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HomeMy WebLinkAboutApplication and WC .-3 Lk)C (A)ATM: iA. TOWN OF YARMOUTH BOARD OF HEALTHr%' . APPLICATION FOR LICEN E/I : T ,lOtt. S S 4 V!** ... ' ' - . I OK, 1:; KA Z 4 Z014 ,. ,..,7...; * Please complete form and attach all necessary fa a Bents y D ' ce ber 15 2014. Failure to do so will result in the return Qf:y1u ' application . ck:". 2' " ' PT. ESTABLISHMENT NAME: Blue Wa t e r TAX ID: LOCATION ADDRESS: 291 South Shore Drive , So Yarmouth TEL.#: 508 - 398 - 2288 MAILING ADDRESS: 20 North Main St . , South Yarmouth , MA 02664 E-MAIL ADDRESS: mpurr i er@ thedavenpor tcompan i e s . com OWNER NAME: Davenport CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: John Verity TEL.#: 508 - 398 - 2288 ' MAILING ADDRESS: 20 North Main St . , 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 Operator(s) and attach a copy of the certification to this form. 1 .14111 provide in the spring prior to oppni /Cg Pool operators must list a minimum of two employees currently certifiedin basic water safety, 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 years' records. You must provide new copies and maintain a file at your place 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. 1 .Wi l l • rovide in the • ' Il • . ' . • • i . . PERSON IN CHARGE: ,,N,.. 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 thep remises 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 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE P RMIT # B&B $55 CABIN $55 j_MOTEL $110 '-O0 INN $55 CAMP $55 j SWIMMING POOL $110ea. - /5=006 007 LODGE $55 TRAILER PARK $105 i WHIRLPOOL $110ea. ITEMBIZI FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 j>100 SEATS $200 4- /5---(1/6 t COMMON VIC. $60 -0/57-617 WHOLESALE $80 RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING - FOOD $25 <25,000 sq.ft. $150 FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ -7 00 i 0 0 ecc. td % g7 $ OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION i Under Chapter 152,. Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal permit to operate a business if a person or company does not have a Certificate of Worker's of any license or p Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Yarmouth taxes and liens must bepaid prior to renewal or issuance of your permits. PLEASE CHECK Town of APPROPRIATELY IF PAID: YES XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: purposes For u oses of the limitations of Motel or Hotel use, Transient occupancy shall be and short term occupancy, ordinarily and customarily associated with motel and hotel use. limited to the temporary Transient occupants must have and be able to demonstrate that they maintain a principal place of residence Transient occupancy shall generallyrefer to continuous occupancy of not more than thirty (30) days, and elsewhere. p y an aggreninety (90) days within any six (6) month period. Use of a guest unit as a residence or gate of not more than nine 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 64G, as amended, shall generally be considered Transient. POOLS OPENING: All swimming, wadingand whirlpools which have been closed for the season must be inspected POOL . Health Departmentprior to opening. Contact the Health Department to schedule the inspection three (3) by the p prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been days p 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: in ground Everyoutdoor swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: p 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 TemporaryFood Service Application form 72 hours prior to the catered event. These forms can be p pp obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: desserts must be tested bya State certified labprior to opening and monthly thereafter, with sample results Frozen 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 CAFÉS: Outside cafes (i.e. outdoor seating with waiter/waitress 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. 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, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ETC.), TO COMMENCEMENT. RENOVATIONS MA ' QUIRE A SIT PLAN. DATE: 11 - 18 - 14 SIGNATURE. PRINT NAME & TITLE: Mary P u r r i e r , Asst . Controller Rev. 11/03/14 The Commonwealth of Massachusetts Department of Industrial Accidents .t Office of Investigations till = 6 1 Congress Street, Suite 100 s.,..:Sittifil= .. ii 41,., 1143Temuilv Boston, MA 02114-2017 ilk, 1 r-- ,, `u www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Blue Water , LP Address: 20 North Main S t . City/State/Zip: So . Yarmouth , MA 02664 Phone #: 508 - 398 - 2288 Are you an employer? Check the appropriate box: Business Type (required): 1 . employer employees IN I am a em to er with em to ees (full and/ 5• U Retail or part-time).* 6. El Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' insurance nsurance required] 3. ❑ We are a corporation and its officers have exercised 9. 0 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 [Nocomp.em to eesworkers' . insurance req.] 12.[Other Seasonal resort P Y *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. Insurance Company Name: Zurich American Ins . C o . Insurer's Address: attached City/State/Zip: Policy # or Self-ins. Lic. # WC 819 6 0 3 5 Expiration Date: 3 - 1 - 15 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 hereby lib, under the pa' and penalties of perjury that the information provided above is true and correct. i , - -. 4,-(--4,-(--Signature. � (.{.1 - 1---) Date: 11 - 18 - 14 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia 4 e s i e C r S DAVEN-1 OP ID: AK ACR ) CERTIFICATE OF LIABILITY INSURANCE . . (MM/DDIYYYY DATE 01/15/2014 4 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 Phone: 610-279-8550 NEACT AM . The Addis Group, Inc. PHONE FAX F (A/ 2500 Renaissance Blvd. Ste 100 ax: 610-279-8543 C, No, Ext): (A/C, No): - King of Prussia, PA 19406-2772 E-MAIL Jeffrey A. Grebe ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Zurich American Insurance Co. 16535 INSURED Blue Water LP INSURER B : c/o Davenport Realty Trust Stephen Aschettino INSURER C : 4 20 North Main St. INSURER D : South Yarmouth, MA 02664 INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYWY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 ,000,000 A X COMMERCIAL GENERAL LIABILITY . GL08196255 03/0112014 03/01/2015 Rat GE TO RENTED500000ISES (Ea occurrence) $ , CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 10,000 • PERSONAL & ADV INJURY $ 1 ,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO- $ JECT LOC AUTOMOBILE LIABILITY EOMaBIc eDtSINGLE LIMIT 1 ,000,000 A X ANY AUTO BAP8196256 03/01/2014 03/01/2015 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ - AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ (Per accident) Comp $ 250 UMBRELLA LIAB OCCUR. EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE : $ DED RETENTION $ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N X TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE WC8196035 03/01/2014 03/01/2015 E.L. EACH ACCIDENT $ 1 ,000,000 OFFICER/MEMBER EXCLUDED? 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 ,0001000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) • CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE *":29-7/ 7/ .- -4•04-.. I J © 1988-2010 ACORD CORPORATION. .AII rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD • .