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Home My WebLink AboutApplication and WC ' ^� TOWN OF YARMOUTA BOARD OF HEALTH i �� APPLICATION FOR LICENSE/PERMIT-2017 � *Please complete form and attach all necessary documents by December I6.20I6. '. Failure to do so will result in the return of your application packet. I � ESTABLISHMENT NAME: Re Jacket Beach Tax m04-� 554�9 � LOCATION ADDRESS_1 South Shore Dr. ,�o Yarmo h TEL.#: 508-39$-6941 ' MAILINGADDRESS: � o1�i—rt�i 1T�i�t. ou�tT-Ya-rmout ma 2664 E-Man.�Dx�ss: mpurrier thedavenportcompanies.com OWNERNAME: RPrI .TackPt RPach Inr � CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �'aul Ront TEL.#: Nrau.IIVG�Dx�ss: 20 North in St. , South Yarmouth� ma 02664 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated 2 � Pool Operator(s)and attach a copy of the certification to this form. p �;`r�u � 1. Will provide prior to openin� 2. i �� Pool operators must list a minimum of two employees curreritly cert'ified m standazd First Aid arid Community C7 � �� Cardiopulmonary Resuscitation(CPR),having one cerhfied empioyee 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 .i J �� years'records. You must provide new copies and maintain a file at your place of business. ` � 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: �t 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. �e ' Please attach copies of cerrification to this application. The Health Department will not use past years'records. 1� �.'ou must provide new copies and maintain a f►le at yonr establishment. O 1. Will provide prior to o�ening 2. , � PERSON IN CHARGE: -t- Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. v 1. 2. 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). Piease 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. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich P>pµL.14..�3_�3 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 Deparhnent will not use past years'record��)gOH$P-I�f-4pb5-03 You must provide new copies and maintain a file at your place of business. �o�g��b,�_�3 1• 2. �"P)Bo�+sP-��-�b-03 3. 4. � $Ol�tF-t�f-066$-�� RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONLY LODGWG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PE IT# _B�B S55 CABIN S55 /MOT'EL SI10 -� INN S55 CAMP S55 �SW[MMINGPOOLSIIOea. 1 – b�F pfos _LODGE $55 =TRAILERPARK $105 �WHIRLPOOL SIIOea�� / FOOD SERVICE: LICENSE REQUIILED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL S35 NON-PROFIT 530 ,�>IOOSEATS �200 �3CJ �COIviMONVIC. S60 �g� =WHOLESALE SSO RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD S25 _�L5,000 sq.ft. $150 _FROZEN DESSERT$40 =TOBACCO $I 10 NAME CHANGE: $15 AMOUNT DUE = S /U�r��✓ i4***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t i 3 � i ADMINISTRATION I ` 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 Compensa6on Insurance. THE ATTACI3ED STATE WORKER'S COMPENSAT'ION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT.OP 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 ESTABLISI�MENTS --- -- - TRANSIENT OCCUPANCYr For purposes of the limitations of Motel ar Hote1 use,Transient occupancy shatl be - limited to the temporary and short term occupancy,ordinariIy 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 aresidence 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 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 OPEMNG: Ail food service establishments must be inspected by the Health Department prior to opening. Please contact the i Health Department to schedule the inspection three(3}days prior to opening. ' CATERING POLICY: Anyone who caters within the Town of Yatmouth 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 Deparlment, 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 revocarion 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. j OUTDOOR COOKING: 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 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 MA QUIRE A SITE PL . . DA�:T_11/1/16 SIGNATU • �C„ �� PRINTNAME&TITLE: Mar� Purri Pr_ Acci ct�nt—�(dont��-�ler ' Rev.l0/1LI6 i ! y i , � The Commonwealth ofMassachusetts Deparlment of Industrial Accidents Office of Investigations � 1 Congress Street, Suite 100 ' Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Aff davit: General Businesses Apnlicant Information Please Print Le�iblv Business/OrganizationName: Red Jacket Beach LP � � Address: 1 South Shore Drive i '' City/State/Zip: So.Yarmouth,MA 02664 Phone#: 508-398-6941 i Are you an employer?Check the appropriate bog: Business Type(required): i 1.� I am a employer with employees(full and/ 5. ❑Retail I or part-time).* 6. ❑ Restaurant7Bar/Eating Establishment j2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl.real estaxe,suto,etc.) I 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 a 152, §1(4),and we have 10.�Manufacturing > * no employees. [No workers comp.insurance required] 4.❑ We are a non-profit organization,staffed by volunteers, 11.� Health Care with no employees. [No workers' comp.insurance req.] 12.�Other �,��4�� }�t e,s e�-�— *Any appGcant that checks box#1 must also fill out the sec6on below showing their workers'compensation policy information. **If the corponte officers have exempted themselves,but the corporation has other employees,a workers'compensation poficy 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 is the policy informution. InsuranceCompanyName: Zur��h American Tnc _ (;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 0 3 5 Expirati�n Date: 3-1 -1 7 Attach a copy of the workers'compensation poIicy declaration page(showing the policy number and expiration 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 andlor one-year imprisonment,as well as civil penalties in the form of a STOP 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 kereby ce ,under the pains a�f�penalties ofperjury that the inforrnation provided above is true and correct. / Si ature• � �zt�; 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: PermitlLicense# Issuing Authority(circle one): 1.Board of HeaIth 2.Building Department 3.Cify/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#• www.mass.gov/dia � ,aco� CERTIFICATE OF LIABILITY INSURANCE °ATE`MM,°°""", �� 1/15/2016 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 tieu of such endorsement s. � PRODUCER NAMEACT Kristina Converse E.K. McConkey(Valley Forge) PHONE FAX .717-755-9237 2555 Kingston Road, Suite 100 E-MAIL York PA 17402 .Kconverse@vfcadvisors.com INSURER S AFFORDING COVERAGE � NAIC# ir,suReRa:Zurich American 16535 wsuReo DAVEN-1 INSURER B: ; Red Jacket Beach, LP ; s/o Davenport Realty Trust iNsuReR c: 20 North Main Street �NsuReRo: � South Yarmouth MA 02664 iNsuReRe: ! INSURER F: - ,' COVERAGES CERTIFICATE NUMBER:73502720 REVISION NUMBER: i 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 VIMICH 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 POL�CY EFF POLiCY EXP � LTR NPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDM'YY MM/DD/YYYY LIMITS i A X COMMERCIAL GENERAL LIABILITY GL08196255 3/1/2016 3/1/2017 EqCH OCCURRENCE $1,000,000 ! CLAIMS-MADE �X OCCUR PREM SES Ea occurrence 5500,000 l MED EXP(Any one person) $1,000 i � PERSONAL 8 ADV INJURY $1,000,000 ; GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY� PR� �LOC PRODUCTS-COMP/OPAGG 52,000,000 i JECT i OTHER: $ A AUTOMOBILELIABILITY BAP8196256 3/1/2016 3/1/2017 Eaaccident $1,000,000 i X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ' AUTOS AUTOS BODILY INJURY(Per accident) $ I X HIRED AUTOS X qUTOS�ED PR PERTY DAMA E $ Per accident X Comp$100 X Coll$500 $ UMBRELLALIAB p�CUR EACH OCCURRENCE 3 EXCESS LIAB CLA�MS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 PER OTH- q AND EMPLOYERS'LIABILITY Y�N WC8196132 3/1l2016 3/1/2017 X STATUTE ER _„ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACH ACCIDENT $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.L.DISEASE-POLICY LIMIT 51,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 701,Additional Remarks Schedule,may be attached ff 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 TOWfI Of Y8RY10UtI1 ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth MA 02664 USA AUTHORIZEDREPRESENTATIVE ':1��r�� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD