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Home My WebLink AboutApplication and WC ' , PcDtrEOL"hfE 5 d TOWN OF YARMOUTH BOARD OF HEAI,TH � � � �� APPLICATION FOR LICENSE/PERNfftT�-, �i`+��pg � h,.V i 4 20i4 Rh * Please complete form and attach all necessary docu��'��y�Secem' r 1 DEPT. Failure to do so will result in the return of your applicahon pac ESTABLISHMENTNAME: Edge of the Sea TAXID: LOCATION ADDRESS: 301 South Shore Drive So Yarmouth TEL.#: 508-398-2288 MAILINGADDRESS: 20 North Main St . , South Ya�mouth� MA 0266[� E-MAILADDRESS: mpurrier@thedavenportcompanies . com OWNERNAME: Blue Water CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: John Verity TEL.#: 508-398-2288 MAILING ADDRESS: 20 North Main St . South Yarmouth , MA n96F4 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. 1Wi11 provide in the sprin,e prior to o�genin� Pool operatars must list a minimum of two employees currently certified in 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 at[ach 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 Will provide in the spring prior to openi�g 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-chokmg 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. 1Wi11 provide in the spring p 'rior to openin�. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# [,ICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 �MOTEL $110 �j�� INN $55 CAMP $55 SWIMMINGPOOL$110ea. � LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 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,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 11 O•00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��-� �5�` �� cf�-4�6t 6 Sa8 lr�z�� ADMINISTRATION ` � •,. , IJnder Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any licanse or pernait to operate a business if a person or company does not have a Certificate of Worker's Compensarion Insurance. THE ATTACHEli STATE WORKER'S COMPENSATION IlYSiJRANCE AFFIAAVIT MUST BE COMPLETED AND SICxNED, OI2 CERT. OF INSCJRANC�E ATTACHED XX OR � WORK.ER'S COMP. AFFIDAVIT SIGNED AND A'I"TACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuanoe of your permits. PLEASE CHECK �PPI2.OPRIATELY IF PAiD: XES XX NC} MOTF.LS AND OTHF;R LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hote1 use,Transient occupancy shall be limited to the temparary and short term occupancy,ocdinrzrily and oustarnarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a grincipal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thiriy(30)days,and an aggregate af not more than ninety(90)days within any six(6)month periad. Use of a guest unit as a residence or dwell'ang unit shall not be considered transient. Occupancy that is subject to the collectian of Room Occupancy Excise,as defined an M.G.L. c. 64G ar$30 CMR 64CT, as amended, shall generally be cansidered Transient. PQ4LS POOL t}PENING:All swimming,cvading and whirlpoals which have been closed f'or tha seasam m�st be inspected by the Health Department prior to opening. ConYact the Health Departmenl to schedule the inspection three(3) days prior to opening. PLEASE NdTP:: Peaple are NC}T allowed ta sit in the pool area until the pool has been inspected and opened. POOL V4'ATER TESTING: The water must be tested for pseudomonas,Yotal coli£orn1 and standard plate count by a State cerCified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. PO4L CLOSING: Bvery outdoor in ground swimming paal must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SER'VICE OPENING: All food service establishments must be inspected by the I�ea(th Depariment priar to opening. Please confaet the Health DepartmenY t4 schedule the inspection three{3)days priar to opening. CATERING POLICY: Anyone who caters withiu the Town of'Yarmouth must notify the Yarrnouth Health Department by filing the requirad Temporary Food Service Applicatian larm 72 haurs prior to the catered event. These forms can be obtained at the Health L7eparhnent,or from the Town's website at www.yarrnouth.ma.us under Health Department, Downloadab2e Forms. FROZEN DES3ERT5: Prozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sarnple results submitted to the Health Department. FaiIure to do so will result in the suspension or revocafion of your Frozen Dessert Permit untii the above terms have been met. CfUTSIDE CAI+'�S: Outside cafes(i.e.,outdoor seating witki waiter/waitress service),must have prior approval from the Board of Health. ()UTDOOR COOHING: _ Qutdoor_cooking,pre�aratian,�r display of any food product by a retail or food service establishment is prohibited. _ _ __ NOTICE: Permits run annually from January 1 ta December 31. IT IS YOUR FLESPONSIBILITY TO RETURN THE CdMPLETED RENL;WAL APPLICA'ITON{S}ANI}REQL3IREI}FEE{S}BY DECEMBER 15,2014. ALL RENOVATIONS TO ANY POOD EST,�BLISHMENT, MOTEL OR POOL (i.e., PA.IN1"ING, NEW EQUIPMENT,ETC.},MLTST BE REPORTED TO AND t1PPROVED BX THE BOARD fi1F HEALTH PRIQR TO COMMENCEMENT. RENOVATIONS MA��QUIRE A SI�T PLAN. DATB: 11-18-14 SIGNATURE: ��lC� �-fiL�t��L4i) PRINTNAMB& TITLE: Mary Purrier Asst Gantroller Rev_ 11/03ti4 - - � � The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigations I Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Legiblv Business/OrganizationName: Ed�e of the Sea / Blue water Address: 301 South Shore Drive City/State/Zip: So .Yarmouth, MA 02664 Phone #: 508-.398-22RR Are you an employer?C6eck the appropriate bos: Business Type(required): 1.❑X I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBaz/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 aze a corporation and its officers have exercised 9. ❑ Entertairunent their right of exempuon per c. 152, §1(4), and we have 10.� Manufacturing no employees. (No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organizarion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other s ea s on a 1 ho t e 1 *Any applicant that checks box#1 must also fill out the section below showiag the'v workers'compensatiou policy information. *•If the co:porate officers have exempted themselves,but the cotporadon has otha employees,a workers'comprnsation policy is requ'ved and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my emp[oyees. Below is the policy information. InsuranceCompanyNazne: Zurich American Ins . Co . Insurer'sAddress: see attached City/State/Zip: Policy#or Self-ins. Lic. # WC 819 6 03 5 Expiration Date: 3-1-15 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration 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 weli 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 fonvarded to the Office of Investiga6ons of the DIA for insurance coverage verifica6on. I do hereby�ertify,under the painy rjnd penalties of perjury that the information provided above is bue and cnrrect. Si ature: t�� -�l�f Date: 11-18-14 Phone#: 508-398-2 93 O�cial use only. Do not write in this area,ta be completed by city or town officiaL City or Town: PermitlLicense# 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 DAVEN-1 OP ID:AK '`'�R CERTIFiCATE OF LIABiLiTY iNSURANCE °AT£`�'"�n�' �� 01/15/2014 THIS CERTlFIGATE IS ISSUED AS A MATi'ER 6F INFORAAATi6N ONIY ANQ C4NFERS h'O RtGHTS UP6N THE CERTIFICATE FtOLDER. THIS CERTIFICATE pOES NOT AFFIRMATIVELY OR NEGATIVELY AMEN�, EXTEND OR ALTER THE COVERAGE AFFpRDED BY THE POUGIES � BEI.OW. 7NiS CERTIFtCATE 6F INSURANCE D6ES NOT GONSTITU7E A CONTRAC7 BE7WEEN TFiE ISSUtNG IN5URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. tMPORTANT. tf the ceRifieate ha�der is an ADDITIONAI ENSURED,the po3icy{ies) must be endorsed. if S�BROGATION IS WAIVED,subject to the terms and contlitions nf the policy, certain policies may require an endorsement A skatement on this certificate does not conier rights tp the � ceR3ficais hoider in fleu of such entlorsement s}. PROOUCER Phone: 610-279-$550 N MEACT The Addis Group,Inc. Fax:69R-279-8543 PHONE � �nr�c wor 260�Renaissanco Blvd.Ste'100 � ��'' �� — King of Prussia, PA 194D6-2772 E-MAIL aoorzess: J6fffCYA.Gf2bE (rySUREWSAFF4RDiNGCOV£RAGE MAIC# ir�suaean:Zurich American Insurance Co. 16535� �NsuReo BlueWaterLP � u�suRerea: .. ... ....—_ c/o Davenport Realty Trust iNsuReRc: .... . Stephen Aschett€no 20 North Main St. irvsureeno:, Saufh Yarmouth,MA 0266A wsuaeaE: _. .._.— INSURER F: COYERAGES CERTIFICASE NUMBER: REVISION NUMBEft: THIS IS TO CERTIFY THAT THE PpLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO TNE WSURED NAMED ABOVE FpR THF. POLICV PERIOD INDICATED. NQTWITNSTANDING ANY REQUIREMENT, TERM OR CONDITfON OF ANY CONTRACT OR OTHER DOGUMENT WITH RESPECT TO WHICH THIS CERTiPiCATE MAY BE ISSUED QR MAY PERTAiN, 7HE INSURANCE AFFORDED BY THE PDLICIES DFSCRIBED HEREIN IS SUBJECT TO All TNE TERMS, EXGLUSIONS ANU CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. INTR A�a e POI.ICY EF P ItCY EXP LIMRS .. TVPE OF iN5�IRANCE POLICV NUMBER MMIDo11'YVY MMI�D Y GENERAWABIIITV EACHOCCURRENCE F 'I�OOO�OO A X coMMERcw�cENERn�uneiurv GL08796255 � 63701M814 03/61i20'IS p E�g�Ea�Occ„��m s 506,006 CWMS-Wt�E �OCwUR MGDEXFiAnypne rson) b _�Q�Ofl� PERSONAI.flAQVINJURY S �A6��000 GGNERAI.AGGHGGFTE S 2�060,OQ ,GEN'IHGGREGATELIMiTAPOLiESPER�. PHODUCTS-C4MP/OPAGG $ 2�000,000 X POtiCY��PftU- �tOC . � AVTOMOBILELIABI4TV � � MBINEDSIN I.ELIMIT ��QOO,OOO aacci nt A X aNvpUro 1BAP818625& 03t09t281R a3t0At2015 s0oav�Nd�RrtP�peEem7 E � ,1UTpS NEn ��u705ULED 9QDILY INJURY(Peraccitlenq S hlON-0NMED PAOPERi'Y DAMAGE ��y X HIRF.DAUTpS x qIJT05 � P raccitlem � , canp e zs �l1MeftELLAUAB OCCUR EACHOCGURRENCE 5 EXCESSLIAS 7 GLAtMS�MACE AGGReGATE 3 DEb RETENTIONS $ WORKERS COMPEkSATiUdI X �G STATU� QTH- ANO EMPLOVERS'LIABILitt � T i A ANVPROPRIETOR/PNRTNER/EXECUTIVEY/� C$1$��35 oara�no�a�oa�avzn+s E.L.EACNACC16EM $ ��0��0 .OFFiCER1btEMeERE%G_UDEfl9 � N!A ' (MandataryinNH) � E1.DIS£ASE-EAEMPI.OVEE 5 M1r��4� nyes,eescnee�nae� i � E�.ois�+se-aoucv umir s 'I,OOfl,000 DESCRIPTION OF OPERATIONS below I DESCRIPTION pF QPERATIONS t LOCATI�tiS 7 VEMIClES (Attacn AC�RD 501,AdCiHonai Remarka Schetlub,if more spaw is re4Wretl} CERTIFICASE HOLDER CANCEL�ATION YARM4-0 SHOULD ANY OF THE ASOVE DESCRIBED POUCIES BE CANGELLED eEPORE THE EXPIRA?i4N pATE THEREOF, N07ICE WILL BE DELWEREO IN TOWIi Of YBfmO�Sh �ACCORDANCE WITH 7HE PqLICV PROVISIONS. Route 28 South Yarmouth� MA�2664 AUTHORIZEDREPRESENTATIVE , ��-� � �.-,�' O 1988-2010 ACORD CORPORATION. All rights reserved. ACOftQ 25(26'19105} The ACQRD name and kogo are regisiered marks of ACORQ �