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Home My WebLink AboutApplication and WC �^� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 `� *Please complete form and attach all necessary documents by December I6.2016. Failure to do so will result in the return of your application packet. ' ESTABLISHMENTNAME:_Riviera Beach Resort TAX ID04-329105�3 LOCATIONADDRESS: 327 South Shore Dr.So.Yarmouth �r..#: 508-398-2273 ' MAILINGADDRESS:20 North Main St. , South YarmoLth, MA 02664 E-��L�D�ss: m�urrier@thedavenportcom�anies.com OWNERNAME: Davenport COR.PORATION NAME IF APPLICABLE): MANAGER°S NAME: �ohn Verity TEL.#: - - Matz.rNG�Dx�ss: 20 North Main 6t. , South Yarmouth� MA 02664 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Qperator(s)and attach a eopy of the certification to this form. i. Will provide prior to opening 2. _ � � °� i�'� Pool operators must list a minimum 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 Deparhnent will not use past - years'records. You must provide new copies and maintain a file at your ptace of business. � � m � 1. 2. -i `:a1 ��" 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 : s� 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 maiatain a file at your establishment. �__�, �._Will provide prior to opening 2. , �F � PERSON IN CHARGE: '�r1 Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. tp ' 1. 2. � �� €,,'< 4:� . :i ALLERGEN CERTIFICATIONS: ` " Ail food service establishments aze 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�le 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 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: VjON L–I�I–Q'3�-03 LICENSE REQUIRED FEE PERMIT ii LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _s�s sss cnstt�r sss f MOT'EL a>>o �# �o� (�1FioNsP-l4-03�1-03 — _ �WH[RL OOL OOL$1�10ea. LODGE $55 —TRAILERPARK $105 C��NSP��'O1j72'O3 FOOD SERVICE: �L CENSE REQUIItED FEE P IT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��uSP�I�-a388�03 0-100 SEATS $125 {�) CONTINENTAL S35 NON-PROFIT $30 _>l00 SEATS 5200 �COMMON VIC. S60 ��O —WHOLESALE S80 (3o�F-1�{"O�Xs4�03 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQU[RED FEE PERMIT k LICENSE REQUIRCD FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. a50 >25,000 sq.ft. $285 VENDING-FOOD S25 _<25,000 sq.ft. 5150 =FROZEN DESSERT$40 =TOBACCO 5110 NAME CHANGE: S15 AMOUNT DUE _ $ �i�Si C�(,, *'•*tPLEASE TURN OVER AND 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 ATTACHED STATE WORKER'S COMPENSA'ITON 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 OCCUPANCY: For purposesof the limitationsof Mote1 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 �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 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 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 Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the reqtured Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departrnent,or from the Town's website at www.yarmouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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 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 establislunent is prohibited. � � NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN : THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMSER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I , EQUIPMENT,ETC.),M[JST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MA, �QUIRE A SITE PL�. DATE: 11/1/16 SIGNATUR�� PRINT NAME&TITLE: 1 e r ' ��.ionvie si � The Commonwealth ofMassachusetts Department of Industrial Acciderzts Of,fice of Investigations • � ' 1 Congress Street, Suite 100 Boston,MA 02I14-2017. www.rnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: Riviera Beach�.P Address: 327 South Shore Drive City/Sta.te/Zip:So. Yarmouth, MA 02664 Phone#: SpF�-�qR-�2Z� Are you an employer?Check the appropriate boz: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantBar/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 requiredJ 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��a�� F�e-s4�� •Any applicant that checks box#1 must also fill out the section below showing their wotkers'compensation policy information. "*If the corponte 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 employer that is providing workers'compensation insurance for my employees Below is the policy information. InsuranceCompanyName: Zurich American In� . Co Insurer's Address: s e e a t t a c h e d City/State/Zip: Policy#or Self-ins.Lic.# WC 819 6 03 5 Expiration Date: 3-1-17 Attach a copy of the workers'compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fu7e 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 O�ce of Investigations of the DIA for insurance coverage verification. I do hereby, tify,under thepai�ndpenalties ofperjury that the information provided above is true and correc�t. Si atureS--r� � Date: 11-1- 6 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 Cterk 4.Licensiag Board 5.5electmen's Office 6. Other Contact Person• Phone#• wHryv.mass.gov/dia '4�aRD� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YWY) 3/9/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS �1P�N 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 NAME: K�IStIIlB COf1V@fS2 E.K. McConkey(Valley Forge) P"o"E ,484-965-9623 FAX .484-965-9627 2555 Kingston Road, Suite 100 E-�A�� ,Kconverse York PA 17402 @vfcadvisors.com INSURER 5 AFFORDING COVERAGE NAIC A iNsuReR n:Zurich American 16535 INSURED DAVEN-1 INSURER B: Riviera LP INSURERC: s/o Davenport Realty Trust INSURER D: 20 North Main Street South Yarmouth MA 02664 INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER:225823872 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. 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 LTR 'iYFE OF INSURANCE INSD WVD POLICY NUMBER MM/DDY� MM/DD� LIMITS A X COMMERCIALGENERALLIABILITY GL08196255 3/1/2016 3/1/2017 EACHOCCURRENCE $1,000,000 CLAIMS-MADE X�OCCUR DAMA E TO RE E PREMISES Ea occurrence 3500,000 MED EXP(Any one person) $1,000 PERSONALBADVINJURY $1,000,000 GEN'L AGGREGA7E LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY� PR� �LOC PRODUCTS-COMP/OPAGG $2,000,000 JECT OTHER: g A AUTOMOBILE LIABILITY BAP8196256 3/1/2016 3/1/2017 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ AUTOS�E� AUTOSULED BODILYINJURY(Peraccident) $ x HIRED AUTOS x NON-OWNED P PERTY DAMA AUTOS Per accident $ X Comp$100 X Coll$500 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ g q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 PER OTH- q AND EMPLOYERS'LIABILITY Y�N WC8196132 3/1/2016 3/1/2017 X STATUTE ER ANYPROPRIEfOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACHACCIDENT $1,000,000 OFFICER/MEMBER EXCLUOED9 (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE 31,000,000 If yes,describe under DESCRIPTIONOFOPERATIONSbelow E.L.DiSEASE-POLICYLiMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEMICLES �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 -'j��-'�' - 7 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD