINGCOVERA�3E
phoae� 610-Z79-8550 Faxi610-Z79-8S43
INBUaED IN9UREaA: AmosiCaa Zurich
D venport SuilBin Co. IN5URERB;
c�o Dnven ort Raa�ty Truet IN8URERC:
�r. Georg� 8aldxin
a 0 North asa3T1 St. INSURER D:
Bouth Yarntouth, 1dA OZBB4 INSURERE:
CC�VERAGES
TME POLICIES OF INSURANCE�ISTFA BELOW HAVE BEEN 158UED TO 7HE INBURED NAMED A80VE FOR THE POUCY PERIOD INDICATED.NOTWITHSTANDINO
ANY REGUIREMENT,7EftM OR CONDITION OF ANY CONTRACT OR OTNER DOCLJMENT WITH RESPECT TO WNICH TH18 CERTIFICATE MAY BE 198UED OR
kIAY PBRTAIN,TIiE INSURANCE AFFORDED BY THE POLICIE9 DEBCRIBED HEREIN IS SUBJECT TO ALL TNE TERMS,F�fCLUS10NS AND CON�ITIONS OF SUCH
POLICIEB.AOOREOATE UMI7B 9HOWN MAY HAVE BEEN REDUCHD BY PAIp CLAIMS.
L P,
TYPE OF INBURANCE POUGY NUMeER DAT� MMJOD uMIT9
EACH OCCURRENCE S
OENERAL LIl+BIL�TY
FIRE DAMAGE{AnY on�fin) 5
COMMERCIAL GENERAL UABI�RY
CIAIMS MADE �OCCUR MED EXP tAnY ona Deraon) �
PER80NAl 6 ADV INJURY 8
GENERALAGGREGATE S
PRODUGTS•COMP/OPA06 6
OEN'L AOOREOATB LIMIT APPLIEB PER:
POLfCY pRO� LOC
JECT
AUTOMOBILE LIABILITY COMBINED BINOLE LIMIT s
{Ea necleent�
ANY AUTO
ALL OWNED AUT08 9001LY INJURY E
(Per pereon)
9CN EDULE�AUT03
HIRED AUTOs 60DILY INJURY g
(Per accldenl)
NON•OWNED AUTOS
PROPERTY OAMAOE �
(Per eccidenl)
QARAAE LIA8ILITY AUTO ONLY•EA ACC�DENT S__
ANY AUTO OTHER THAN EA ACC 3
aUTO ONLY: A0� 6
EACH OCCURRENCE !
excesa u�arrr —
OCCUR �CIAIMS MADE AGORE(3ATE �_,,,
S
6
DEDUCTIBLE :
a ,
IiETENTION a
WORKERB COMPEN9ATION AND X TORY UMITB ER .l��: '
A lMPLOY8R5'LIABIUTY �C819602403 03�01/00 03/O1/81 E,L.EACHACCIDENT S1�OOOi000 ,
E.L.DISEASE•EA EMPLOYE S '1�Q O O�O O O
E�L�DISEASE•POUCY LIMIT 3 1.r O O O e O O O
OTHER
DE9CWPTlON OF OPERATIONS/LOCaTIONONlHICLlS/PJ(CLU810N8 ADDED 6Y ENDOR9EMENT/SP�CIAL PROVISIONS
CEIZTIFICATE HOLDER jj ADGITIONAL INBURED;IN9URER LBiTT�R; CANCELLATtON
YARMQ—Z gNOULD ANV QP TN�ASQV�D�SCRI88D POLICIEa BE CANCELLED BEFCRE TNE DCPIRATIO!
QAT!THEREOF,THE 188UIN0 IN9URER WILL ENDEAVOR TO MAIL 3 O wY8 wRIT'feN
NOTICE 70 YHE CERTIFICATE NOLDER NAMED TO TIiE LEPT,eUT FAIL�R!TO DO SO SHALI
TOM/i�. o t Yarnaouth IMPOSE NO OBLiGpT�ON OR UA D U THE tNBURER,IT8 AOENTB OR
ATTN� Permst aapt. �"'
114 6 Route 2 B R=pp�ElNTATIVES.
�
�. Yaratouth, �6A OZ664 '
Ami• M. 'b�cHal'�a..:w��•'� �✓i.
AC��RD 25-3(T/97} ° ;� � mACOR RPORATION 1988
�'~x.,� ��
�
, THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #01-023 FEE: $25.00
This is to Certify that_ Blue Water .;,,,i P�p rtnershin dfb/a Blue Water Resort
291 Sou h Sh re Drive ou h Ya outh A
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN T'HE 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 and conditions,and to the rules and regulations in regard to the
carrying on of the occupation so licensed as adopted by the Boazd of Health,and expires December 31,2001 unless
sooner revoked.
- March 5 ,2001 BOARD OF HEALTH: �� �e�, ����tQ�c
��t�ed�r�. i�d�, �/ice L�,rraol
��iart�. �'rau�, (�
��� d "1'
�
. .
Bruce G.Murphy,MP ,R .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #01-063 FEE: $50.00
This is to Certify that Blue Water Lim__ited Partnership d/b/a Blue Water Resort
_ 291 South hore Drive, South Yannouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At_ Blue Water Resort -INDOOR POOL
291 South Shore Drive
South Yannouth
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
March 5 , 19�9 BOARD OF HEALTH: �� j1et'�`Cd, �tQvu�tQ�t
���an��. �e��i. �/ice ��ca;6r.xa.t
,�°�,e�t? i'�our�.��
��raee Q' �.L�
� . .
����� �r
� �� D e tor of Health� �
` THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLTMBER: #01-062 FEE: $50.00
This is to Certify that _�lue Water Limited Partnershi�d/b/a Blue Water Resort
_ 291 South Shore Drive Sou Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Water Resort - OUTDOOR POOL
291 South Shore Drive
South Yarmouth. MA
This permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
March 5 ,2001 BOARD OF HEALTH: �� �¢�d, (�t�t
�tQlteCd s�'�. /�¢��Plt. �/tCe �t��6to�,t�
i��i�7�� t�Ytouio,G. �%s�r�w
%��iC`i� � �.�
� � ( , .D.
D rector of Ha lth �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #01-0170 FEE: $50.00
This is to Certify that Blue Water Limited Partnershi�d/b/a Blue Water Resort
- 91 So� h �hor Driv , �o � h Y rmo� h, l��A
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2001 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 licensing authorities by General Laws, Chapter 140, and amenclments thereto.
In Testimony Whereof,the undersigned have hereunto �xed their official signatures.
BOARD OF HEALTH: �d�L. �et�.`ed, �iavt,ua�c
sEnT[tvG: 205 total (26,dining room 1; �tQfi�¢d s��, i�¢���, �/� �itQ�
26,dining room 2; 153,main dining room) �p�♦�', ��r��, ��
�zlic�ra� d ".L'
� . �l�.
March 5 ,2001
�����`����� ruce G.Murphy M .5., CHO
Director of Health
. TOWN OF YARMOUTH
' BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLIMBER: #01-115 FEE: $150.00
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:
Rl �P Wa r i imi Pd P rtn rshi�, 291 So�th 4h� T)rive, S� � h �'arm� � h, 11�A
Whose place of business is:__. Blue Water Re�nrt
Type of business:__ Food ervice
To operate a food establishment in: Town of Yarmouth
Permit expires:_December 31 2001 BOARD OF HEALTH: �d� �etr`ed, ��c�a.vr�rrra�cc
SEA�nvG: 205 total (26,dining room 1; ��Q�l ��(��� �� ���a�
26,dining room 2; 153,main dining room) �����', ��,��� �
��� d '.C'
D. 7�1.D.
March 5 ,2001
ruce G.Murphy, , .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #01-006 FEE: $50.00
THIS IS TO CERTIFY THAT AN
INNHOLDER'S LICENSE
is hereby granted to Blue Water Limited P�r�i�ership d/h/a Blue Water Resort
at _ 29 South Shore Drive South Yarmouth MA
in said Town of Yarmouth And at that place only and expires December thirty-first,2001 unless sooner suspended
or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in
conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto
and is subject to sections twenty-two to thuty-two, inclusive, and of said chapter and sections twenty-five to twenty-
seven,inclusive,of Chapter 272.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Fifth day
of Mazch A.D. 2001.
BOARD OF HEALTH: �d� j1etr'ea, C�xa.,t
(�,lra�cF,ed�,�. �e��. �/ice �iavr.,ra�
�a�rt� �'now.,c. L�
��� d '1'G�
� � , 'D.
�
��, �_� � . �� ruce G. Murphy,MPH, . CHO
Director of Health
Yf I
. �,�'�� � � � � �� � �
�� � �� TOWN OF YARMOUTH BOAR�F�,,��.LT�
` APPLICATION FOR LICE�T �T'�-��OUO N 0 V 2 9 1999
���:3�r;� `r�`-����� ALT!-! DEPT.
* Please complete form and attach all necessary documents b��ecember 31, 1999. Fa� HE o so wi result in
the return of your application packet.
------------F E--------------------------------- -------- -- -- ------ -- �-.S'a�t ---------------------------L-#,S6�--?9 � 2Z�
L ATI Z �l' � 2�v
' LIN D ;,-1 a�Hn��i , st azGG
N
� V- # - - � z�
D 2 � a��f�F-
�OOL CERTIFICATIONS:
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 tlug form.
1. � lx- J'�DP�►c4� 9R.la�c � /'e��. ' 2.
� �
, Pool operators must list a mitimum of two �mpl yees 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 Heatth Department wilt not use past years' records. You must provide ��
new copies and maintain a file at your place of business.
;
1. �6 � f'c.r�o�iQd�h,,c�a1 �► �� � 2. �
3. 0 4.
�
FiEIlbiLICH CERTIFICATI NS: �
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I
Maneuver on the premises at a11 times. Please list ydur employees trained in anti-choking procedures below and
I attach copies of ernployee certifications to this form. The Health Department will not use past ye�rs' records.
You must provide ne�v copies and maintain a fde at yaur place of business.
1. �°� ° � _�'-°� �M� - , 2
3. � '7'� 4.
�STAL�RANT SEAT�NG:-�flT1�;# - _N(3A�SMOI£�Tfr 5EA3'S: �'OTA€;# ---- - ----- - -
----------------------------------------------------------------- ---------�-------------------------------------------_--------------------
QFFICE USE UNLY '
LODGING•
�
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERNIIT# ;
B&B $50 _CABIN $50
�INN $50 k- _CAMP $50 �
LODGE $50 TRAILER PARK $50
MOTEL $50 �SWIlVIlVIING POOL $SOea. �_� � ',
�WI�LP4UL $25ea. Y21C-3
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
�>100 SEATS $150 y2 2 NON-PROFIT $25
�COMMON VICT. $50 y2k—T13 WHOLESALE $75
RETAII, SERVI�E:
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 = $__��]Cj�—
*"""PLEASE TURN dVER AND COMPLETE��.i V ��� ��•�R
�r � �i�f !
[
�
,
t...�.._.�,....
� _ _... , f , .
j � ADMIlVISTRATION � ;" '.
U1�TDER CHAP'TER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUTRED
T(� Hf7�.D ���:U�41�C� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A �
PERSOIV�OR CUlVIPA1VY DOES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR.
CERT. OF INSURAIVCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRI�R TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID: �
YES� NO '
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YQUR
RESPONSIBILTTY TO RETURN 'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY j
DECEMBER 31, 1998.
SEASONAL ESTABLISHIVV�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 �
DAYS PRIOR TO OPENING FOR THE SEASON. �
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-iMENT, MOTEL �R 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.
Q�DDITIONAL REGULATIONS
POOLS ,
POOL OPENtNG: ALL SVV:�VIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CL4SED FOR ��,
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE WATER TESTED FOR !
-- PSEUDOMONAS,TQTAL EOLlF4RM AND STANDARD PLATE C�UNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEIVING, AND QUARTERLY THEREAFTER.
POOL CLOSIlVG: EVERY OUTDOOR IN GROUND SVV'IlVIlVIII�IG POOL MUST BE DRAINED OR COVERED ��I
WITHIN SEVEN(7)DAYS OF CLOSING. ',
FOOD SERVICE
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 T'HE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT 'THE HEALTH
DEPARTMENT.
�ROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENf. FAII,URE TO DO SO W1LL RESULT IN TI-�
SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE
_----
—---— ----------___--
BEEN MET.
OLI'�'ST�E CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLT5T HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD
.
SERVICE ESTABLISI�VIEENT'IS PROHIBITED.
p � lc � U •
DATE: �( w 1� `t SIGNATURE:
PRINT NAME& TITLE: ►c ��+�2� �- �� �cs r� �i � ,
11/12/99
� - -- ----�` -
. . ' �
� ' The Commoawealth of Massachusetts
� � Department ojlndustrial.-�ccidents
' ; OIllce o/I�stl�s�liis
' ; 600 Washington Street
' ,: Boston. Mass 02111
~ '�� W'orkers' Compensation Insurance Affidavit
A{�nlicant informallon: PleasePRi�T�.'i�ia
n�m��
location�
��� ohone#
� I am a homeowner perturmin;all w�ork m}�seif.
� ( an� a sole proprizror�-,a, ha�e no one��ori:ine in am•capacit�• '
� I am an emplo}erpro���ing w�orker_s� comp_ensation fqr my employees w•orkine on this job. _ _ _
comoanv name:
�ddress•
siri•• ehone t!•
insurance co. policylt
� I am a sole proprietor. generai contractor, or homeow•�er(circle oneJ and hace hired the contractors listed below �tiho ha�e
the follu��in� ��orker�� ;ompensation polices:
com�anv ��me•
address•
�ty: ohone Il•
insur�ncc co. Qelicy#
comnany name•
add ress•
eijy: ehoee M•
insurance co. � notiey N
t
Failure to secure covera;e as required under Secnon 25A of MGL IS2 ca�lad to tbe i�paidoa otcrioi�al pesdtles ota d�e ap to 51,500.00 a�d/or �
oae years'imprisooment as w•ell a�eivii penaiNe�io tbe fo�m of a STOP WORK ORDER asd a Aae o�S100A0 a day a��iost ma I atdenta�d t6at a
eopy of thy statement may be fonvarded to the Oflice of Invcstig�dom of t6e DU tor eoven;e veritiptio�.
/do hrreby cerrify� er th porns and p nalh s q jp�ry'ury that the rnjornratioa providtd abovt is nttt and eorr�e�
� '
Signature � U' � �q`- 1 9�
Print name f���Kd�- V- l( one 1l fb � ��1 � Z Zt�X�
.. o(Ticial use onl� do not writt in this�rea to bt completed by citv or tMvn oAlci�l
ciry or town: yA��IIT$ _ pennitAieeax p n8uildiog Departmeot
Q � �._,e �Licensiog Board
� eheck if immediate response is requi�ed V��' ��'i���� 261 ❑Seiectmen'�OlTice
08� 398�?231 eat. �Hea1tA Department
contact person: ------pAee�Ri--5.,�._ _ nOther
.. .,�,
acaRv �;�KTIFICATE OF LIABILlTY INSURANCE�, °"�'"'""'°°""'
CSR
PRODUCER Vi�T-1 03 04 99
The Addis �roup, Iac. THIS CERTIFICATE(S 15SUED AS A MATTER OF lNFORMATIOfV
ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
Suite� 200 HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
100 Four Falls Corgorate Ctr. ALTER THE COVERAGE AFFORDED BY THE POLICIES BEL�W.
west Coaehohocken PA 19428-2976
Phone: 610-832-27.00 Fax:610-825-9I36 INSURERSAFFORDINC3COVERAGE
INSl1RED
INSURERA: Aat@t'j,C3tl Z11Y'�CL3
B 11B Water LP INSURER B:
c o Davenport Realty Trust
Mr. C�feorge Haldwia fNSURER C;
SouthrYarmouthS�MA 02664 INSURER D:
INSuRER E
COVERAC3ES
THE POLICIES OF fNSURANCE LISTED BELOW hIAVE BEEN ISSUED TO THE INSURED NAtiED ABOVE FOR THE POLICY PERIOD INDICATEO.NOiWITHSTANDINf3
ANY REQUIREMENT,TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC7 TO WHICN THIS CERTIFICATE MAY BE IS5UED OR
MAY PERTAIN,TFIE INSURANCE AFFORDEO BY THE POIJCIES DESCRIBED HEREIN IS SUBJEGT TO ALL THE TERMS,EXCLU510NS AND CONOITIONS OF SUCN
POLICIES.AGC3REOATE LIAMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANAS.
� TYPE OF INSURANCE POLICY NUMBER ATE M!D DATE M1D LIMITS
GENERAL LIA6lLI1Y EACH OCCURRENCE S -
COMMERCIA�GENERAL LIABIUN FIRE DAMAGE(Any ona tire) S
CLAIMS MADE �OCCUR M�p p(P(AnY one person) 3
PERSONAL&AOV INJURY S
OENERALAGGREOATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCT&-COMP/OP AGG S
P01-�CY JEG`aj' LOC
AUTOMOBfLE 11AB1UTY
COMBINED SINGLE LIM(T
ANY AUTO (Ee eccldentJ S
ALL OWNED AUTOS
SCHEDULED AUTOS BOD�tY INJURY s
(Per petson)
HIRED AUTOS
NOtJ�OWNED AU705 BODILY INJURY $
(Per aecWeM)
PROpERTYDAMAGE $
(Perecoideng
DARAGE LIABILITY AUTO ONLY-Eq ACqDENT S
ANY AUTO EA ACC $
OTHHR THAN
AUTO ONtY: A� $
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR �q,A��q,S MApE A(3GREOATE g
a
oEoucne�E $
REfENiION §
S
WORKERS COMPENSAl10N AND X TORY LIMtTS ER
A EMPLOYER5LIABILfTY q�C819fi03602
03/01/99 03/01/00 E.L.EACHACCIDENT s1,000,000
E.L�ISEASE-EAEMPLOYE s l,000,000
OTHER
E,L,Di5EA5E•POLIGY LIMR S 3,�O O O�Q O O
DESCRIP110N OF OPERATIONSII.00ATIONS/1/EF{�C���USIONS ADDED BY ENDORSE�qEM/SPEdAL PROVIS�ONS
CERTIFICATE HOLDER Y AODiTIONALINSURED;INSURER�.EITER; CAIVCELLATION
�(ARMa„a SHOULD ANY OF TH6 ABOVE DESCRIBED pOLiCIES BE CAWCELL�BEFORE 7NE DCP�RA1101�
DATE THEREOF,THE ISSUINf3 INSURER WILL ENDEAVOR TO MAfI 3 O DAYS WRITtEN
TOT�Vl1 o f Yarmouth NOn�T�TME CERTIFlCA7E HOLDER NAMED TO TNE LEFf,BUT FFULURE TO Do SO SHRLL
ATTN: Permi t Dep t. ��P�E NO OBLIGATION OR LfA81LIlY� ANY�KIN N TH SURER,R5 AGENTS OR
1146 Route Z8 REPRESENTATIVES.
s• Ya�lOuth� MA OaGG� AUTHORIZEOREPRE5ENTA7i
ACORD 25-5 7l9 �ie M• �cFiale
( � � �' " ACORD C ORATION 1
� � � ��
!
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-24 FEE: $150.00
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:
Blue Water Resort, 291 S�uth Shore l�rive, South Yarm�nth, MA
Whose place of business is: Blue Water Resort
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�d �/. �Bt�a, C'�atp,,,,a�
SEATING: 205 total (26,dining room 1; �oan G. �ullivar�, �//., Vice ��xairma
26,dining room 2; 153,main dining room) �odert� a,rown, C�ler�
adrielle�a�ol��iy-J�tooPea
ic�l oCo �lin
December 3 , 19 99 �
Bruce G.Murphy, MPH, R .,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-4 FEE: $50.00
THIS IS TO CERTIFY THAT AN
INNHOLDER'S LICENSE
is hereby granted to Blue Water Resort
at 291 South Shore Drive. South Yarmouth.MA
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 innholders. This license is issued in
conformity with theauthority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is
subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty-seven,
inclusive,of Chapter 272.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Third day
of December A.D. 19 9�.
BOARD OF HEALTH: �cI� ..te�ea, C�airntan
�oar�C�. �ul�an, �//., Vice l.�irman
Ko�e�,1. 9�rown
a�rielle�a�o��y-.�ooPea
/i/' ��� �i�
�+ .� � l.�c_,e��
`����_; ���� Bruce G.Murphy, MPH,R .,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-13 FEE: $50.00
This is to Certify that Blue Water Resort
291 South Shore Drive, Sonth Yarm�u h, MA
IS HEREBY 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 conformit�vv�th the authonty granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their o�cial signatures.
B�ARD �F HEAI.TH: �c�� �alta�, (.�airman
SEATING: 205 total (26,dining room 1; oaa� �ullivaa, ��, Vice C�`iairman
26,dining room 2; 153,main dining room) �o�srt� �rown, C.6e��
a��ie[[e�akoldh y-.J�too�oe�
' haa[Q� ou� a
December 3 , 19 99 L�..Ai
ruce G.Murphy,MPH, .S. O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-7 FEE: $50.00
This is to Certify that Blue Water Resort
291 South Shore Drive South Yarmouth_M�
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Water Resort -OUTDOOR POOL
291 South Shore Drive
South Yarmouth
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 , 1999 BOARD OF HEALTH: �c�� �a�, t��iai�man
�oan� �ullwan, K.//., Vica C.hairman
Kobert� 9�rown
a�.ie[!e�a�ol��y-.l�toope�
• �.u...�o��,ln
i
ruce . urP Y�
���' -�� �_���� Director of Health
� , . . •
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-3 FEE: $25.00
'rhis is to Cer�ify that Blue Water Resort
291 South Shore Drive South Yannouth, MA
HAS BEEN GRANTED A LICENSE TO
ENGAGE IN THE BUSINESS OR PRACTICE OF
- GIVING OF VAPOR BATHS
This License is issued in conformiry 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 pmvisions 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 expires December 31,2000 unless sooner revoked.
December 3 , 1999 BOARD OF HEALTH: Ld ir/. �eltee, l,�zairman
�oan� �ullivaa, �//•s Vice ��irman
Kobert}. �rown
� a�rielle�a�ol�k y-J�ooPe�
'i/� �[�� �lin
�� ,
�_� 1�
ruce G. Murphy, MPH, .S., O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-8 FEE: $50.00
This is to Certify that Blue Water Resort
291 South Shore Drive, South Yarmouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At Blue Water Resort -INDOOR POOL
291 South Shore Drive
South Yazmouth. 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 , 19Q� BOARD OF HEALTH: �c`� �`eltea, ��iairman
�oan.� �ul[ivan, K.1/., Vice (..�irman
�obsrE,}. O.�rown
a�ri�[le�al�o[��iy-.�/�ooPee
• �O' ���,�
� �
���:" ,��E� � . um y, , .
Director of Health
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; _ The Commonwealth ojMassachusetts
� � � Department ojlndustria/,accidents '
� o Ofllce o1/eresllostliis '
� 600 Washington Street
� Boston, Mass. 02111 '
/� 1V'y�. � , ',.:
W'orkers Compensation Insurance A�davit
Anolicant informallon: P'►essePRINTTe�'i,Tic
namr�
i�cation:
cit� phone#
� I am a homeowner pertorming all w�ork myself.
� f am a sole proprietor�r;� ha�e no one��orking in am�capacin�
� I am an employer pro�iding w�orkers' compensation for my employees working on this job.
om a • na
address• '
i
t -
insurance co (� Aolicy# _
� I am a sole proprietor. _eneral contractor. or homeowner(circle onel and hace hired the contractors listed below ��ho ha�e '
the follo��in� ��orker� �ompensation polices:
�
sompanv oame•
�ddress
S�Ly: Fhone#•
insur�ncc co Qolicy#
com�any namr ;
_ ___ a�dr sa:--- — ------ — __----- ,
Sjsy• - -- —nhoee M•
insurance c4 nolieY M
Failure to secure covenge as required uoder Sectioo 25A of MGL 1S2 ea�lead to t6e iepaidoa ot erisi�al pe�altla of a li�e�p to 51,500.00 a�d/or
one yean'imprisonment a�w•efl��eivil penaltia io tAe form ot a STOP WORK ORDER aod a tine of 5100.00 a dar a=�iast sa i a�dersta�d trst a
copy of thy statemrnt may be forwarded to the OtTiee of Invatigatioa�ott6e DU for eoven`e ve�itieatio�. ;
/do hrreby cerrijj�unde�the pains and penalries ojperjury thot�ht injor►nation providtd abovt is hue and eorr�e�
Signature �
Print name Phone N
.. o(Ticial use onl� do not M rite in this area to be completed by ciry or town ofllcial
city or town• y�M�� _ permit/licease N nBuildiog Departmeot
OLiceasing Board
�eheck if immediate response is required 261 ❑Seleetmen's Oliiee
�Health Departmeot
contact person: phone p;_ �508} 398�2231 eat. nOther
Ire��ised i;9t P1A1 ��.
I
�+xr ' DATE(MM/DD/Yl�
��RA �������iv��`:� �� ������1�� ��������V83�-1 .. . ._.. 04/17/98
pRooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Addis Group, Inc. ONLY AND CONFERS NO RIGHTS UP�N THE CERTIFICATE
Suite Z00 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 COMPANIES AFFORDING COVERAGE
Gary W. D�arrea, CPCII, ARM COMPANY
PhoneNo. 610-832-2100 F�No.610-825-9136 A American Zurich
INSURED
CAMPANV
Blue Water LP B
c/o Daveaport Realty Trust CAMPANY
Mr. George Baldwin C
2 0 North Main St. �MPA�
South Yarmouth, MA 02664 p
�p���/k�� '
_ _
- . .. _. ._ ,.:: ,:,; ; ,; _ ,. > ;::
;. ,:
_..: ;; <..
THIS IS TO CERTIFY THAT TNE 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 OTNER DOCIR�AENT 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 CLAMAS.
�TR TYPE OF INSURANCE POUCY NUMBER �CY EFFECTNE POLICY EXPIRATION LIMITS
DATE(MNWD/YY) DATE(MNUDD/YV)
(iENERAL LIABILITY GENERAL AGGREGATE E
COMMERGAL GENERAL LIA&LITY PRODUCTS-COMP/OP AGG $
CLAIMS MADE �OCCUR PER�NAL 8 ADV INJURY $
OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $
FIRE DAMAGE(Any one firo) S
MED IXP(Any one person) S
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMR $
ALL OWNED AUTOS
BODILY INJURY a
SCHEDULED AUTOS (Px person)
HIRED AUTOS
BODILY INJURY $
NONAWNED AUTOS (F'a accider�
PROPERTY DAMAGE $
OARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO
OTHER THAN AUTO ONLY: ` '
EACH ACCIDENT S
AGGREGATE S
EXCE55 LIABILfTV EACH OCCURRENCE $ '
UMBRELLAFORM AGGREGATE y
OTHER THAN UMBRELLA FORM s .
WORKERS COMPENSATION AND x TWORYS IJM S �ER
EMPLOYERS'LIABIUTY .
�.encHAcclDErrr S1,OOO,OOO
A PA�PR���� 8 �- WC819603601 03/O1/98 03/O1/99 �aSEASE-POLICYLIMIT s 1,000,000
OFFICERS ARE: IXCL EL DISEASE-EA EMPLOYEE S 1�O O O�O O O
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNENICLES/SPECIAL ITEMS
<:
f�ER'EIS[CAT�[���R ' >;�IkN�EELATIff�# ;.
,, ,.. ; ,. _
_._ _._. _. . -.. _. ::
YARMO-a SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUINf3 COMPANY WILL ENDEAVOR TO MAI�
TOWII of Yarmouth �_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
ATTN: Permi t Dep t. BUT FAILURE TO AAAIL SUCH NOTICE SHALL IMPOSE NO OBLICiATION OR LIABILITY �
114 6 Route a 8 OF ANY NIND UPON THE COMPANY,ITS AIiEPITS OR REPRESENTATIVES. I
S Yarmouth� MA OZGG4 AUTHORIZEDREPRESENTAxIVE !
_
;
Gary al �arre�i, CP II�D� '
�1C��tR 2S=S�; : �-d' �..�
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TOWN OF YARMOUTH ;
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: 99-34 FEE: $150.00
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:
_ Rlue Water Resort, 29l S�Lth Sh�re Drive� S�uth Yarmouth, MA
Whose place of business is: Blue Water Resort
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 1999 BOARD OF HEALTH:�d{�/. �eE��, C�tr,�,�
SEATING: 205 total (26,dining room 1; �oan G. �u�iivar�,��, Vice �`iairma�
26,dining room 2; 153,main dining room) Ko�e�t�}. �rou�n, l,�er�
a�rielle�a�xol��r�-J�tooPe9
ichael oCo hdin
December 16 , 19 98
, ruce G. Murphy,MPH,R.S. H
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: 99-22 FEE: $50.00
This is to Certify that Blue Water Resort
291 So � h Shor nriv ;, So� h Yarmn � h�MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�pires 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 conformity with the authority granted
. to the licensing authorities by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof,the undersigned have hereunto a�xed their official signatures.
. � Bo� oF��.�: �d� �n6�Q�, c��,��
SEATING: 205 total (26,dining room 1; �oaa� Ju[livaa���, Vice ��zai.rrnaa
26,dining room 2; 153,main dining room) �o�erE� 9,row�., �[er� ;
abrieLLe�a�oidktf-.../VooPed `
/ r �
ichae�o u� i
f
December 16 , 19 98 '
Bruce G.Murphy, H,RS., �
Director of Health I
�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-2 FEE: $25.00
This is to Certify that Blue Water Resort
291 South hore Drive, 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 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 expires December 3 l, 19 99 unless sooner revoked.
December 16 , 1998 BOARD OF HEALTH: �c�� �ettBe, C,�iai.�mah
�oan G. �ul[ivan� K.//.� Vice (�hairman.
Ko�ort.}, p�rorun
a�rie�le�ako[��cf-J�too�nee
' e�o oC li�t
ruce G.Murphy,MPH,RS.,C O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-11 FEE: $50.00
This is to Cer6fy that Blu�Water Resort
291 South hore Drive Sou�h Yannouth,MA ;
IS HEREBY GRANTED A PERMIT '
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Water Resort -INDOOR POOL
291 South Shore Dnve
South Yarmouth_ '
TLis 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.
December 16 , 1998 BOARD OF HEALTH: �c�� �}ot�s�, ��aar'.rs,ua
- �oaa(�. Ju[6ivan�/C.�� Vic� l,hairm�an
Ko�rE� /�rown
abrielle�a�o[ekc�-..J`�tooPea
e�ooC '
C0 �
Director of Healtyh � �' �
�
�
- THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: 99-3 FEE: $50.00
THIS IS TO CER1'IFY THAT AN
INN�OLDER'S LICENSE
is hereby granted to Blue Water Resort
at 291 South Shore Drive South Yarmouth MA
in said Town of Yarmouth And at that place only and expires December thirty-first, 19 99 unless sooner suspended
or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. Tlus license is issued in
confotmin��vith theauthority grantcd to the licensing auWorities by General Laws,Chapter 140,and amendments thereto and
is subjcct to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-frve to twenty-seven,
inclusive,of Chapter 272.
In Testimony Whereot;the undcrsigned have hereunto affixed their official signattues,this Sixteenth day
of December ' A.D. 19 98 .
BOAItD OF HEALT'H: �c�� �eltee, C��iair�m,an.
�oan� �ullivar�� K.i"/.� Vice C��irmarc
Kobert� �rouin
• abrie6le�akole�c�-..l�tooPed
�e�0' �,.�� '
ruce G. Murphy,MPH,R.S., H
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-10 FEE: $50.00 ;
This is to Certify that Blue Water Resort
291 South Shore Drive, South Yarmouth,MA '
IS HEREBY GRANTED A PERMIT '
To Operate a Public, Semi-Public Swimming or Wading Pool
At Blue Water Resort - OL OOR POOL
291 South Shore Drive
South Yarmouth_ MA
This permit is granted in conformity with Arkicle VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31. 1999 unless sooner suspended or revoked.
December 16 , 1998 BOt1RD OF HEALTH: �cl� .}a#ee� C�iaerman
� �oan� �ultivan,/C.i!•� Vice l.�irmah
Ko�erE�}. 9�rouin
abrie[[a�akoldkc�..J`�tooPe�
�e�0' o �� •
Director of He�alth � �
• I
,
i