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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMTT-2017 ' ~'' *Please complete form and attach all necessary documents by December 16.20I6, Failure to do so will result in the return of your application packet. ESTABLISHMENTNAME: Rl tiP R�ck C'1 iih TAX ID: — � LocATioN.�Dx�ss:39 Todd Rd. So Yarmouth TEL.#: SOH-398-6962 ' MAILING ADDRESS: 2 - E-MAIL ADDRESS: mpurrier e a en or com anies.co OWNER NAME: avenport Rea tV CORPORATION NAME IF APPLICABLE): MANAGER°S NAME: � an 0�Lou h in TEL.#: — 8-6962 MAILING ADDRESS: Nort Main St. , South Yarmouth, MA 02664 POOL CERTIFICATIONS: The pool supervisor must be certiSed 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. 1. Will gr�vide �rior to ogeni_ng 2. -------- ---- --------- ---- - ---- -- - -- ----�=--- -___ _ Pool operators must list a minimum of two employees currendy certified'in standard First Aid and Community � Cardiopulmonary Resuscitation(CPR),having one cerhfied employee on premises at all times. Please list the m '; employees below and attach copies of their certifications to this form.The Health Department will not use past D �� years'records. You must provide new copies and maintain a file at your place of business. � _ � z � 1. 2. � � C7 _._� '� 3. 4. � .�.�� "� L.!1 � FOOD PROTECTION MANAGERS-CERTIF'ICATIONS: All food service establishments are required to have at least one fizll-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. ' Will provide prior to openir�g _2, �� .. �:,g, PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. O� � 1. 2. � r 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 Estabiishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Iiealth Department will not use past years'records. You must W CD provide new copies and maintain a file at your establishment. (y � i. 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. i. 2. 3. 4. RESTAURANT SEATING: TOTAL# B�N L{`��9-0 j '°) PaowSP-t�(-63R�-�3 OFFICE USE ONLY ��•�P� �P-I'f-6�j�-6?j LODGING: LICENSE REQUIRED FEE PERMIT/! LICENSE REQUIRED FEE PERTvIIT# L CENSE REQUIRED FEE P RMIT# B&B $55 CABIN S55 �MOTEL 5110 INN S55 —CAMP S55 SWIMMINGPOOLS110ea. t — $ _LODGE S55 _TRAILERPARK SI05 �,WHIRLPOOL SIIOea. � Z FOOD SERVICE: �L CENSE REQUIRED FEE P RMI LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 �j?�a CONTINENTAL S35 NON-PROFIT $30 6��"��'�✓�IZ'�3 >100 SEATS 5200 �COMMON VIC. S60 ��j —WHOLESALE S80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =QS,OOOsq.ft. $150 -FROZENDESSERT $40 _TOBACCO 5110 NAMECHANGE: $IS AMOUNTDUE _ $ ,��5•� � *r*'''pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**''** , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth 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 ATTACH�D STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.Or 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�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS - - - -TRANSIENT-OCEUPANGY: For purposesof the limitarions of Mote1 orHotel use,Transient occupancy shail 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 thirly(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 �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 aze NOT allowed to sit in the pool area until the pool has been j inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couni by a State certified lab, and submitted to the Health Department three(3)days prior tb 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 OPEMNG: All food service establishments must be inspected by the Health Department prior to opening. Please contact the . Health Deparhnent 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.�rmouth.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 Deparhnent. Failure to do so wiil result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. j OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � ' NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'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 I TO COMMENCEMENT. RENOVATIONS M QUIRE A SITE PLAI�T:� , DaTE: 11/1/1,6 SIGNATU ��- ✓�� , PRINTNAME&TITLE: MarV P i ri Pr Acc; etal�t �9��e�ler ' ' Rev.10/12/16 � .� The Commonwealih ofMassachusetls Department of Industrial Accidenfs Office of Investigations ' I Congress�treet, Suite 100 Boston,MA 02II4-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: R 7 �,P R n�k .�.� „h.�� Address: 39 Todd Road City/State/Zip:So .Yarmouth, MA 02664 Phone#: 50�-398-6962 Are you an employer?Check the apprapriate bog: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant7Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] $• ❑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 10.0 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 P a�n n a 1 r e s��'� "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 end such an organization should check box#1. I am an emp[oyer thal is providing workers'compensation insurance for my employees. Below is the policy inforrnation. Insurance Company Name: Z u r�b.h Am e r i c a n T n s ('n Insurer's Address: S e e a t t a ch e d City/State/Zip: Policy#or Self-ins.Lic.# WC 819 6 03 5 Expiration Date: �-1 -1 7 Attach a copy of the workers'compensation policy declarafion page(shawing the policy number and ezpiration date). Failure to secure coverage as requireci 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$250.40 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 ' ,under the pai nd penalties ofperjury thai the information provided above is true and correct. � Si�nature. `'��2� �,�/1�l�/� 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 HeaIth 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia i 1 j ' ACO� DATE(MM/DD/YYYY) �� 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 i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I 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 cor,rAcr Kristina Converse NAME: , E. K. McConke &Co. Valle For @ PHONE Fax y �• Y 9 � .610-458-3659 2555 Kin ston Road Suite 100 g ' E-MAIL kconverse vfcadvisors.com York PA 17402 �° . INSUREF S AFFORDING COVERAGE NAIC# iNsuReRn:Zurich American 16535 INSURED DAVEN-1 INSURER B: Kingsbury Management LP INSURER C: dba Blue Rock Resort 20 North Main Street wsuReR�: South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1490838143 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. NONVITHSTANDING 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 OP INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DDM(YY MM/DD/YYYY A COMMERCIAL GENERAL LIABILITY GL08196255 3/1/2016 3/1/2017 EqCH OCCURRENCE $1,000,000 DAMAGE TO REN ED CLAIMS-MADE OCCUR PREMISES Ea occurrence 8500,000 MED EXP(Any one person) $1,000 PERSONALBADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 82,000,000 POLICY❑PR� �LOC PRODUCTS-COMP/OPAGG 32,000,000 JECT OTHER: $ A AUTOMOBILE LIABILITY BAP8196256 3l1/2016 3/1/2017 Ea acddent $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ AUTOS JED AUTOSULEO BODILY INJURY(Per accident) $ HIRED AUTOS NON-OVV�IED PR PERTY DAMA E $ 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 a N�A E.L.EACHACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED7 � (Mandatory in NH) E.L.DISEASE-EA EMPLOYE• $1,000,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.�.DISEASE-POLICY LIMIT 31,000,000 DESCRIP770N OF OPERATIONS I LOCATIONS/VEHICLES �ACORD 707,Additlonal 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 ��r��-�!"'� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD