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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 l6.20I6. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAM�• Green Or � T LOCATIONADDRESS: zx er ve. , est armo�t TEL.#: - - 26 ' MAILING ADDRESS: 20 North Main E-MAIL ADDRESs: m urrier t edaven ortcom anies.com OWNER NAME: reen r t nc. CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: Craa��rBo er TEL.#: _ _ MAILINGADDRESS: ort Main St., South Yarmouth� MA 02664 POOL CERTIFICATIONS: m c��; � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated D ��; � Pool Operator(s)and attach a eopy of the certification to this form. � e,., l, Will provide �rior to opening 2. o -�'` � Pool operators must list a minimum of two employees currently certified m standard FiTst Aid and CQmmuniry ro ' �� Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the � --�3 �� employees below and attach copies of their certifications to this form.The Health Department wiil not use past years'records. You must provide new copies and maintain a file at your ptace of business. 1. 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 ¢ ' 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. �j ' 1. 2. , � '3 :,; �;� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 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). 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 employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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• RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONLY BOk�-1,.��y-0�23-03 LODGING: LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERMIT# L(�ENSE REQUIRED FEE P.�o�(�p�SP��I _B&B S55 CABIN $55 / MOTEL 5110 I� �cP1�� [NN S55 CAMP S55 =SWIMMINGPOOLS110ea. � �.ODGE $55 _TRAILER PARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE FtE�UIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEA S $125 _CONTINENTAI. S35 NON-PROFIT S30 >l00 SEATS 5200 COMMON VIC. S60 WHOLESALE S80 — — —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SO sq.ft. S50 >25,000 sq.ft. $285 VENDING-FOOD S25 _<15,000 sq.ft. $150 =FROZEN DESSERT$40 _TOBACCO 5110 NAME CHANGE: SIS AMOUNT DUE = S oCoC� �CJV *•***PLEASE TURN OVER AND COMPLETE OTAER 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 Compensarion Insurance. TIiE ATTACI�D STATE WOI2KER'S COMPENSAT'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OP TNSURANCE ATTACHED_� OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces 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:-Forpurposesof the limitations of Motel ar 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 swinnming,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 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 S�RVICE 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 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 obtauied at the Health Department,or from the Town's website at www.yarmouth.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 Department. Failure to do so will result in the suspension or revocahon 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establiskunent is prohibited. � ' NOTICE:Permits run annually from January 1 to December 31. IT IS YOURRESPONSIBILTfI'TO RETURN , THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ! ALL ItENOVATIONS 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 M� , UIRE A SITE PLA� , �A�: 1 1/1/1 6 SIGNATU • �G �-f��L-L/I PRINT NAME&TITLE: 1 e r Rev.t0/12/l6 � The Commonwealth ofMassachusetts Department of�ndustrial Accidents Office of Investigations � I Congress Street, Suite 100 Boston,MA 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: Green Harbor Vi llage, LP Address: 20 North Main St City/State/Zip:So .Yarmouth, MA 02664 Phone#: 5(�,R_Z,,71 ��.�.� 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. ❑ Restaurant'IBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � p{�ce and/or Sa1es(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 R G�r t �`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 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: ZurtG$h AmPr� an TnG ('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 Expiration Date: 3-1 -1 7 AtEach 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 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 hereby c ' ,under the pains�d penalties ofperjury that the information provided above is true and correct. , Si ature: f �`'�'�� Date: 11-1-16 Phone#: 508-398-2293 Official use only. Do not write in this area,to be completed by city or town officiat City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cify/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: wwwmass.gov/dia � � DATE(MM/DD/YYYY� A�?�D CERTIFICATE OF LIABILITY INSU�iANCE 3/9/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFEI2S 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 REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the ceRificate 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 con,rncr Kristina Converse NAME: E. K. McConkey&Co. (Valiey Forge) P"o"E .484-965-9623 FAX •484-965-9627 2555 Kingston Road, SUItB �OO E-MAIL York PA 17402 .kconverse@vfcadvisors.com INSURER S AFFORDiNG COVERAGE NAIC# iNsuReR n:Zurich American 16535 INSURED DAVEN-1 INSURER B: Green Harbor Village L.P. wsuReR c: c/o Davenport Realty Trust 20 North Main Street INSURERD: South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1070317696 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 TypE OF INSURANCE POLICY EFF POLICY El(P LTR INSD WVD POUCY NUMBER MMIDD/YYYY MM/DDIYYYY� � LIMITS A X COMMERCIAL GENERAL LIABILI7Y GL08196255 3/1(2016 3/1/2017 Ep,CH OCCURRENCE $1,000,000 DAMA E T R NTED CLAIMS-MADE X�OCCUR PREMISES Eaoccurrence 5500,000 MED EXP(Any one person) $1,000 PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑PR� �LOC PRODUCTS-COMP/OPAGG $2,000,000 JECT OTHER: $ 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 BODILY INJURY(Per accidenl) S X HIRED AUTOS X NON-OWNED pe�acatlent MAGE $ AUTOS 5 UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ � $ q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 � X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACH ACCIDENT � $1,000,000 OFFICER/MEMBER EXCLUDEDI (Mandatory in NH) E.L.DISEASE-EA EMPLOYE 51,000,000 If yes,describe under � DESCRIPTION OF OPERATIONS beiow � E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIP770N OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 107,Additional Remarks Schedule,may be altached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth MA 02664 USA AUTHORIZEDREPRESENTATIVE ==5��,�� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD