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Home My WebLink AboutApplication and WCI ' ' d TOWN OF YARMOUTH BOARD OF HEALTH ��5� P � APPLICATION FOR LICENS /PERN�IT q-2014 nr, �� ' ` * Please complete form and attach a�Lne��d��htsP by D cem��r 13'�I� Failure to do so will result in the return of your applicatio pa�TM� ESTABLISHMENTNAME: Blue Rock Pro Sho� TAXID: LOCATIONADDRESS: 48 Todd Road, South Yarmouth TEL.#: 508-398-6962 MAILINGADDRESS: 20 North Main St. , South Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNERNAME: Davenport 1�ealty CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Ryan 0'Loughlin TEL.#:508-398-6962 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 Operatar(s)and attach a copy of the certification to this form. L 2. Pool operators must list a minimuxn of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a116mes. 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. l. 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 establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one fixll-time employee who has Allergen certificaUon, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of ' certificadon to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your estab6shment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee 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 Deparhnent 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# � B&B $55 CABIN $55 MOTEL $55 —�NN $55 CAMP $55 SWIMMING POOL $80ea LODGE S55 TRAILERPARK $105 WHIRLPOOL $80ea FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# I 0-100 SEATS $85 �4-oe°i _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $(60 �COMMON VIC. $60 #Ft4-CGfr WHOLESALE $SO . —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. $225 VENDING-FOOD $25 � =<25,000 sq.ft. $80 =FROZEN DESSERT $40 _TOBACCO $95 � NAME CHANGE: $15 AMOUNT DUE _ $ {�5.Q G *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***'* ! ADMINISTRATION ` x � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient 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 of not more than thirty(30)days,and an aggregate of ' not more than ninety(90)days within any six(6)month period. Use of a guest unit 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. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ' POOLS POOL OPENING:All swimming,wading and wlurlpools which have been closed for the season must be inspected by ', the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Depar[ment three (3) days prior to opening, and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE ' SEASONAL FOOD SERVICE OPENING: All food service establishments 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: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required ' Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departxnent, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: I Outside cafes (i.e., outdoor seating with waiter/waitress service),must have priar approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT I5 YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 13, 2013. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT PLAN. DATE: 11-1-13 SIGNA L ��(-/�1.C.1/L-� PRINTNAME&TITLE: Mary Purrier , Assistant Controller Rev. 10/08/13 � The Commonwealth ofMassachusetts Department of Industrial Accidents O�ce of Investigations 1 Congress Street, Suite l00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/OrganizationName: Blue Rock Pro Shop Address: 48 Todd Road ,I City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-6962 i Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with employees(fuil and/ 5. ❑ Retail � or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment 2.❑ I am a sole proprietor or parmership and have no 7, � pffce 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 o�cers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workecs' 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 Pro Shon *Any applicant that checks box#1 must also 811 out the section below showing the'v workers'compensa[ion policy infocmation. **If[he coipolate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is reqniied and such an organization should check box#I. � � � �� - I am an emp[oyer that isproviding workers'compensation insurance for my employees. Below is thepolicy information. InsuranceCompanyName: Zurich American Ins . Co . Insurer'sAddress: see attaehed City/State/Zip: Policy#or Self-ins.Lic. # WC 819 6035 Expiration Date: 3-1-14 Attach a copy of t6e workers' compensafion policy declaration page(showing the policy number and expiration 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 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 fonvazded to the Office of Investigations of the DIA for inswance coverage verificarion. I do hereby c ify,under the p 'ns andpenalties ofperjury that the information provided above is true and correct. Si ature: � � �/'�Gl Date: 11-1-13 Phone#: 508-39 -2293 O�cial use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: ��(/�p�� Permit/License# I circle one): 1.Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. er Contact Person: Phone#: 5�B-39B-��3 I X �Z-yl ' www.mass.gov/dia ; �. �,/� OP ID: KD � '`�`�R�T CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDIYVYY) 02/28/13 THIS CERTIFICATE IS ISSl1ED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTiFICATE DOES NOT AFFIRMATIVELY OR NEGAl7VELY AMEND, EXTEN� 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 INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions ot the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the � certifica[e holder in lieu of such endorsement s�. . PRODUCER CONTNCT PIlOf12:G�O-�L79-HSSO NAME: 7he Addis Group,Inc. Fax:610-279-8543 PHONE Fnx . 2500 Renaissance Blvd.Ste 100 o ac No: King of Prussia,PA 19406-2772 EiAAIL Jeffrey A Grebe PRooucEic � c T enea ox:DAVEN-1 INSURERS AFFORDINGCOVERAGE NAICp �. INSUREO Davenport Realty/ wsunenn:American Zurich Insurance Co. 40142 Blue Rock Motor Inn �Nsunea e:Zurich American Insurance Co. 16535 . clo Davenport Realty Trust Stephen Aschettino INSURER C: 20 North Main St. u+suneRo: �, South Yarmouth„ MA 02664 WSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEM WRH 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 POLIGES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypEOFINSURANCE SUB POLICYEFF POIICYEXP LTR POLICYNUMBER MM/DDIYVYY MMIDDIYYri ��M� GENERALLIABILITY � EACHOCCURRENCE S ��OOO�OOO B X COMMERCIAIGENERALLIABILITY GL08796255 03IO1N3 O3IO'II'I4 pREMI5E5 Eaoaurrenre E SOO�OO CIAIMS-MADE �OCCUR MED EXP(Arry orie person) 8 '1�00 PERSONALBA�VINJURY E ��OOO�OO GENERALAGGREGATE � S ?�OOO�OO GEN'IAGGREGATELIMITAPPLiESPER: PROWCTS-COMP/OPAGG S ?�OOO�OOO X PO4CY PRa LOC E nUTOMOBILEIIa&LITY - COMBWEDSINGLELIMIT S 'I�OOO�000 B qHvquio BAP8196256 03/01l13 03/O7/14 (Eaamdent) � BODILYINJURY(Pe�persan) b X ALLOWNE�nIfr05 BODILVINJURV(Pereaitlenq S SCHEDL/LEDAUTOS - PROPERTYDAMAGE � X HIREDAlJrOS (Peracciden�) E X NON-OWNEDAUTOS $ X 250 Comp s UMBRELLALIAB OCCUR EACHOCCURRENCE S EXCESSIJHB CLAIM$-MADE AGGREGATE E DEDUCTIBLE E REfENT10N S � E WORKERSCOMPENSAl10N � X WCSTATU- OTH- ANO EMPLOYERS'LIABILITY A ANYPROPRIEfORiPARTNER/EXELUTIVE y�N WCS�9BO3S O$/O1H3 OSIO'IN4 E.L.EACHACCIDENT S 'I�OOO�DO OFFICEWMEMBEREXCWDED9 � N�A (MantlatorylnNH) E.L.DISEASE-FAEMPLOVEE E 1,000,000 If yes,tlescnbeuiMer DESCRIPTION OF OPERATIONS Oelow E.L.DISEASE-POUCV LIMIT E 'I�OOO�OOO DESCRIPTION OF OPEMTON51 LOCA110NS I VEHICLES (Ptbch ACORD 101,Atltlitlanal Remarks Schatlule,H mort epace is rcqulrctl) CERTIFICATE HOLDER CANCELLATION YARMO-0 � � - - SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth � rHe EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERE� IN ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth, MA 02664 qUTHORI2ED REPRESENTATNE T�� OO 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD