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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-201? , `� *Please complete form and attach all necessary documents by December l6.2016. Failure to do so will result in the return of your application packet. ' ESTABLISHMENT NAME: ue oc ro op T,ax ro: 4-2298107 LOCa,T1oN EwDxEss: 48 Todd Road So. Yarmo'th 1�L.#:50 - - ' MAILING ADDRESS: ort ain t. , out Yarmout , MA 02664 E-MArLADDRESS: mAurrier@theda._v.�e.1,�ortconmaniPs_c�m OWNER NAME: venpor ealty - CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: RYan O�Loughlin TEL.#:S�A-39R—hAh� MATLING ADDRESS: 20 North Main St. , Sot�th Yarmrn rth_ M�.�2(6� POOL CERTIFICATIONS: rn �d � The pool supervisor must be cert�ed 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. 2. _ � D �,,,°�;' Pool operators must list a minimum of fwo employees currently certified in standard First Aid and Community � � �� Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the -i �;'; �; employees below and attach copies of their certifications to this form.The Health Department will not use past years'records. You mast provide new copies and maintain a�ile at your ptace of business. L 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 Proteetion Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certificarion 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 Will provide prior to opening 2. , � � PERSON IN CHARGE: D Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. O ` 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Aliergen 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. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one empIoyee tcained 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 ta 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUtRED FEE PERMIT f! LICENSE REQUIRED FEE PERMIT# LICENSE R�QUIRED FEE PERMIT 1! _B&B $55 CAHIN S55 MOT'EL 5110 [NN S55 —CAMP S55 —SWIMMINGPOOLS110ea. _I.ODGE a55 =TRAILERPARK $105 WHIRLPOOL SllOea — 6o1kF-tS-lOz2-0Z FOOD SERVICE: LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0.100SEA�S 5125 _CONTINENTAI. S35 NON-PROFIT $30 >l00 SEATS $200 COMMON VtC. $60 —WHOLESALE S80 —RESID.KITCHEN $80 RETAIL SERVICE: L CENSE REQU[RED FEE PERMIT# LICENSE REQUIRHD FEE PERMIT# UCENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 r I—d�($ >25,000 sq.ft. $285 VENDING-FOOD $25 _QS,DOOsq.ft. 5150 =FROZENDESSERT$40 _TOBACCO S110 IYAME CHANGE: S15 AMOUNT DIJE _ $ ,7 G>D� �••**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** , ADMINISTRA.TION . 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 Compensa6on Insurance. THE ATTACH�D STATE WOI2KER'S COMPENSATTON 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�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS - -- -- -TRANSIENT OCCUPANCYrForpurposesof the limitationsof Motel or Hotel 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 condnuous occupancy of not more than thiriy(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 OPEIVING: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: 'i'he 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 OPE1vING: � All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Departrnent 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 obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Deparhnent, 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 Departrnent. Failure to do so will 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. i 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 lanuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i ` 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/ DA�: 11/1/16 SIGNATU PRINT NAME&TITLE: M a r v P u r r i P r �s s i s ta n t �a�t��-�1 e r ` Rcv.!0/l2/16 ; i � The Commonwea[ih of Massachusetts . Department of Industrial Accidents � Office of Invesiigations ' I Congress Street, Suite 1 DO Boston,MA 02II4-2�17. www.mass.gov/dia Workers' Compensation Insurance Affdavit: General Businesses Applicant Information Please Print Le�ibly Business/Organization Name: Blue Rock Pro Shop Address: 48 Todd Road City/Sta.te/Zip:So .Yarmouth, MA 02664 Phone#: 508-398-6962 Are you an employer?Check the apprapriate boz: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant7Bar/Eating Establish.ment 2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl.real estaxe,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 10.0 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 Pro Sh� "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 t6emselves,but the corporation has other employees,a workers'compensation policy is required and such an organization shouid check box#1. I am an emp[oyer ihat is providing workers'compensation insurance for my employees Below is fhe policy information. InsuranceCompanyName: Zur�bh American TnG ('� Inswer's Address: S e e a t t a ch e d City/State/Zip: Policy#or Self-ins.Lic.# WC8196035 Expiration Date: -1 -1 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration date}. Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a fuie 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 stazement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' ,under the pains penalties ofperjury that the information provided above is true and correc� Si ature• 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: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ww�v.mass.gov/dia nCo� CERTIFICATE OF LIABIUTY INSURANCE °A�'MM,°°"�,", . `••—�� 3/9/201 C' THIS CERTIFICATE IS ISSUED AS A MA7TER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT� FiOLDER. 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 .484-965-9623 .484-965-9627 York PA 17402 E-"'A'� .kconverse@vfcadvisors.com . INSURER S AFFORDING COVERAGE NAIC# wsuReRn:Zurich American 16535 � INSURED DAVEN-1 INSURERB: Davenport Realty Trust INSURERC: dba Blue Rock Golf Course 39 Todd Road INSURER D: South Yarmouth MA 02664 iNsuReRe: INSURER F: COVERAGES CERTIFICATE NUMBER: 1506935167 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 i 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 LTR INSD WVD POLICYNUMBER MM/DD/WW MM/DDlYY`/Y LIMITS � COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ i ❑ DAMA E RENTED i CLAIMS-MADE OCCUR � PREMISES Ea occurcence $ � � MED EXP(Any one person) $ � � PERSONAL 8 ADV INJURY 3 � GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ i POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ ! OTHER: $ ' AUTOMOBILE LIABILITY � Ea accident $ ANY AUTO BODiLY INJURY(Per person) $ AUTOS�E� AUTOSULED BODILY INJURY(Per accident) S HIRED AUTOS NON-0WNED R PERTY DAMA AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ � $ q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 x PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER " ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACH ACCIDENT $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 LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATYONS/VEHICLES (ACORD 101,Additional Remarks Schetlule,�may be attached if more spaee is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOP, NOTICE WILL BE DELIVERED IN TOWfI Of Y8ff110UtI1 ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth MA 02664 USA AUTHORIZED REPRESENTATIVE ;'S��`��-�""�..." O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD