The URL can be used to link to this page

Home My WebLink AboutApplication and WC , �idi�1.R +� a TOWN OF YARMOUTH BOARD QF,I�EALTH �� APPLICATION FOR LICENSE/PERMIT-2015 ea �`' '� - 4 ZU 14 v,, �--�o��3n $�E * Please complete form and attach all necessary documents by Dece er DEPT. Failure to do so will result in the return of your application p . ESTABLISHMENTNAME: Riv�era Beach Resort TAXID: LOCATION ADDRESS: 327 South Shore Dr. , So . Yarmouth TEL.#: 508-398-2273 MAILINGADDRESS: ZO North Main St . , SouthYarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Davenport CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: John Verity TEL.#: 774-208-1305 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.Wi11 provide in thP anrin;p�.��rinr tn nipni � 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. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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.Will provide in the sDring nr; nr tn nnani .� PERSON IN CHARGE: Each food estabiishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2• ALLERGEN CERTIFICATIONS: All food service establishments aze 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. i. 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 Sle at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 �MOTEL $110 � �( _INN $55 CAMP $55 SWIMMINGPOOL$110e�03`{ _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $ll0e FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �� CONTIIVENTAL $35 �}7'�h4,'�j NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEAMIT# 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 _ $ (p 2S .00 �Q � �f��.JOd *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** '�`� a ��JZV I f Y �-�ON3 7 � ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town o£Yarmquth is now required to hold issuance or renewal o£any license ar permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE AT'TACHEU S'CATE WOItKER'S COMPENSATI(}N INSURANCE AFFIAAVIT 1VIUST BE COMPLETED AND SIGNED, OR GERT. OF INStIRANCE A'CTACHED__�X OR WOI2K.ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannoutlz taxes and liens tnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELX IF PAID: YES XX NO MOTELS AND OTHF.R LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lirnited to the temporary and short tetm occupancy,ordinarily and customarily associated with motel and hptel use. Transient oceupants must have and be able to demanstrate that they maintain a principai giace of residence elsewhere.Transient oceupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more th�n ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha13 nat be cansidered transient. Occupancy Yhat is snbject to the coIlectian of Room 4ccupancy Excise,as defined in M.G.L. c. 64G or 830 CMR 64C'r, as amended, shall generally be considered Transient. PQOGS P40L QPENING:A11 scuimming,wading and whiripoals which have been closed for the season snust be inspected by the Health Department prior to opening. Contact the Health Deparkment to schedule the inspectian three(3) days prior to opening. PLEASE NOTE: Peaple are I�IOI'allowed to sit in the pool area until the paol has been inspected and opened. POOL WATER'TE5TING: The water must be tested for pseudamonas,total coliforrn and standard plate count by a State certified lab, and submitted to the HeaIth Department three (3) days prior tp opemng, and quarterly therea8er. POOL CLOSING:Every autdoor in ground swimming pooi rnust be drained ar covered within seven{7)days af closing. FC)Ol) SERVICE SEASONAL FOOD SERVICE OPENINC�: All food service establishments must be inspacted by the Healih Departrnent prior to opening. Please contact the Health Department to schedule the inspection three{3) days prior to opening. CATERING P4LICY: Anyone who caters within Yhe Town of Yannouth rnust notify the Yarmauth Health Department by filing the required Temporary Foad Service Application form 72 hours priar to the catered event. These forms can be obtained at the Health Departxnent,or frarn tl�e Town's website at www.yarmouth.ma.us under Health Deparhnent, Downloadabte Forms. FROZEN DESSERTS: Fzozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failurc to do so wili result in tha suspension or revoeation 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 Board of Health. OUTDOC/R COOHING: — dutd�Qr cooki�g.prepazation>t�r�ispIay of any faodproduct by a retail or fUadserv�ce e�talik�st�ent-is prohi�iited. - NOTICE:Pernuts run annually frora January 1 to December 3 I. IT IS YOTJR R.ESPONSIBILITY TO RETURN THE COMPLETET3 RENF;WAL APPLICATION{S)AND REQIJIREI?FEE{8}BY DECEMBER 15,2qi4. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POdL (i.e., PAINT'ING, NEW EQUIPMENT, ET'C.}, MUST BE REPORTED`I'O r1ND APPROVED BY THE BQARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA�EQUIRE A SIT " PLAN. �/ �.�yy ' 17ATE: 11-18-14 SIGNATURE: � �'t �2��' � ,u,� PRINTNAME & TI"I'LE: Mary Purr�er. Asst . Gontroller Acv. lf143t74 � � The Commonwealth ofMassachusetts Department of Industrial Accidents Offace oflnvestigations 1 Congress Street, Suite I00 Boston, MA 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Af�idavit: General Businesses Applicant Information Please Print Legiblv Business/OrganizationName: Riviera Beach, LP Address: 327 South Shore Drive City/State/Zip: So .Yarmouth, MA 02664 Phone #:508-398-2273 Are you an employer? Check t6e appropriate boa: Business Type(required): 1.� I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Earing 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. ❑ Entertauunent their right of exemption per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Heakh Caze 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other S e a s o n a 1 R e s o r t *Any applicant that checks box#1 must also fill out the section below showing their workers'compeasation policy information. '•If the coiporete officexs have exempted ihemselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. InsuranceCompanyName: 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' compensafion policy declaration page(showing the policy number and espiration 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-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for inswance coverage verificafion. I do hereby�fy,under the pai nd pena[ties ofperjury thal the informatfon provided above is true and correct. SiQnatur�� _ ��C L 4 ; Date• 11-18-14 �— Phone#: 508-398-2293 Official use only. Do not write in this area,to be comp[eted by city or town official City or Town: Permit/Liceuse# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia � . � ,,,..� � , ' pAVEN•1 OP ID:AK � '`;��"z� CERTIFICATE QF LtABIL1TY 1NSURANCE °A�E`M�o°�" . � �,�� 01/15/2014 THIS CERTIFtCATE 1S iSSUED AS A MATTER OF lNFQRMATION 4NI.Y AND CONFERS NO RtGHTS UPpN THE CERTIFICAT� HO�DER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NECaAT1VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES � � 6E�OW. SHt$ CER7IFICATE OF tNSURANCE D6ES NOT CONSTITU7E A GONTRACT BETNEEN THE ISSUtNG tNSURER{S}, AUTHQRIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFIGATE HOLDER. tMPORTANT: if ihe certiticaie hoider Es an ADDITtONAI tNSURED,the poticy(ies) must be endorsed. if SUBROGATION IS WAIVED,subject to� � the terms and¢onditfons of the policy, certain policies may requiro an entlorsement A statement on this certificate does not canfer rights to the certificate holder in lieu of such endorsement s. PRODUGER pfione:610-279•8550 NFMEACT . � � 7he Addis Group,Ina � rHONe 2500 Renaissance Btvd.Sta 100 Fax:610-279-8543 ��,w,o eMr � ., tw+c 'mr ... E-MHTL - Ring pf Prussia,PA 79406-2772 � aooaess: . .. �. - JeffreyA.Grebe . � wsuRexs-nFFoaoa�ccov�zaoe Nn�ce ,. � � wsoseaa:Zurich American Insurence Co, 16535 INSURED RIVIQI'd LP � MSURERB: � . c/o Davenport Realty Trust INSURERC: Stephen A'schettino � . �'�� 20 North Main.$t. wsuaeao; _ . � � SouthYarmouth,tvtAA2664 wsuHeee: .. � � INSURERF: COVERA.('aES CERTIPiCATENUMBER: � ftEViSiONNUM86R: � THIS IS TO CERTIFY THAT THE PpLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE�TO THE INSURED NAMEp ABOVE FOR THE POLICY PERIOD INOICATED. NOTWITHS7ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CUN7RACT OR 0?HER DOCUMENT WITH RESPEC7 TO WHICH THIS CER71RCATE M1MY BE i55UED OR MAY PERTAIN, THE lNSURANCE AFFORDED BY THE P6lICIES DESCRBED HEREIN IS SU6JEGT TO Atl THE T£RMS, ' . �EXCWSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID GLAIMS. ��R qp � � PO:.ICY E PpIiCY F LiMtTS �ny TYPE OF INSURANCE � � YDLiCY NUMeER M 6IYYYY MM�D�M'YY 6ENERALL1A911JTV � EACHOCCURRENCE $ � ��OOO�OOO AM�-£2�ETbR"E�TT€O.. A X .cOmnnErzcin�cENErin�unei�rtv . GL08198255 . � 03/01t2014 83/Oti2015 ppEMisEs Eaaccunen„�eL $ ��04 � cw�ms-Mnd= �accuk n+Eo�ataro�+aperson) a 70,000 PERSONAL 8 ADV INJUftY $ 'I�DOO,OOO GENEftALAGvREGAT£ S Z,040,40 GEN'LAGGREGATELIMITHPP4IESPER PRODUC7S-COMP/OPAGG E 2�000,00 � X F6CICY PRO� L� ...5 MBINEDSIN LELIMIT � Qp0tl00 AUTOMOBILELW6ILITY gacci ent .. A X nNvauiO BAP8198258 03101t2814 03t0172015 BOa�r�N.ioRv(Perpersan� -b ALLOWNE� �SCHEDUL[D " � BOOILYINJURV(PereccitlenQ $ � AUT�S nUTOS NON-JWNED � P OPERTYDAMAGE y Y. HIRE�AUTOS X qUTOS Peracci Bntl ,� Gomp .s 25 UMBRELLA LIAB OCCUR . EACH pCCURRENCE S �EXCESSIiAe CL�.IM$-AiFDE AGGREGATE S � � �ED RETENTIONB ' $ WORIfERSCOMPENSA'RON � X j NCSTATU� OiH- AND EMPLOYERS'LIA81LrtV �•I � � A ANYPRQPRIETORIPARTNERIEXEClIT1VE v� IVVC8196035 � 0 3101/20 1 4 O�/O'I/ZO'IS E.LEACHACCIDENT $ ��OOO�OOO OFFICERtMEM9ERE%CLUPED? N+A ( (MantlatpryinNHj E.L.DISEASE-EAEMROYEE $ �r4��4� If yes,tleacn�euntler E.I..CISEASE-POLICYLIMIT % �,a�Or00� DESCRIPTION Of OPERATIONS below DESCRIPTiON qF pPERATiONS t IOCATM}NS 1 VEHIC�ES{Affich ACQRD 101,Afltlttia�ai Remsrka Schetl�le,SE rtrore space is rzquireE} CERTIFICATE HOLDER CANCEL�ATI4N YARM4-0 � SHOl7L0 ANY OP 7NE ABOVEbESCR18E�POLIGIES BE CANCELLED BEFQRE 7NE EXP�RA770N DATE TFiEftEOF, NOTIGE WILL BE .�ELNERED IN � TOWO Of Yeffil0USI1 � pCCORDANCE WITH THE POUCY PROVIBIONS. Route 2$ South Yarmouth,MA 02864 AUTHORIZED ftEPRESENTATIVE T— � Jeffrey A.Grebe . O 1988-2D10 ACORD CORPORA710N. All rights reserved. . ACORD 25{2Q'I OIQS} ' The ACORD name and logo are registered marks af AdORD