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Home My WebLink About2025-26o.\t n6'lttz PLEASE COMPLETE ALL QUESTIONS NAME OF BUSINESS BIue RocK GoIf Course Bil I|IJ )Y4Q) BUSINESS 1p1. a 508-394-4440 LICENSE FEE: $ 150.00 TOWN OF YARIT{OUTH BOARD OF HEALTH 202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION PLEASE COMPLETE THIS APPLICATION AND RETURN IT WITH THE LICENSE FEE BY .tt_rNE 30.2025 BUSINESS ADDRESS IN YARMOUTH MAtLING ADDRESS same 48 Todd Road South Yarmouth MA 02664 EMArL ADDRESg wjones@bluerockgolfcourse.com REQ r ,r RE D MANAGER/coNTACT pERg61 wes Jones TELEpH9NE a 508-394-4440 REQ ItREL) owNER 1'141y6 Davenport Realty Trust 'rEr.r 508-398-2293 HOME ADDRESS 20 North Main Street, South Yarmouth, MA 02664 CORPORATION NAME (IF APPLTCABLE)TEL. # CORPORATION ADDRESS MAILING ADDRESS 04-2208671 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENINC. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Please check appropriately ifpaid: yes X no_ nla Under Chaprer 152. Sec. 25C, subsection 6. the Town of Yarmouth is required to hold issuance or renewal of any license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofrenewal or issuance ofyour permits, you must complete the enclosed Workers Compensation Allidavit. Ifnot applicable. please explain REGISTRATION FORM SIGNED AND COMPLETED CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED ALL SAFETY DATA SHEETS ON FILE X Y X N APPLICANT'S SICNA RE,l ) b .-lao2{DA'IE ,-) <G"$#iiil:D rAx rD (FErN oR ssN) B4IBEU YN ANY NEW CHEMICALS MUST BE PRE.APPROVED BY THE HEALTH DEPARTMENT. RENEWAL APPLICATION X IEW APPLICATION The Commonwealth of Massochusetts Deport me nt of I ndustr ial Acc idents Olfi c e of I nvest igation s Lafayette City Center 2 Avenue de Lofayelle, Boston, MA 02111-1750 www.mass.gou/dia Workers' Compensation Insurance Alfidavit: General Businesses l: Aoolicant lnformation Please Print Lesiblv Business/Org anization yumg. Blue Rock Golf Course Address: 48 Todd Road City/State/Zip . South Yarmouth, MA 02664 Are you an employer? Check the appropriate box: I . E t am a employer with - employees (full and; or paft-time).* I am a sole proprietor or partnership and have no employees uorking lbr me in an1 capacig. [No workers' comp. insurance required] 3. E We are a corporation and its officers have exercised their right of exemption per c. I 52. S I (4). and we have no employees. [No workers' comp. insurance required]* 4. ! We are a non-profit organization. staffed by volunteers. with no employees. [No workers' comp. insurance req.] Phone #:508-394-4440 5. 6. 7. 8. 9. 10. I l. Business Type ( required) Retail Restaurant/Bar/Eating Establishment Office and/or Sales (incl. real estate. auto. etc.) Non-profit Entertainment Manufacturing Health Care g11,", Golf Coursel2.E *Any applicant thar checks box #l must also fill out the section below showing their workers' compensation policy information. trlfthe corporate otlcers have exempted themselves. but the corpomtion has other employees, a workers' compensation policy is required and such an organization should check box # I . I am un empkryer thot is providing workers' utmpensatbn insurance .for my employees. Below is the policy information. lnsurance Company Name Insurer.s Address: See attached City/Stale/Zip: Policy # or Setf:ins. Lic. #WC 8196132 Expiration Date 3t1t2026 Attach a copy ofthe workers' compensrtion policy declaration psge (showing the policy number and expiration date). Failure to secure coverage as required under $ 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa 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 tine of up to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Oflice of lnvestigations of the DIA for insurance coverage verification. I do herehy cerl , under the pains and penalties of perju4' that the informotion provided above is tue and correcL Si re Tlunnt 'z{7W Phone #. 508-760-9270 Pernrit/Licensr # Pbone #: S.flCity/Towtr Clerk {.DLicensing Board City or Tol n: Issuing Authoritv (check one): l.[Board of Health 2.E Builditrg Department wurv.mass.gov/dia Zurich American lnsurance Company OlJicial use only. Do not h'rite in this area, to he compleled b! ci'' ot lob,n ofJicial. 5[ Selectmen's Oflice 6. Eother Contact Person: . ---\ACOFTD DAVEREA-01 ,THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY ANO COT'IFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTENO OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITIJTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 211012025 IMPORTANT: lf tho certiflcate hotder t3 an ADOITIONAL INSURED, the policy(ies) must have ADDITIONAL INSUREO provisions or be endorsed. If SUBROGATIOT.I IS WAIVEO, this cortificate doe3 not conlor rl ndltlons of tho policy, cortain pollcl6s may roqulrs an sndoisement. A statement on n lieu ot such ondo6ement(s).subject to the tsrms and co qhts to tho certlflcato holdsr I ftL n.r,(oa) ges-gszzlil3lfi,.,u, (sr o) nss-sesg INSURER(SI AFFORDING COVERAGE 16535ri/suRER A :zurich American lnsurance ComDanv vallev Foroe Caotlvo Advisors E- K.fucco;nkev & Co.. lnc. 630 Froodom duslnoss Center Ddve King Of Prussia, PA 19,106 Davenpoit Realty Trust 20 North Main Stroet South Yarmouth, irA 0266i1 INSUREO COVERAG TE NUMBER:REVISION N HAVE ICAT ICATE ETH CPOLI PE toDETHNRESUNDEDFORAEOVEBELBEENESSUTODosLITEDLtcPOsIEoTTHAETHTIRTHsSoTTHDNTRESHToCPECoOTHEROCU[48OFONcDITIONRIVTENYEDND TEHE SRtvINERESBJUTTOTLLHISCDESR8EDTHBYECRANENUSETHORDSSUEBERTICEENBEcEDUEDDCLAIMS,tMrL SHO\tNTS VEHAOFCHSULtctPOSEsUSLNtoANscoDTIONNDIEXC UMITS '1,000,000ax1,000,000RENTED 1,000 1,000,000& AOV I TE 2,000,000 2,000,000x 3h120251O819625sx COMMERCIAL GENERAL LIABIUTY CLAIMS.MADE OCCUR EN'L POLICY TBER 1,000,000NGLE LIMIT x s AGE 31112026AP81962563t1t2025 ovlmEoAUTOS ONLY AI]TOS ONLY AIITOMOAILE UABILITY RENCE 5OCCUR CLAIMS.MAO€ Ui,ARELLA UAB EXCESS UAB DEO REIENTION$ x PER 1,000,000EL 1,000,000 '1,000,000 96132 3t1t2025 3t1t2026 WORI(ERS COMPEI{3ANONAND ET'PLOYERS' LI BIUTY ANY PROPRIE'OR/PARTNER,EXECUTIVEOFFICER/MEMAER EICLUOEO? OFOPERAIIONS oEScRIPnON OF OPERATIONS / LOCAT|ON S / VEHICLES (ACORO 101 . Addltlon.l R.m.ri! Schedol., m y be .li.ch.d l, moE .p.c. h EqqiEdl I SHOULO ANY OF THE AAOVE DESCRISED POLICIES BE CANCELLEO BEFORETHE EXPIRATION OATE THEREOF, T{OTICE WILL BE OELIVERED INACCORDANCE wlTH THE POLICY PROVISIONS. AUlHORIZEO REPRESENIANVE*r/- @ 1988-2015 ACORO CORPORATtON. Alt rights reserved The ACORO name and logo are registered marks ot ACORO ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE REOUIREMENT, INSURANCE THISCONTRACTORNOTWTHSTANDING POLtCtESAFFORDEDPERTAIN 3t112026 3gg fl .oc SCIIEDUL€DAIJIOS NONOWNEDAI-ITOSONLY E Town ol Yamouth Route 28 South Yarmouth, f,,tA 02664 ERTI