The URL can be used to link to this page

Home My WebLink AboutApplication and WC, I . ; d TOWN OF YARMpUTH BOARD OF HEALTH ; �� APPLICATION FOR LICENSE/PERMIT-2018 ' " *Please complete form and attach all necessary documents byDecember IS 20I7. � Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAME: u e a e r e s o r — LOCATIONADDRESS:29 So . S ore Dr. So.Yarmouth �.#: 508-398-2288 MAILING ADDRESS: o. a1.n t. o . armout E-MAILADDRESS: mpurrier thedavenportcompanies .com OWNERNAME: Davennort CORPORATION NAME IF APPLICABLE): MANAGER'SNAME: �ruce Pelczars 1 TEL.#: — — 8 MAILINGADDRESS: or ain . , o. armout , POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. Will provide prior to openin� 2. � o � � 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 Department will not use past p � ,;� years'records. You must provide new copies and maintain a file at your place of business. � o �-:�� 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 tile at your establishment. 1. Will provide prior toopenin� 2, a � PERSON IN CHARGE: �� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ' c�-"*t ;-j 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 Aealth 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-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 fle at your place of business. ' 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY IJOI�L� 4�-�j�p��jo LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L ENSE REQUIRED FEE P, IT# �Q 3 _B&B $55 CABIN $55 MOTEL $�� P"�✓"SL� INN $55 CAMP $55 SWIMMING POOL$i l0ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea.,txeJ� �w� _03 I�f�•Qv FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �p��S�q SZ 0-]00SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �,�b. �>]00 SEATS $200 �� COMMON VIC. $60 � _��D.KITCHEN $80 r O� RETAILSERVICE: ! ��,�ey rC�_c LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#LW t�� / <50 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 �� J J . =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $ll0 �02 '7 NAMECHANGE: $IS AMOUNTDUE _ $ � **'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �0��5,�,�5/ �o �03 a � • I � Tlze Commonweczlth of Massacliusetts Print Form'� �� . � Department of Industrial Accidents � � -�:�� Office of Investigations �,- ,� 1 Congress Street, Suite I00 ��,, -'. ,� Boston, MA 02114-2017 `�'Y��'"°'u rvN�bv.mas�.g�v/�iw �._ Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/OrganizationName: Blue Water LP Address: 20 North Main St . City/State/Zip: So.Yarmouth, MA 02664 Phone#: 508-398-2288 Are you an employer?Check the appropriate box: Business Type(required): l.� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(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 reGuired]* �� Health Care 4.U We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[X.�. Other S e a s o n a 1 R e s o r t *Any applicant that checks box#I must also fi11 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#L I am an employer tlzat is providing workers'compensation insurance for my employees. Below is t/ie policy information. Insurance Company Name: Z u r i ch Am e r i C a n Insurer's Address: a t taChed City/State/Zip: Policy#or Self-ins. Lic.# WC 819 6 0 3 5 Expiration Date: 3�1/18 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 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 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 Office of Investigations of the DIA for insurance coverage verification. I do/zereby certify,under the pain��dpenalt�es of perjury t/zat t/ze information provided above is true and correct. Si ature: Date: 11/1/17 Phone#: 508-398-229� Official use only. Do not write in t/iis 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/T'own Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: ' www.mass.gov/dia � � j � ! � 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 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OFiNSURANCE ATTACHED X`< 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 XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS 1'RANSIENT OCCUP.e.NCY: For purposes of the limitations of Motel 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 thirry(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 h-ansient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparhnent 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 :;spected 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 OPENING: ' 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 obtained 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 revocation 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 ofHealth. 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 January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M REQUIRE A SITE PL _ ' DATE: 11/1/17 SIGNATU : , PRINT NAME&TITLE: r ' Rev.10/12/17 . � . I i I , . I Ac�� CERTIFICATE OF LIABILITY INSURANCE °ATE`MM,°°""", � �� 2/8/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDfR. 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. iNiPORTANT: if the certificate holder is an ADDiTItSNAL INSURED,the poiicy(ies)musi be endorsed. If SUBRGGATION IS 1filbIVED,subject to the terms and conditions of the poticy,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: KflStlflB COt1V@fS8 E. K. McConkey&Co. (Valley Forge) PHONE Fnx 2555 Kingston Road, Suite 100 N�: York PA 17402 E-"""'� .kconverse@vfcadvisors.com � INSURER S AFFORDING COVERAGE NAIC# wsuReRa:Zurich American 16535 INSURED DAVEN-1 �� iNsuReR s: Blue Water LP INSURER C: c/o Davenport Realty Trust INSURER D: 20 North Main Street South Yarmouth MA 02664 wsuRea e: INSURER F: COVERAGES CERTIFICATE NUMBER: 1754122111 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 POLICY EFF POLICY EXP �7R TYPE OF INSURANCE INSD WVD POLICY NUMBER, MM/DD/YYYY MM/DD/YYYY LIMITS A y� COMMERCIAL GENERAL UABILIN GL08196255 311I2017 3/1/2018 EACH OCCURRENCE $1,000,000 " CLAIMS-MADE �X OCCUR PREMISES Ea occurrence 8500,000 MED EXP(My one person) $1,000 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: .GENERALAGGREGATE $2,000,000 X POL�CY�PR� �LOC � PRODUCTS-COMP/OPAGG $2,000,000 JECT OTHER: $ A AU70MOBILELIABILITY BAP8196256 3/1l2017 3/112018 EaaBcddent $1,OD0,000 X ANY AUTO BODILY INJURY(Per person) $ � ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED P'R DAMA AUTOS Per accident $ $ UMBRELLA LIAB. OCCUR . EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE � $ . DED RETENTION$ g q WORKERS COMPENSA710N WC8196035 3/1l2017 3/1/2018 X STATUTE E�RH AND EMPLOYERS'LIABILITY Y/N � ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N�N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth MA 02664 USA AUTHORIZED REPRES� �.��! O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I