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Home My WebLink AboutApplication and WC . ��- a TOWN OF YARMOUTH BOARD OF HEALTH � J�. �� APPLICATION FOR LICENSE/P�RMIT -�0��5�3`� �1 �;,V � � [U14 " * Please complete form and attach all necessary docum�en s by Decem r I S 2014. Failure to do so will result in the return of yow application pac ESTABLISHMENTNAME: Green Harbor Village TAXID: LOCATION ADDRESS: 182 Baxter Ave . , West Yarmouth TEL.#: 508-771-1126 MAILINGADDRESS: 20 North Main St . , South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Green Harbor, Inc CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Richard Schott TEL.#:508-771-1126 MAILINGADDRESS: ZO North Main St . , South Yarmouth, M�i POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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, Will provide in the sprinQ prior to open�Q Pool operators 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 Sle at your place of business. 1. Z• 3, 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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. Z• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Z• 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-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. 1. 2• 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L(CENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P RMIT# B&B $55 CABIN $55 �MOTEL $110 –0 —[NN $55 � CAMP $55 �SWIMMINGPOOL$IlOea ' Z 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 Q5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: �$15 AMOUNT DUE _ $ 2Zc�.Oa ,� �� taS oO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** G e�-�vo�3�3 ►�/urlt� ADMINISTRATIOIY * Under Chapter I 52, Section 25C, Subsection 6,the Town of Xannouth is now required to hold issuance or renewal of any license or permit to aperate a business if a person or company daes not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOI2KER'S COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETk:D AND SIGNED, t7R CERT. OF INSURANCE ATTACHED XX OR WflI{.KER'S CQMP. AFFTDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid priar to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IP PA1D: YES XX NO M4TELS AND OTHER L4DGING ESTABLISIiMENTS TRANSIENT OCCUPANCY: For ptuposes of the limitations of Motel or Hotel use,Transxent occupancy shall be limited to the Temparary and shorc term accupancy,ordinarily and customarily associa€ed with matei and hotel use. Tra�isient 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 afnot more than thirty(30)ctays,and an aggregate of nat more than ninety{9Q)days wiThin anu six(6}month period. Use of a guest un3t 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. a 64G or $30 CMK 64G, as amended, shall general2y be considered Transient. PO4LS POOL OPEIVING:All swimming,wading and whirlpools which hava bean closed for the season must be inspected by the Health Departinent prior ta opening. Contact the Health Department to schedule the inspectian fhree{3) days priar to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool area until the paol has been inspected and opened. k'OOL WATER TESTING: The water must be tested f'or 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 thereaftec. POOL CLOSING: Every outdoor in ground swimming pool must be drained ar covered within seven("7)days of clasing. k'OC}I3 SERVICF, SEASONAL FOOD SERVICE OPENING: All food service sstablishments 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: Anyane who caters within the Town of Yarmauth must notify the Yarmouth Heaith Department by filing the required Temporary Pood Service Application form 72 hours prior to the catered event. These forms can be obTatneri at the Health Department,or from the Town's website at www.varmouth.ma.ns under Healih 3aepartment, Downloadabie Farrns. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to ppening and monthTy thereafter,with sampTe results submitted to the �Iealth DepartrnenY. Failure to do so will result in the suspension or revocation of your Frozen I)essert Permit until the above terms have been rnet. OUTSIDE CAFFS: Outside cafes(i.e.,outdaor seating with waitertwaitress service},must have prior approval from the Baard of Haalth. dUTDOOR COC}KING: Outdoor cooking,preparation,�r display of any faod product by a retail ar food service establishment is prohibited. NOTICE:Perxnits run annually frorn January 1 to December 31. IT IS XOLTit RESPdNSIBILiTY TO RE7'l7RN "I'HE COMPLETED RENEWf#L APPLICATION(S) AND REQUIR�D FEE(S) BY DECEMBER 15, 2014. ALL RENOVATTONS TO ANY FOOD ES1'ABT,ISHMENT, MOTEL OR POOL {i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPdRTED TO AND APPROVED BY THE BQARD OP HEAT TH PRTOR TO COMMENCEI�fENT. RENOVATIONS MAY REQU'IR.E A 5F��PLAN. DATE: 31-58-14 SIGNATURL� �(,�,"...i-j ,f��,�C%/�� PRTNTNAME&TITLE: Mar�, p�,�,-; ��_��r r�»r,-oller _ Rav. 11/p3/14 � � � The Corrzmonwealth ofMassachusetts Department of Industrial Accidents � - Office oflnvestigations 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Af�idavit: General Businesses Applicant Information Please Print Leeiblv Business/OrganizationName: Green Harbor VillaQe , LP AddTess: 20 North Main Street City/State/Zip: So .Yarmouth, MA 02664 Phone #: 508-771-1126 Are you an employer?Check the appropriate box: Business Type(required): 1.[,� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant7Baz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � 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 are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I.� Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other c a a c n„a 7 r a c n r r 'Any applicant that checks box#1 must also fill out the section below showing their workecs'compensation policy infoimation. *•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 isproviding workers'compensation insurance for my emp[oyees. Below is the policy information. ' InsuranceCompanyName: Zurich American Ins . Co . Insurer'sAddress: see attached City/State/Zip: Policy#orSelf-ins.Lic. # WC8196035 ExpirationDate: 3-1-15 Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date). Failwe to secure coverage as required under Section 25A of MGL c. 152 cac�lead to the imposirion of criminal penalries of a fine up to$1,500.00 and/or one-yeaz 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 forwazded to the Office of Invesrigations of the DIA for insurance coverage verifica6on. I do hereby c ' ,under the pai nd penalties ofperjury that the information provided above is true and correct. Si nature �-2U ��C�(-� Date: 11-18-14 � Phone#• 508-398-2293 Official use only. Do not write in this area,[o be comp[eted 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 O�ce 6.Other Contact Person: Phone#: www.mass.gov/dia ` �� ' � DAVEN-1 OP ID:AK '`��R� CERTIFIGATE OF LIABILITY INSURANCE , DPTE�MMIDDIYVYY) o,nsizo,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 COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTR4CT 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 WkIVED,subJect to � the terms antl conditions of the policy, certain policies may require an endorsement. A statement on this certificate tloes not confer rights to the certificate holtler in lieu of such�endorsement(s. PRODUCER Phone:610-279-8550 NAMEpCT � - The Addis Group,lnc. FaX:610-279-8543 PHONE . FAX � 2500 Renaissance Blvd.Ste 100 ac r+o st: NIC No: � King of Prussia,PA 19406-2772 E-MAII Jeffrey A.Grebe � nooaess: � INSI/RER 5�AFFOROING COVERAGE NAIC i ir+suaean:Zurich American Insurance Co. 16535 � INSURED Green Harbor Village L.P. iNsuReRa: c/o Davenport Realty Trust - wsuaers c: � .. Stephen Aschettino . � 20 North Main St. irvsuaeao: South Yarmouth,MA 02664 INSURERE: INSURER F: � COVERAGES CERTIFICATENUMBER: REVISIONNUMBER: ' THIS IS TO CERTIFY THAT THE POLICIES-0F INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVJITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTR4CT 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 BV PAID CLAIMfi � INSR rypE OF INSURANCE ADOL pOLICV NUMBER MMIDOVIYVYY MM/DOvIYYYV LIMRS LTR � GENERNLLJABILITY .. EACHOCCURRENCE $ ��OOO�OO � P. X COMMERCIALGENERALLIABILITV GL081962$$ 03�0��20�4 03/01@015 pREM�SES Eaoccurtence $ $��0 CLnIMS-MnDE � OCCUR MEDEXP�Anyweperson) S 1D,OO PERSONALBADVINJURV E 'I�OOO�OOO � GENERALAGGREGATE S Y�DOO�OO GEN'LAGGREGATELIMITFlPPLIESPER'. I PRODUCTS-COMP/OPAGG E Y�DOO�OOO X POLICY PR� LOC � 5 AUTOMOBILELIA91LItt EOM�BIN�E�DSINGLELIMIT E �,000,000 /� X qNYAUTO Bi1P819fi256 03/07/2054 03105/2015 BODILVINJURv(Perperson) 8 ALLOWNE� SCHE�ULED BpDILVINJURY(Perauitlent) 8 AUTOS AUTOS �X HIREDAUIDS I X NON-0WNED PROPERTY DAMAGE $ AUTOS . Pe�accitleni Comp s 25 ❑MBRELLA LIAB p�CUR EACH OCCURRENCE 5 E%CESSLIAB CLAIMS-MADE AGGREGATE E --� OED RETENTIONE $ WORKERS COMPENSFTION X WC STATU- OTH- FND EMPLOVERS'LIABIIITY A ANYPROPRIETOR/PNRTNERIEXECUTNEvIN C8196035 03��2��4 03101/2015 E.LEACHACCI�EM E �r0��0� OFFICERIMEM9EREXCLU�EDt+ � N�A (Mantla[oryinNH) EL.DISEASE�EAEMPLOYEE $ ��OOO�OO If yes,tlesaibe untler DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICVLIMIT E �,OOO,OO DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES �Amc�ACORO 101,AtltlMional Remarks Schetlule,If more space is requlrttl) CERTIFICATE HOLDER CANCELLATION YARMO-0 � SHOULD ANY OF THE ABOVE DESCRIeED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. . Route 28 � � South Yarmouth,MA 02664 qUTHORIZEDREPRESENTATIVE T�� . - . OO 1988-2010 ACORD CORPOR4TION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD