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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH �� . ,� �_ �z �� APPLICATION FOR LICENSE/PERMIT-2017 " *Please complete form and attach all necessary documents by December 16.2016. Failure to do so will result in the retum of your application packet. ESTABLISHMENT NAME:Rl t�e Wa tPr RPs�rt T X ID:' 04-3290877 - LOCATION ADDRESS• 2 1 S h re Dr. , So.Yarmot�th TEL.#:5(1R-39g_��aR ' MAILING ADDRESS: or � ain ��ou armout , I�6�-� E-MAIL ADDRESS: m urrier@thedavenportcompanies.com OWNER NAME: avenport CORPORATION NAME(IF APPLICABLE): tv1.�NAGER'S NAME: John Verity TEL.#:508-398-2288 MAILING ADDRESS: �n �orth Mai n St_ _ Sniith Varmntith_ MA n�F,hG. POOL CERTIFICATIONS: The poo!supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a eopy of the certification to this form. �. Will provide prior to o�ening 2. --- — -_ ----- -_ Pool operators must list a m'inimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past _ � years'records. You must provide new copies and maintain a file at your place of business. �j b �`_`< 1. 2. ri �"� 3. 4. � y fi'�� a FOOD PROTECTION MANAGERS-CERTIFICATIONS: � -M �`A� _� ,�� All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager,as defined in the State Sazutary 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 yonr establishment. 1, Wil.l provide prior to opening 2, , � PERSON IN CHARGE: � -� Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. � 1. 2. O ' � ALLERGEN CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who has Allergen certification, � as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a}. Please attach ^ copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. HEII�7LICH 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 aad maintain a file at your place of business. 1. Z 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# L CENSE REQUIRED FEE P RMIT# _B&B S55 CABIN $55 MOTEL $l10 �!bO3 INN S55 CAMP S55 SWIMMLNGPOOLSl10ea c� p0(e �.ODGE $55 =TRAILERPARK $]OS WHIRLPOOL SIIOea.��3 � FOOD SERVICE: LICENSE REQUIItED FEE PERMIT q LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENfAi. S35 NON-PROFIT $30 �>l00 SEATS 5200 �1t �COMMON VIC. S60 �p� =WHOLESAI.E S80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# L7CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� _<50 sG.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD S25 _QS,OOOsq.ft. 5150 =FROZENDESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $_��j O � C�� •+t*rpLEASE TURN OVERAND 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 ATTACfi�D 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 Iiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS - — ---TRANSIENT OCCUPANCY: Forpurposes of the limitationsof Mote1 or Hotel use,Transient occupancyshall 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 generaily refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more tlzan 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 �xcise,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 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 azea 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 quarteriy 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 establishments must be inspected by the Health Department prior to opening. Please contact the Health Depar[ment 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 Departrnent, 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. OUT5IDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. j OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � ' NOTICE:Pemuts run annually from January i to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCBMENT, RENOVATIONS MAY,P��UIRE A SITE PLA� , DATE: 11/1/16 SIGNATURE: � �-I��/;�-''� �.�.�C' ' PRINTNAME&TITLE: Mar� Purri Pr _ Acci st�nt �eri��9�ler Rev.l0/12/16 : i � The Commonwealth ofMassachusetts Department of Industrial Accidenfs Office of Investigations ' I Congress S'treet, Suite 1 DO Boston,MA 021I4-2017. www.mass.gov/dia Workers' Compensation Insarance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: B L e wa t P r T P Address: 20 North Main St . City/Sta.te/Zip: So.Yarmouth,MA 02664 Phone#: 508-398-2288 Are you an employer?Check the appropriate bo�: Business Type(required): l.[� I am a employer with employees(full and/ 5. ❑ Retail or,�art-time).* 6. ❑ RestaurantlBar/Eati.ng Establishr.ient 2.❑ I am a sole proprietor or partnership and have no �, � O�ce andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing no employees. [No workers' comp.insurance required]* 11.� Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.[�Other S e a s o n a 1 r e s o r t "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. *'If the corpomte of�cers 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 employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Zur;i$h American Tn c (`� Insurer's Address: S e e a t t a ch e d City/State/Zip: Policy#or Self-ins.Lic.# WC8196035 Expiratian Date: -1 -1 7 Attach a copy of the workers'compensation poficy declaration page(showing the policy number and eupiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead 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 STQP VJORK 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 a�penalties of perjury that the information provided above is true and correct. /� Si ature: �/ ��-'�-` ��2`�--ti'J Date: 11-1-16 Phone#: 508-398-2293 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmea's Office 6. Other Contact Person: Phone#: wwnv.mass.gov/dia ACO� DATE(MM/DD/YYW� �� CERTIFICATE OF LIABILITY INSURANCE 3/9/2016 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 endorsement s. PRODUCER CONTACT E. K. McConkey&Co. (Valley Forge) PHONE Kristina Converse FAx 2555 Kingston Road, Suite 100 E-MA�� ,kconverse vfcadvisors.com York PA 17402 @ INSURER S AFFORDING COVERAGE NAIC# iNsuReRn:Zurich American 16535 INSURED DAVEN-1 INSURER B: Blue Water LP �NSURER C: c/o Davenport Realty Trust �NSURER D: 20 North Main Street South Yarmouth MA 02664 INSURERE: MSURER F: COVERAGES CERTIFICATE NUMBER:205254272 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. NOTIMTHSTANDING 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYW MMIDDIYYYY A J�. COMMERCIAL GENERAL LIABILITY GL08196255 3/1/2016 3/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE �OCCUR DAMAGE TO RENTED PREMISES Ea occurrence 3500,000 MED EXP(Any one person) 81,000 � PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY� PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG S OTHER: $ A AUTOMOBILELIABILITY BAP8196256 3/1/2016 3/1/2017 Eaaccident $1,000,000 X ANY AUTO BODILY INJURY(Per person) S AUTOS�ED AUTOSULED BODILY INJURY(Per accident) $ X HIREDAUTOS X NON-OWNED PERTYDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 PER OTH- AND EMPLOYERS'LIABILITY Y�N x STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACHACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY�IMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCA710NS/VEHICLES (ACORD 701,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISiONS. Route 28 South Yarmouth MA 02664 USA AUTHORIZED REPRESENTATIVE ''T��G��."'� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD