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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH >E - APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITHLIQCOR LICENSES MUST RETURN FORMS BY NOVEMBER/.1.4. Failure to do so will result in the return of your application packet. I _ p wfn ESTABLISHMENT NAME:Ocean Mist Beach Hotel&Suites TAX ID: D (,j LOCATION ADDRESS:97 So.Shore Drive TEL.#:508-398-2633 = N Gil MAILING ADDRESS: 28 Jacome Way Middletown.RI 02842 o , E-MAIL ADDRESS: susanpl@newporthotelgroup.com m q N 11,111 OWNER NAME:Ocean Mist LLC --I co L, CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME:Scott Alemany,Director of Operations TEL 401.258-3089 MAILING ADDRESS:28 Jacome Way Middletown,RI 02842 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. I.Randy Russell 2. 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 ,> `' yearsrecords. You must provide new copies and maintain a file at your place of business. i' 1 RandyRussell I. 2.Heather Powers 6.!...$ >a';,,, 3. 4. 4 .t. 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. 1. 2. 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-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. I. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � LI S'«3?'0`'f LODGING: LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE ��,►"��� to e0at>F5P-�S-1434-09 B&B $55 CABIN 555 1 MOTEL S110 Gil-=J -INN S55 CI AMP $55 SW1MMINGPOOL Sil0a1--s •G LODGE $55 TRAILER PARK 5105 ,WHIRLPOOL S110es -.mONSP ts��� v FOOD SERVICE: V 12O,n'fieAS-tG`'t I''OLAI LICENSE REUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMIT 4 0-100 SEATS $125 __CONTINENTAL S35 NON-PROFIT $30 >I00 SEATS $200 _COMMON VIC. S60 WHOLESALE S80 —RESID.KITCHEN 580 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT It <50sq.ft. $50 '25,000 sq.ft. $285 VENDING-FOOD $25 '25,000 sq.i. $150 FROZEN DESSERT$40 —TOBACCO $110 NAME CHANGE: SI 5 AMOUNT DUE = S 440.00 "*"**PLEASE 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 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED X OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and Hens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: 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 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 Excise,as defined in M.G.L.c:64G or 830 CMR 640,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. FOODSERVICE 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.vannouth,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 waiterhvaitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January Ito December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. 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 MAY REQUIRE A PLAN, DATE:April 24,2019 SIGNATURE: A PRINT NAME&TITLE:Donald c I,CFO Rev.10u13n13 NEWPORT MAY 022019 HOTEL GROUP HEALTH DEPT FAO: Mary Alice Town of Yarmouth Department of Health 1146 Route 28 South Yarmouth MA 02664 April 26th 2019 Re: Pool and Spa. Dear Mary Alice, Thank you so much for your help via telephone this afternoon. Please find attached:the following documents as needed prior to the opening of Ocean Mist Beach Hotel &Suites. (1) Check No.007979 in the amount of$400.00 (2) Application to the Town of Yarmouth Board of Health (3) Application page two-Administration Section (4) CPO Certification—Randy Russell (5) American Red Cross—Randy Russell (6) ECSI Emergency Care&Safety Institute Certificate of Completion—Heather Powers (7) Certificate of Liability Insurance—Section B Workers Compensation and Employee Liability ETC. If you have any questions please, do not hesitate to contact this office. - i - el , "nnifer O'Dwyer Administrative Assistant 28 Jacome Way, Middletown, Rhode Island 02842 • Phone: (401) 845-0900 • info@newporthotelgroup.com Discover our hotels at newporthotelgroup.com ,y r AD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYW) L..---- 4/26/2019 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 lieu of such endorsement(s). PRODUCER CONTACT GENATT V LLC NAME: PHILIP GINEXI JR. 3333 NEW HYDE PARK RD (n/cNr o.Exn:516-387-3069 FAX No):516-869-8765 SUITE 400. ADDRESS: pginexi@genattspecialty.com NEW HYDE PARK NY 11042 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ACE Property&Casualty Insure 20699 INSURED NEWPHOTE INSURER B:Zurich North America Newport Hotel Group LLC, ETAL 28 Jacome Way INSURER C: Don McCall INSURER D: Middletown RI 02842 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:86278315 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) LIMITS B COMMERCIAL GENERAL LIABILITY Y GL011456104 4/12/2019 4/122020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $1,000,000 — MED EXP(Any one person) $5,000 X INCL LIQUOR 1MIL PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y BAP011657504 4/12/2019 4/122020 COMBINED SINGLE LIMIT (Ea accident) $1.000.000 _ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED —SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ _ X DRIVE OTHER CAR $ A X UMBRELLA LIAB OCCUR HLI18AG71362954 4/12/2019 4/12/2020 EACH OCCURRENCE _ $50,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $50,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WC014008004 11/152018 11/15/2019 AND EMPLOYERS'LIABILITY Y/N STATUTE X ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The Newport Beach Hotel&Suites,1 WAVE ST.,MIDDLETO\\N,RI 02842 HYANNIS HARBOR HOTEL,213 OCEAN ST.,HYANNIS.MA 02601 NORTH CONWAY GRAND HOTEL,SETTLERS GREEN,RTE.16.NORTH CONWAY,NH 03860 Inn on the Square,40 NORTH MAIN ST.,FALMOUTH,MA 02540 New Haven Hotel,229 GEORGE ST..NEW HAVEN,CT 06510 Newport Beach Hotel&Suites,20 WAVE AVE„MIDDLETOWN.RI 02842 Ocean Mist Beach Hotel&Suites,97 SOUTH SHORE RD..BLDG.#I,SOUTH YAMOUTH.MA 02664 Ocean Mist Beach Hotel&Suites,97 SOUTH SHORE RD.,BLDG.#2.SOUTH YAMOUTH,MA 02664 See Attached... CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EVIDENCE OF INSURANCE AUTHORIZED REPRESENTATIVE J/ / / / I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: NEWPHOTE LOC#: A`CPR ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED GENATT V LLC Newport Hotel Group LLC,ETAL 28 Jacome Way POLICY NUMBER Don McCall Middletown RI 02842 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE SNAKE RIVER LODGE&SPA,7710 GRANITE LOOP RD.,TETON VILLAGE,WY 83025 Ocean Mist Beach Hotel&Suites,97 SOUTH SHORE RD,SOUTH YAMOUTH,MA 02664 (BLDG#1 GULL HOUSE,BLDG#2 SALT HOUSE,BLDG#3 JETTY HOUSE) Bristol Harbor Inn,259„251,267 THAMES ST,BRISTOL,RI Ocean House Hotel at Bass Rocks,107-108 ATLANTIC RD.,GLOUCESTER,MA(BLDG#1 STACEYHOUSE,BLDG#2 OCEAN HOUSE,BLDG#3 SEASIDE HOUSE) Nantasket Beach Resort,45 HULL SHORE DRIVE.HULL.MA 02601 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD