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Home My WebLink AboutApplication and WC w �-N.-F o�e3`r73 �iK/S � � ..._F:-TTfl . GfL'NOOS�/3�J $`LIJ _._ ... . . .�•uIJ � TOWN OF YARMOUTH BOARD OF HEALTH� „ - �� APPLICATIONFORLICENSE/PER1kI�Ta��015 i i�:.,V � 4 LU1� �"'" * Please complete form and attach a11 necessary docutnents;by Decem r 1 p� . Failure to do so will result in the return of your applicahon pac ESTABLISHMENTNAME: Blue Rock Club TAXID: LOCATIONADDRESS: 39 Todd Road South Yarmouth TEL.#: S�R- �Ast-�Ayz MAILINGADDRESS: 20 North Main St , o � h a moi, h , Ma n��61, E-MAILADDRESS: mpurrier@thedavengortcompaniec cnm OWNERNAME: Davenport Realty CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Ryan 0'Loughlin TEL.#: 508-39A-69F,� MAILINGADDRESS: 20 North Main �t r Snuth v rmouth, M[! 9�66'i POOL CERTIFICATIONS: The pool supervisor must be certi6ed 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�r; nr tn n�ani .,2o Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR), hauing 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 tile at your place of business. 1, 2. 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 �le at your establishment. 1W111 �1'OVi d i n thp cnri noa �ri nr t.. ..Fo .+�. s 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 Deparhnent 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 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. 1. Z• 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 LMOTEL $110 �(_ � f INN $55 CAMP $55 �SWIMMINGPOOL$110ea _LODGE $55 _TRAILERPARK $105 +WHIRLPOO[. $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. $I50 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ S IS .00 *•***PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM***** iP2c� ��yS � �#�7j $?a.S.00 c�+#5Ti38 !t�zy�� I ADMINISTRr1TION iJnder Chapter 152,Section 25C,Subsection 6,the Town uf Yarmouth is nc>w required to hold issuance or renewal af any license or permit to operate a business if a person or company does npt have a Certificate of Worker's Campensation Insurance. THE ATTACHED 5TATE WOI2KER'S COMPENSATION INSiTRANCE AFFIDAVIT MUST BE COMPLETF.D AND SIGNED, OR CERT. 4F INSURANCB ATTACHED�y� OR WORK.ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 'T'own of Yarmouth taxes and liens must be paid prior to renewal or issuance of your perrnits. PLEASE CHECK APPROP}tiATELY IF PAID: YES XX 1VC} MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limiYations ofMot�l or T3ote1 use,Transient oocupancy shall be lirnited to the temporary and shart term occupancy,ordinarily and customarily associated with mutel and hatel use. Transient occupants must have and be able to denzonstrafe that they maintain a principal place of residence elsewhere.Transient occupancy sha(!generally refer to continuous occupancy of not rnore than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a�uest unit as a residenoe or dwelling unit shall not be considered transient. Occupancy that is subject ta the collection af Raom Oecupancy Excise, as defined in M.G.L. c. 64G or$30 CMR 64Cr, as amended, shall geneeally be corssidered Transient. PQOLS Pt}OL 4PENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. Contact the Health DepartrnenY to schedule the inspection three (3) days prior to apening. PLEASE N4TI�: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. 1'OOL WATER 1'ESTING: The water must be tested for pseudomonas,tota!coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quartezly ther�after. Pt}OL CL4SING: Every outdoor in ground swimm3ng paol must be drained or covered within seven{7}days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENTN(�: All food service establishments must be inspected by the Health Department prior ta opening. Please contact the Health Deparkment to schedule the inspectian three(3) days prior to opening. CATERING P4LICY: Anyone who caters wrthin the Town of Yarmouth rnust notify the Yannouth Health Department by filing the required Temparary Food Service Appiicatian form 72 hours prior to the catered event. These forms can be obtained at the Health Lleparhnent,or from the Tawn's website at www,yarmouth.ma.us under Health 17epartment, Downloadable Forzns. FROZEN DESSERTS: Frozan desser[s must be tested by a State certified lab prior to apening and monthly thereafter,with sarnple results submitted to the Health DeparGnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit iantii the abcive terms have been met. flUTSII}E CAF'ES: Outside cafes(i.e.,autdaor seating with waiter/waitress service),must have prior appraval from the Board of Health. OUTllOOR COOKING: Outdoor cpolting,preparation,or display of any faod 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 RETURN THE COMPLETEI7 RENEWAL APPLICA'i`ION{S)AND REQUIREI}FF,E(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TQ ANY FOOD FSTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MUST BE REPORTF,D T4 AND APPROVED BY THE BC7r1R.T�O�HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SLT¢;PLAN. yT DATE; 11-18-14 STGNATLI : 1( ��r� ��(�ti,,G�,-j � PRINTIYAME &TITLE. M�r�er, Asst . Gontroller Rev. 11103tI4 ' t � The Commonwealth ofMassachusetts . Department of Industrial Accidents O�ce oflnvestigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Legiblv Business/OrganizationName: Blue Rock Club, Inc . Address: 39 Todd Road Clty/State/Zip: So .Yarmouth, MA oz664 PIlOriC#: SOR-39R-6967 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. ❑ RestauranUBazBating Establishment 2.❑ I am a sole proprietor or parmership 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 corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization, stafFed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other .SeysPnal resos t *Any applicant that checks box#1 must also fill out the sectioa below showing their workers'compensation policy information. *•If the cotpornte officers have exempted themselves,but the corporation has other employees,a workers'wmpensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Befow is the policy informntion. InsuranceCompanyName: Zurich American Ins . Co . Insurer'sAddress: see attached CiTy/State/Zip: Policy#or Self-ins. Lic. # W C 819 6 0 3 5 Expiration Date: 3-1-15 Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiratiou date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to $1,500.00 and/or one-year 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 Inves6gations of the DIA for insurance coverage verification. I do hereby certify,under the pqi�qs and penalties of perjury that the information provided above is true and correct. � Sienatur . ,� � ��"t-�� 'Z/��1� Date: 11-18-14 Phone#: 508-398-2293 Official use on[y. 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 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 DATE(MMIDDIYWY) • . 01/15/2014 • 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, EXTEN�D OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. � IMPORTANT: If the certificate holtler is an ADDITIONAL INSUf2ED, the policy(ies) must be endorsed. 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 certificate holtler in lieu ot such endorsement s . PROOUCER Phone:610-279-6550 NAMEACT The Atldis Group,Inc. Fax:610-279-8543 PHONE rax 2500 Renaissance Blvd.Ste 100 HIC No Ert: AIC No: King of Prussia, PA 19406-2772 � - E-M^i� . � Jeffrey A.Grebe nooaess: INSURER 5 AFFOR�ING COVERAGE NAIC p ir�suaeen:Zurich American Insurance Co. 16535 . INSURED DavenportRealty/ irusuReea: � Blue Rock Motor Inn � c/o Davenport Realty Trust � �NSURER C: Stephen Aschettino INSURER D: - � 20 North Main St. South Yarmouth,MA 02664 INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER: � REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 6ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD � INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OP ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS . � CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MP,Y HAVE BEEN REDUCED BY PAID CLAIMS. � � ��TR TYPEOFINSURNNCE �A I B POLICVNUMBER MMIDDVIY`/VV MM��/VVYV LIMITS GENERALl1AeILITY EACHOCCURRENCE �5 ��OOO�OO A. X COMMERCIALGENERALLIABILITV GL08196255 03I01/2014 03/01/20'IS pREMISES Eaoccurtence S $00�0� CL41MS-MADE O OCCUR MED E%P(An wie person) $ 1 O,OO � PERSONALBADVINJURV $ ��OOO�OOO � GENERALAGGREGATE $� Z�OOO�OOO GEN'LAGGREGATELIMRAPPLIESPER: PRODUCTS�COMP/OPAGG S Y,OOO,OOO X POLICY PR� LOC � S AUTOMOBILELIABIl1TY EasBcdeD`SINGLELIMIT $ ��OOO,OO A X nNvnuro BAP819fi256 � 03/01/2014 03I01/2015 eoouviwURv�Perparson) a � � ALLOWNE� � SCHEDULED BOOILYINJURY Pe�accitlent 8 AUTOS AUTOS � � ) X HIREDAUTOS J( � NON-OWNED PROPERTVDAMAGE $ NUTOS Peraccitlent i Comp s 25 UMBRELLALIPB� OCCUR � EqCHOCCURRENCE $ .EXCESS LIAB -CLAIMS-MADE � ' AGGREGATE $ � DED RETENTIONS � ' g WORKERSCOMPENSATION WCSTATU- OTH- ANO EMPLOYERS'IJABILITY X T R R � A ANYPROPRIETOR/PARTNERiE%ECIITiVEY�N WC8196035 O$/O'IIYO'I4 03/0112015 ELEACHACCIDENT $ 'I�OOO�OOO OFFICER/MEMBER EXCLUDEDi � N�A �MantlatoryinNH) E.L.DISEASE-EAEMPLOYEE 8 7�000�00 Ifyes,tlescnoeunaer � DESCRIPTION OF OPERATIONS Gelow I EL DISEASE-POLICV LIMIT 5 ��OOO�OO DESCRIPTION OP OPERATIONS/LOCATIONSI VEHICLES (HttacM1 ACORD 101,Atltlitional Remerks SCM1etlule,if more spece is repWretl) � CERTIFICATE HOLDER � CANCELLATION - � YARMO-0 � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCV PROVISIONS. Route 28 � South Yarmouth� MA OZBB4 � pUTHORIZEDREPRESENTATNE T�� . OO 1988-2010 ACORD CORPORATION. All rights reserved. ' ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD '