HomeMy WebLinkAboutApplication and WC , � o S+�oP
� � � � TOWN OF YARMOUTH BOARD OF HEALT
= APPLICATION FOR LICENSE/PERMIT -201 ��r �, �,,J �Q��
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* Please complete form and attach all eeess�,�d�c�e�its � � D 12. �
Failure to do so will result in t��"'return o�`your appli
ESTABLISHMENT NAME: Blue Rock Pro Shop TAX ID• _
LOCATIONADDRESS: 48 Todd Road, South Yarmouth TEL.#: 508-398-6962
MAILINGADDRESS: 20 North Main St . , South Yarmouth
OWNERNAME: Davenport Realtv
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: Ryan 0'Lou hlin TEL.#:508-398-6962
MAILING ADDRESS: 20 North Main Street , 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.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2•
3. 4•
FOOD PROTECTION 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.
l, To be supplied at openin� _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�le at your place of business.
1. 2.
3. 4•
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY !
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ';
B&B $55 _CAB1N $55 _MOTEL $55 I
INN $55 _CAMP $55 _SWIMMING POOL $80ea
_LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. �,
I
-- _ FQ9�SERVICE• _--- ----- -- - ---- - ------- — — '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �''
I 0-100 SEATS $85 �c3''D�� _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 �COMMON VIC. $60 I�J���0 _�OLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 �'I
<25,000 sq.ft. $80 —FROZEN DESSERT $40 TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ •O�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
j _ "_
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
i 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
i
� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES XX NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place 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 OPENING:All swimming,wading and whiripools 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 E
j prior to opening.PLEASE NOTE: People are NOT allowed to sit m 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. ,
,
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishtnents 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.varmouth.ma.us under Health Department,
Downloadable Forms.
r
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.
OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOHING:
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, 2012. �
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 I
TO COIVIMENCEMENT. RENOVATIONS MAY REQUIRE A S PLAN. �
. �
DATE: 11-1-12 !
SIGNATURE: ,��(�G�i1�i�✓1 �
PRINTNAME& TITLE: Mary Pu rier, Assistant Controller
Rev. 10/09/12
- i
. . '-y
. � � The Commonwealth of Massachusetts
Deparhnent 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
Anulicant Information Please Print Le�iblv
Business/Organization Name: Blue Rock Pro Sho�
Address: 48 Todd Road
City/State/Zip:So . Yarmouth, MA 02664 Phone#: 508-398-6962
Are you an employer?Check the appropriate box: Business Type(required):
1.Q'X^�I am a employer with employees(full and/ 5• ❑Retail (
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment '
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.Q Manufacturing
no employees. [No workers' comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.�]Other Pro Shop
*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
organization should check box#1.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Below ds the policy information.
Insurance CompanyName: Zurich American Ins . , Co .
Insurer's Address: s ee a t tached
City/State/Zip:
Policy#or Self-ins.Lic.# WC 819 6 0 2 4 Expiration Date: 3-1-13
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 c ' ,under the pains d penalties of perjury that the information provided above is true and correct.
Si ature: ^ Date: 11-1-12
Phone#: 508-398-2293
Official use only. Do not write in this area,to be completed by city or town offzcial
y��tE�i�� (
City or Town: Permit/License# �
Issu' ' ' cle one):
1. oard of Health 2 Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office '
�
6. t ,
Contact Person: Phone#: t�B� t'14—c�o�-�� �I 2-�� I
www.mass.gov/dia
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�,�.� OP ID: KD
���R�� CERTIFICATE OF LIABILITY INSURANCE DAT01/10/12 �
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVEIY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'TWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certifcate 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 endorsement s.
PRODUCER 610-279-8550 NAMEACT �.
The Addis Group,Inc. 610-279-8543 ac"no Ext: AIC No:
2500 Renaissance Bivd,Ste 100
King of Prussia,PA 19406-2772 AooR�ess '
Jeffrey A.Grebe PRODUCER DAVEN-1
C STOMER ID#:
�INSURE S APFORDING COVERAGE NAIC#
INSURED Davenport Realty Trust INSWRERA:AIII@1'IC811 ZUCICFI IqSU�8I1C@ CO. 4O'I4Z � �,
dba Blue Rock Golf Course wsuReRe:Zurich American Insurance Co. 16535
Stephen Aschettino INSURERC:
20 North Main St.
South Yarmouth„ MA 02664 INSURERD:
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 PERfOD
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 ADDL SUBR pOLICY NUMBER MM/ODYlYWY MM/DDY/YYYY LIMITS �
lTR
GENERAL UABILITY � . � � EACH OCCURRENCE � i �,OOO,OOO �'��..
B X COMMERCIAL GENERAL LIABILITY GL08196255 03101112 03/01/13 DAMA REN 500,00�
PREMISES Ea occurrence a
CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 1 O,OOO '
PERSONAL&ADVINJURY a 1,000,000
GENERAL AGGREGATE $ Y,OOO,OOO '
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG a 1,000,000 '
POLICY PR� LOC $
AU70MOBILE LIABILITY COMBINED SINGLE LIMIT $ �,000,000
B ANY nuro BAP8196256 03I01/12 03/01l13 �Ea accident)
BODILY INJURY(Per person) 5
X ALL OWNED AUTOS BODILY INJURY(Per acGdent) S '
SCHEDULED AUTOS PROPERTY DAMAGE $
X HIREDAUTOS (Peraccidenq
X NON-OWNEDAUTOS a
X 250 Comp $
UMBRELLA UAB OCCUR EACH OCCURRENCE 5
EXCESS LIAB CLAIMS-MADE AGGREGATE E
DEDUCTIBLE a
RETENTION E a
WORKERS COMPENSATION X WC STATU- OTH- � �
AND EMPLOYERS'LIABILITY
/� ANY PROPRIETOR/PARTNERIEXECUTIVE Ya N/A C8196024 � 03/01/12 03/01/13 E.L.EACH ACCIDENT $� ��00�,�0�
OFFICERIMEMBER�EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE E � r
if yes,describe under E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERAl10NS!LOCATIONS/VEHICLES�(Attach ACORD 107,Additionai Remarks Schedu�e,If more space Is requ{red)
CERTIFICATE HOLDER CANCELLATION
YARMO-0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWfI Of Y81'1170UtIl ACCORDANCE WITH THE POLICY PROVISIONS.
Route 28
South Yarmouth�MA OZG64 AUTHORIZED REPRESENTATIVE
T�� � ��
i O 1988-2009 ACORD CORPORATION. All rights reserved.
� ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
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