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Home My WebLink AboutApplication and WC . . , -v—S`,a�-r d TOWN OF YARMOUTH BOARD OF HEALTH _. �� . APPLICATION FOR LICENSE/PE�LT=�2�0_1�� f - � CU 14 �.� * Please complete form and attach all necessary doc�unetrfs by�Decem r I DEPT. Failure to do so will result in the return of your applicahon pac . ESTABLISHMENTNAME: Red Jacket Beach TAXID: LOCATION ADDRESS:l South Shore Dr. , So . Yarmouth TEL.#: 508-398-6941 MAILINGADDRESS: 20 North Main St . , South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Red Jacket Beach, Inc. CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Kenneth Smith TEL.#: 508-398-6941 MAILINGADDRESS: 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. Will provide in the sprine prior to opec�� 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 file at your place of business. �?ill provide in the spring prior to openin�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. 2• PERSON IN CHARGE: Each food estabiishment must have at least one Person In Charge (PIC) on site during hours of operation. j, Kenneth Smith 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 5le at your establishment. 1Wi11 provide in the spring prior to o nin� 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 a11 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. 1Wi11 rovide in the . 3. 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 $110• lS- Ol7 INN $55 —CAMP $55 �.SWIMMING POOL$110ea-��3z _LODGE $55 =TRAILERPARK $105 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 I >100 SEATS $200 f � ��2 I COMMON VIC. $60 'T��g WHOLESALE $80 —RESID.KITCHEN $SO 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 _ $ �700 .� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• ��'� ��0 cGC#o zza 94 ��z'!�i�{ ADMINISTRATION Under Chapter 152, Section 25C, Sixbsectioiy 6,the Town of Yarmouth is now required ta hold issuance or renewal o£any license or permit to operate a business if a person or company does npt have a Certificate of Worker's Compensation Insurance. THE AT"T'ACHEI? STATE VVOI2I{EEt'S CfIMPENSATIQN INSURANCE AFFIDAVIT iVIUST BE COMPLETF.D AND SIGNED, OR CERT. 4F INSCJRANCE ATTACH}?D XX OR WORKER'S COMP. AFFIDAVIfi SIGNED ANll A`TTACHED Town of Yarmouth taxes and liens rnust be paid prior to renewal ar issuance of youx permits. PLEASE CHECK APPROPRIATELY IF PAID: YES. XX NO _ MOTELS AND OTHFR LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shnrt term occnpancy,ordinarily and customariiy associated with motel and hotel use. 1'ransient occupants must have and be able to den�onstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally rePer Yo continuous occupancy of not rnore than thirty(30)days,and an aggregate ofnot more than ninety(90)days within any six(6)month period. tJse of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to tl�e collectian af Room {7eeupancy Excise,as de�ned in M.G.I,. c. 64G or 830 CMR 64G, as amended,sha11 generally be considered Transient. POOLS POOL CIPENING:All swimming,wading and whirlpoals which have beeezi ciosed far the season must be itrspected by the Health Department prior to opening. Coniact the Health Deparhnezat to schedule the inspection three(3) days priar to opening. PLEASE NtJTE: Peaple are NO"1'allawed to sit in the pool area until the paol has been inspected and opened. POOL WATER TESTING: The water must be tested f'ar pseudomonas,total coliforcn and standard plate caunt by a State certified lab, and submitted to the HeaIth Departrnent three (3) days prior to opening, and quarterly thereafter. PQOL CL4SING:Every outdoar in ground swimmang pool must be drained ar covered within seven(7)days of closing. FOOD SERVTCE � SEASONAL FOOD SERVICE QPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Departrnent to schedule the inspection three{3) days prior to opening. CATERING PQLICY: Anyone who caters within the Town af Yarmouth must notify the Xarmouth Health Department by frling the required Temporary Foad Service Application form 72 haurs priar to the catered event. These forms can be obtained at the Hettlth Department,or fram the Town's website at www.yarmouth.ma.us under Health Department, I7ownloadable Forms. F1tOZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montl�ly thereafter,with sample results submitted to the Health Department. Failure to do so wili resuIt in the siGspension or revocation of your Frozen Dessert Permit untii the abave terms have been met. CIUTSIDE CAF�`S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. (7UTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited. 1WOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOTTR RESkONSIBILITY TO RETUIZN THE COMPLETED RENEWAL APPLICA'TIt}N(S)ANI?REQtIIRBD FEE(S}BY DECEMBER 15,2Q14. ALL RENOVATIONS TO ANY POQD ESTABI.ISHMENT, MOTEL dR POOL (i.e., PAINTING, NEW F;QUIPMENT',ETC.},MUST BE REPORTED TO AND APPROVEl7 BY THE BOAI{D OF HEALTH PRIOR TQ COMMENCEMENT. RENOVATIONS M ItEQUIRE A�TE PLAN. L7ATE: 11-18-14 SIGNATIJR�i��Gl, �%��L�C�'�2G2'�- PRINTNAME& TITLB: Mary Purrier Asst . Gantroller Rev. i1t03t14 V � The Commonwealth ofMassachusetts Department oflndustrial Accidents O�ce oflnvestigations ' I Congress Street, Suite 100 Boston, MA 02II4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/OrganizationName: Red Jacket Beach, LP Address: i South Shnra Ilriva City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-6941 Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with employees (full and/ 5. ❑ Retail or part-rime).* 6. ❑ RestauranUBaz/Ea6ng 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] g• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I 0.Q Manufacturing no employees. (No workers' comp. insurance required]* 4.❑ We are a non-profit organizafion, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.� Other S e a s o n a 1 Ho t e 1 'Any applicant that checks box#I mus[also fill out the secfion below showing the'u workers'compensatioa policy infoimatioa. *}If the cocpornte officers have exemp[ed themselves,but the corporalion has other employees,a workers'compensation policy is requ'ved and such an organi��tion should check box#1. I am an employer that is providing workers'compensation insurance for my emp[oyees. Be[ow is the po[icy information. InsuranceCompanyName: Zurich American Ins . Go. Insurer'sAddress: see attached City/State/Zip: Policy#orSelf-ins. Lic. # WC8196035 ExpuationDate: 3-1-15 Attach a copy of the workers' compensafion policy declaration page(showing the policy number and eapiraHon date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penal6es 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 Invesfigations of the DIA for insurance coverage verificafion. I do hereby fy,under the p�s and pena[8es ojperjury that the information provided above is bue and correct. SiQnatu�i�'��C�/'�.� d�CUv(-Cic� Date• 11-18-14 Phone#: 508-398-2293 O�cial 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 Aealth 2. Building Department 3.City/Town Clerk 4.Liceasing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia . y..,...� , ' DAVEN-1 � OP ID:AK ' DnTE{MMIDDfYYYY) `��R4 CERT(FICATE 4F LIABILITY INSURANCE ov�sizo�a THIS GERTtFICATE IS ISSUED AS A MATTER OF INFORd11ATtON OtiLY AND CONFEi2S NO RIGHTS UPdN TiiE CERTtFiCATE NO�DER.THIS � CERTIFICATE DOES N07 AFFIRMATIVELY OR NEGATNELV'AMEND, EXTEN� OR AL.TER THE GOVER4GE AFFORDED BY-THE POLICIES 6El.OW. FHIS CEftTiFiCA7E OP tNSURANCE DOES NOT CONSTITU7E A GON7R4GT BETNtEEN 7HE tSSU1NG INSURER{Sj, AU7HDRtZED - REPRESENTATIVE 4R PRODUCER,AND THE CERTIFICATE HOLCrER. � IMPORTANT: ii zhe certificate holder is an A4DCffONAL ENSUREb,the policy(ies} must be endorsed. tf SUBROGATION IS WAIVED,subjact ta the terms and contlitfons of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificato holder in lieu of such endorsement{s). PRODVGER � P}1017E:G�O•Y7B'BSSO NNME:CT —�� y-- The Addis Group,Inc. Fax�8'i0-279-8543 'H°NE """' � i � 25Q6 ftenaissance SNd.Ste 106 - °`°a° E�ar ;A`C."°s: _, King of Prussia,PA�9406-2772 � n o�ess: _ JeffreyA.Gre6e INSURER{5}AFF4R61MGCOVERAGE NAIGi wsuaeaa:Zurich Americen Insurance Co. 16535 �xsuREo Red Jacket Beaeh t,P � iNsuaeas: � � clo Dav6nport Realty Tr'ust INSURER C i ' Sfephen Aschettino � � 20 North Main St . iNsueeao: 3outh Yarmouth,MA 02664 � wsuaene: ... .. INSUNER F: COVERAGES GERTIPICATE NUMBER: REYlSIOM NUMBER: � THIS�S TO CERTIFv TNAT THE PQUCIES OF INSUftANCE LISTEp BELOW HAVE BEEN ISSUED TO 7HE INSURED NAMED ABpVE FOR TNE POLICY PERIOD INDICATED. NOTWITHSTAN�IN6 ANY ftEQUIREMENT, TERM Oft CONLIITION OF ANY CONTRACT OR OTHER DpGUMENT WITH RESPECT TO WHICH THIS CERTtFICATE M1AAY 6E ISSUED OR MAY PERTAIN, THE IN5URANCE AFFORDED BY THE POIICiES DESCRiBED HEREIN iS SUBJECT TO ALl TNE TERMS, EXCLUSIqNS AND CONpITIONS OF SUCH POLICIES�IMlTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS � � INSR n•pE OF iNBURANCE A POLICY WUMBER PMNO E�F MMIDO� 4I�RS i iR GENERA4LIABIWTV � EACHOCCURRENCE $ 'I�OOO,OOO /A X� CDMMERCIALGENERALLIABILITV Z"aL081�fi255 03�0�/2�'i6 03/0172Q15 pREM15ES Eaacwrrence s 506,000 CLAIMS-MADE �OCCVft MED EXP(Any aoe perepn) i__,,,,,,,�0,000 PERSONALBAOVINJUftY 8 ��O�O�OOO GENE3AL AfifiREGATE S Z�OOQ,OO ('rEN'LAGGREGATELIMITnPPLIESPER: � PRODUCTS-COMP/OPAGG S Y�OOO,000 X PO�IGY PRQ- � ��G S MBWEDSIN� ELIMI� ��OOQOO � AUTOMOBILELIABILIiV EaacciM nfl 3 A X aNvauTo BAP8146256 03t0�M014 03t01t2U15 �06i�vIN�uRv{ce.pe�'san} -5 " ALLOWNED SCHEOULEO i 60DILVINJURY(PetaCCitlentJ $ AUTOS AU'f05 NON-OWNEu 6PERTYDAMAGE y X HIftEOAUTUS X qUT05 Pereccipen0 ,,, _ Comp a 25 UMBRELLq41PB OCCUR EACHOCCURRENCE _ $ E%CESSLIAB C�p��ny,pqp� AGGRE6ATE S DEO RETENTION$ § 'WO�ERSCDMPENSATION � X WCY1A'�TVG OEH- AND EMPLOYERS'LIABILITY ` /a ANVPROPRIETQR/PNRTNER/E%ECUTIVE YO N!A C8196035 � 03101/2014 03/01/2015 E�.EqCHACCIUENT �$ �r��,000 pFFICER+MEMBGR EXCIUPEDi �dp�� (MantlatorqinNHY I EL.DISEASE-EAEMPLOYE �S �i If yes,tlesai�eunder �,L.OISFASE-POLICYIIMIT $ � 1,0OO,4a0 OESC�RIf'TI�N Of OPERATION$�=1ow OESCRIPTtON OF�PERAiiON81 LOCATKAYS f VEtqCi.ES{Attacn AC�R�t0i,Atltlitienai Remarks ScIreEWe,if rtwre spece is required} CER7IFICA7E HQLDER CANCELl�ATION � YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED AOUqES BE CANCELLED SEFORE � THE EXPIRAT�ON DATE THEREOP, NOTICE WILL BE DELNERED iN Town of Yarmouth ACCORtiANCE WITH THE POLICY PROVISIONS. RouYe 28 _ T Soukh Yarmouth,MA 02664 ApTHORiZEbREPRESENTATIVE� � �� , O 19$8-2010 ACORp CORPORATION. All rights reserved. ACORD 25{2Q14/b5) The AGpRD name and logo are registered marks af ACORD � �