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Home My WebLink AboutApplication and WC ' B�vE KocK. �o�P � TOWN OF YARMOUTH BOARD OF HEALTH �„�,� ;_� � � APPLICATION FOR LICENSE/PERMIT -2012 � ;4�� '�'�j�$�� `�; '_ ' �� * Please complete form and attach all necessary documents by Il`eciem� � ��d Failure to do so will result in the return of your application pac e . N�jV � ESTABLISHMENT NAME: Blue Rock Pro Shop • - . LOCATION ADDRESS: 48 Todd Road South Yarmouth TEL.#:5 - - i MAII.INGADDRESS: 20 North Main St . , South Yarmouth ' OWNERNAME: Davenport Rea�ty CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: Ryan 0'Loughlin TEL.#508-398-6962 MAILINGADDRESS: 20 North Main St . , South Yarmouth 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. L 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�le 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 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. TO BE SUPPLIED AT OPENING 2 ' PERSON IN CHARGE: ' 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-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. ; L 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY � ; LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea _LODGE $55 _TRAII,ER PARK $105 _WHIRLPOOL $80ea. i FOOD SERVICE: - - --- --- -- _ ___ _- ___- -___ _ __ j —__- - -- -- _ _ -- _ __- _ _ _- - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' �0-100 SEATS $85 �ra-Or3�� _CONTINENTAL $35 _NON-PROFIT $30 ' _>100 SEATS $160 �COMMON VIC. $60 ��5 _WHOLESALE $80 RETAIL SERVICE: —RESID.KTfCHEN $80 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 ' i NAME CHANGE: $is AMOUNT DUE _ $ ('-f5.02� � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ; ; ! 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 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 to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES KX NO MOTELS AND OTHER LODGING ESTABLIS��VVIENTS TRAN5IENT 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 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 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. POOLS POOL OPE1vING: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 CLO5ING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of '' closing. � FOOD SERVICE SEASONAL FOOD SERVICE OPEI�IING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection 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.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 terms have been met. � i OUTSIDE CAFES: ��', Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. I OUTDOOR COOKING: I�� 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 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, 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 S PLAN. � DATE: 11-4-11 SIGNATUR�� PRINTNAME&TITLE: Mar� Purrier A��i �tant ��ntrolle� Rev.10/25/I 1 _ _ � � �� The Commonwealth of Massachusetts ' Departnreat of Industrial Accidents N�fe.arr�rM�s 600 Washingtoa Street, 7`"'Floor Boston,Mas� 02111 Workers'Compen�allon Inserance Aftidavit: tln• Please PR�11'fepibh name: addtess: ciri state• zin• �hone# work site location(fiill addressl: ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity. � I am an e�nployer providing workers'compensation f�my employees wodcing on this job. �mm.v.�: B1ue Rock C1ub Pro hon ,d�. 48 Todd Road citv: S o u t h Y a m o � h ol�oee N• S n R �A R h,A�i2 t��,.�sca Zurich American Ins . Co � W�C ,1 h�� : < :.., :,. ❑ I am a sole proprietor,geaeral co�tracMr,or bomeowser(circlt oni)and have hired the contrxtors hsted below who have the following workers'compensation polices: COmDfYY�S: � '� fdd�T citv ntoae�• iesuaaee ea �� conouv tame• sd�tress: , c1ts: oro�e*• ie�Qa�ee eo. �� j A11�ehaii■nldi�t�sar�t . � , Fail�re r xc�e aa�va�e as reqdr�ed ude SeetlN ZSA�t MGL 132 eaa Ind b IYe�dui�i�al pe�attln�t a me�p b f1,SM.N adl�r ooe Ynn'ta�►tMen�eet n wU as cM peuNin h t6e t�r�o[a 3TOr WORK ORDER aed�ese e(fll�.N a dar apimt tie. 1 s�da�d tiN a cepy of tW�taeeseot s�y 6e forwarded 1s tAe Omee�tlaveNlptl�as ot tie DIA fir e�rerase veNAaUw /!o be►+�by c rnder Nie peiwf �hles oJeerjrrry Nir�t tlYt iwfon�r�fion provlde�abeae h trare awd con+ert ' i s�s� nen 11-4-11 ! pr;mname Mary Purri;er �as agent onlv�_Phone#�08-39�-��3'� � efBefal ox soly do aAt write�t6b area to 6e csoPieted b�'cilp er�we aBkid . , city ar t�wn: permifMeeme M OBaYdlna Dcpartment ❑eheek i[Imsed�le re�psase b reqaired 0�,�� i OHeaItY Dqq��e�t I coatad peraoa: p6��e N• �Q tm.oa s�.mw► � � . � � j I � I �� OP ID:EE A�OR09 DATE(MM/DDlYYYY) ; ; `.� CERTIFICATE OF LIABILITY INSURANCE o2/24/11 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 POUCIES � BELOW. THIS CER77FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED I 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 WAIYED,subject to i the terms and conditions of the poiicy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the � certificate holder in lieu of such endorsement s. i � PRODUCER s��-279-8550 NAME:CT � i The Addis Group,Inc. 610-279-8543 PHONE FAX 2500 Renaissance Blvd.Ste 100 p✓c No wc No: � King of Prussia,PA 19406-2772 E-MAIL � Jeffrey A Grebe PRooucER ,DAVEN-1 MERI INSURER S AFFORDING COVERAGE NAIC# INSURED Davenport Realty/ . iNsuReRn:American Zurich Insurance Co. � 40142 i Blue Rock Motor Inn �r,sur�Ra:Zurich American Insurance Co. 16535 c/o Davenport Realty Trust INSURER C: Stephen Aschettino 20 North Main St. INSURER D: South Yarmouth„MA 02664 iNsur�Re: � 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 7ypE OF INSURANCE A �B POLICY EFF POLICY EXP L7R POLICY NUMBER MM/DD MM/DD/YYYY LIMITS GENERAL�IABILITY EACN OCCURRENCE $ 'I,OOO,OOO B X COMMERCIAL GENERA�LIABILITY GL08196255 03/01/11 03/01/12 pREMISES Ea occurrence a 500,0� CLAIMS-MADE �OCCUR MED EXP(My one person) a 10�0� PERSONAL&ADV INJURY S ')�OOO,OOO GENERALAGGREGATE y 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Y,OOO,OO POLICY PR� LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a 1,000,00 B ANY AUTO BAP8196256 03l01/11 03/01/12 (Ea accident) BODILY INJURY(Per person) 3 X ALLOWNEDAUTOS BODILYINJURY(Peraccident) S SCHEDULED AUTOS X HIREDAUTOS (Peraccid ntDAMAGE a X NON-OWNEDAUTOS E X 250 Comp E UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LtAB CWMS-MADE AGGREGATE t DEDUCTIBLE S RETENTION S a WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILI7Y A ANYPROPRIETOR/PARTNER/EXECU7IVE YI N W(�,$�96Q2f� 03/01/11 03/01/12 E.L.EACH�ACCIDENT E �r0��0�0 OFFlCER/MEMBER EXCLUDED9 � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE a 1,��0�0� If yes,describe under E.L.DISEASE-POLICY LIMIT E 1,�0�,�00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES �Adach ACORD 101,Additional Remarks Sehedule,(f more apace is required) � CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DE5CRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED (N ROUt@ 28 ACCORDANCE WITH THE POUCY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE � T�� O 1988-2009 ACORD CORPORATION. Ali rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD