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Home My WebLink AboutApplication and WC APPROVAL FOR PAYMENT ACTIIORIZED B1 VE�DORq IVVOICF.k P.O.N ]0414 Refund ORG OBJF;CT PROJECT 05104420 442017 �rowi nT ro r.�v� 95.00 February 10, 2015 Payable to: Davenport Realty Trust 20 North Main Street South Yarmouth, MA 02664 For: Refixnd: Blue Rock Pro Shop licenses Paid for Food Service & Common Victualler : $145.00 Should be Retail Food Service<50 sq.ft.: $50.00 TOTAL REFUND: $95.00 L-si . , �JC12oc�l�eo �qp d TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERNTIT-�3pA, ,,�e��-(� '�G„�Y ;'4 �(111 `" * Please complete form and attach all necessary doou�e`�f".s��?�ece3ri er I S 2014. � Failure to do so will result in the return of you�appTication pa et. �� - ESTABLISHMENTNAME: Blue Rock Pro Sho� TAXID• LOCATIONADDRESS: 48 Todd Road South Yarmouth TEL.#: 508-398-6962 MAILINGADDRESS: 20 North Main St . South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Davenport Realty CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Ryan 0'Loughlin TEL.#: 508-398-6962 MAILINGADDRESS: ZO 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. 1Will provide in the spring prior to openi� Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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,Wi11 provide in the spring prior to openi� 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 establishxnents 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $ll0 INN $55 CAMP $55 SWIMMING POOL$ll0ea LODGE $55 TRAILERPARK $105 WHIRLPOOL $il0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# f 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: � IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . � —<50 s .ft. $50 � - � >25,000 sq.ft. $285 _VENDING-FOOD $25 p.sqB �lsp =FROZENDESSERT $40 _TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $ I SS .O O � d �l��oo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � 2�vN��- ��s_oa c�o��7 �� z��`Y ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or"renewai 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 XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe 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 transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G ar 830 CMR 64G, 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 azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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.varmouth.ma.us under Health Department, Downioadable 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 Boazd of Health. 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 RET[7RN 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, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAR�UIRE A SIT�AN. DATE:_11-18-14 SIGNATU ��'C� ��li(/l/�.lil� PRINTNAME& TITLE:_M��g�.�}��.T��s� 6en��e��e� Rev. I1/03/14 � The Commanwealth ofMassachusetts Department oflndustriat ficcZdents Office oflnvestigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017. www.mass.gnvldia Workers' Compensatian Iusnrance Affidavit: General Businesses Ano&cant Information Please Print Le�iblv BusinessJOrganizationName: Blue Rock Pro Shon Address: 48 Tadd Raad City/State/Zip: So .Yarmouth MA 02664 Phone#: 508-398-6962 Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with employees(full ancf! �• ❑ �etail or part-time).* 6. �RestaurantlSaz/Eating Esiablishment 2.❑ I am a sole proprietor ar partnership and have no �, � Office and/or Sales{incl.real estate,auto, etc.) emplayees working for me in any capacity. (No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We are a corporation and its offrcers hava exercised 9. ❑ Entertainment their right af exemption per c. 152, §I(4},and we have 10.�Manufacturing no emplayees. [No workers' comp. insurance required]* �1.�Heaith Care 4.❑ We aze a non-profit organization, sta£fed by voiunteers, with no employees. [No workers' comQ. insurance req.] 12.[� Other pr�qy,�n *Any applicant that ohecks box#1 must also fill out the section below showing t6eir workers'compensation pplicy information, **I£tha corpomte ofiicexs have exempted t6emsefves,but the corporation has other employees,a wozkers'campensatioa policy is requit�d and sucb an or�anization should check box#1. I am an employer that is prov�ding workers'compensaBon insurance for my empXoyees. Below is the poCicy information, InswanceCompanyName: Zurich American Ins . Co . Insarer'sAddress: see attached CiTy/State/Zip: Policy#orSelf-ins.Lic. # WC8196035 ExpirakionDate: 3-1-15 Attach a copy of the workers' compensation policy declaration page(showing the pplicy number and eapiration date). Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the impasition of crim'snal penalries of a fine up to$],500.00 andlor one-year imprisonment,as we11 as aivil penalties in the form of a STOP 4V(7RK ORDER and a fine of up Go $2SO.Oq a day against the violator. Be advised that a copy of this statement may be forwarded to tha Office of Investigations of the DIA for insurance eoverage verifiearian. I do here� rtify,under fhe ins and penatfies of perjury that tke infarmn#on provtded above is true and rorrecY. / Si a e: � �t-�' --�LC�f.%vt �a : 11-18-14 Phone#: 508-39 -2293 OJfzciat use only. Do not write in this area,ta be completed by city or town off?ciaG City or Town: PermitlLicense# Issuing Authority(circle ane): 1. Board af Healt6 2. Building Department 3. CitylTown Cierk 4.Licensing Board 5. Selecfman's d�ce 6.Other Contact Persan: Phone#: www.mass.govldia � � /� � � � ' DAVEN-1 • OP ID:AK ACORO DATE(MM/DDM'VY' �.� CERTIFICATE OF LIABILITY INSURANCE ov�s�zo�a 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 COVER4GE AFFORDED BY THE POLICIES BELOW. THIS CERTIPICATE OFINSURANCE DOES NOT CONSTITUTE A CONTRACT BETVJEEN THE ISSUING INSURER(S), AUTHORI2ED �� REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. - � IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be entlorsed. 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� certifcate holder in Ileu of such endorsement(s). PRODUCER Phone:610-279-8550 NAMEALT The AddiS Group,lna FaX:610-279-8543 PHONE � � FAX 2500 Renaissance Blvtl.Ste 100 ac r�o e,�: nrc r�o: King of Prussia, PA 19406-2772 A DRIE55: Jeffrey A Grebe INSUftER S AFFORDING COVERAGE NAIC p wsueean:Zurich American Insurance Co. 16535 ir�suReo Davenport Realty Trust INSURER B: dba Blue Rock Golf Course 1 INSURERC: Stephen Aschettino 20 North Main St. wsuaEao: South Ya�mouth, MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATENUMBER: REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTUJITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH�RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE APFORDED 8Y THE POLICIES DESCRBED HEREIN IS SUBJECT TO ALL THE TERMS, - EXCWSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS � INSR rypEOiINSURANCE IA � PO4CYNUMBER MMID�YIYVYY MMIDDIYEVI'V � LIM?5 � LTR GENERALLIABILITY EACHOCCURRENCE E ��OOO�OO A X COMMERCIALGENERALLIABILITY GL08196255 03f01/2014 �3/U�/20�5 pREMISES Eaoccunence 3 5��,�0 CLAIMS-MA�E � OCCUR MEOEXP(Anyoneperson) S �O,OO PERSONALBADVINJURV E ��OOO,DO Ii GENERALAGGREGATE S Y,OOO,OOO GEMLAGGREGATELIMITAPPLIESPER: i PRODUCTS-COMPIOPAGG E Z�OOO�00 X POLICY PR� LOC � a HUTOMOBILELIABILRV � I EOM�BM�EDSINGLELIMIT E ��OOO�OO A X nNvaUTo I BAP8196256 � 03/Ot/2014 03/01/2015 Booi�vwduRv(Perperson� E ALLOWNED SCHEDULED �i BODILYINJURY(PerauAtlenp S �AUTOS AUTOS ' X HIREDAUTOS X NON-0WNED I PROPERTYDAMAGE a AUTOS . Peracutlent Comp s 25 UMBRELLALIaB OCCUR � EACHOCCURRENCE E ESLE55 LIAB CLAIM$-MADE AGGREGATE S �ED RETENTIONS d WORKERSCOMPENSATION X WCSTATLL OTH- � ANO EMPLOYERS'LIABILItt . T RV IMIT R A ANVPROPRIETOR/PARTNERIE%ECIITIVE Y�N C8196035 O3/O'I/YO'I4 O3/O'I/YO'IS E.L.EACHACCIDENT 8 'I�OOO�OOO OFFICERIMEMBER EXCLUDED4 � N�A , (MantlatoryinNH) E.LOISEASE-EAEMPLOYEE E �,OOO,OOO Ify es,tlescnbe untler i DESCRIPTIONOFOPERATIONSbelow EL.OISEASE-POLICYLIMIT E �,OOO,DOO DESCRIPTION OF OPERATION51 LOCATIONS I VEHICLES �AttacM1 ACORD 101,Atltlitional Remarks ScheEule,if rtwre space Is repuiretl) CERTIFICATE HOLDER CANCELLATION � YARMO-0 . SHOULD ANY OF THE AeOVE DESCRIBED POLiCIES BE CANCELLED BEFORE TOwO Of Y8fR10ULI1 THE EXPIRATION DATE THEREOP, NOTICE WILL eE DELNERED M . � ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 . SOUYII YdffIl0UYI1� MA OZG64 � qUTHORIZEDREPRESENTATNE T�� - � . OO 1986-2010 ACORD CORPORATION. All rights reserved. ACORD 25(20'10/OS) The ACORD name and logo are registered marks of ACORD . '