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Home My WebLink AboutApplication and WC � ^' �� TOWN OF YARMOUTH BOARD OF HEALTH - � APPLICATION FOR LICENSE/PERMIT-2011 p�j �,� l, � ��' . * Please complete form and attach all necess documents 6'Dece er IS 2010. ' �'3' Y _fJ�f Failure to do so will result in the return of your application p e . � F� �- i ESTABLISHMENTNAME: Blue Rock Pro Shop LOCATION ADDRESS: 48 Todd Road, South Yarmouth TAXID' i TEL#508-398-6962 MAILING ADDRESS: _ 20 North Main Street, South Yarmouth MA 02664 OWNERNAME:,_ Davenport Realty CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Diane Kingman TEL.#:508-398-6962 MAILING ADDRESS: 20 North Main St. , South Yarmouth POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desienated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minnnum of two employees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use pxst years' records. You must provide ne�v copies and maintain a file at your place of business. 1. 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 cenification to this application. The Health Department will not use past}�ears'records. You must provide new copies and maintain a 61e at y�our establishment. i._ <��;.'� �rat#ti��S- �� .(t�ei�rf'trg � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heinilich Maneuver on the premises at all times. Please list your employees n•ained in anti-choking procedures below and attach copies of employee ceiYifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at vour place of business. 1. 2 3- 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&�IIT¢ LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIItED FEE PERiYIIT� _B&B S55 _CABIN 555 �407EL S55 _1NN S55 _CA:YIp S�i _S4�'I1bL�VIINGPOOL S80ea. _LODGE S55 _TRAiyERPARK SI05 _�4'HIRLpppL S80ea. FOOD SER�'ICE: LICENSE REQUIRED FEE PER*vIII'= LICENSE REQU[RED FEE PER\411"# LICENSE REQUIRED FEE PERNIII'ri �0-100 SEATS S85 (�'O�j�f _CONI'INENI'AL S35 NON-PROFII' S30 _>100 SEA'IS 5160 �COMMON VIG S60 I—O _R'HOLESALE S80 RE'I.11L SER\7CE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER�fII'# LICENSE REQUIRED FEE PER�fII'# LICENSE REQUIRED FEE PE&YIII'!k _<50 sq.R. 550 _>25,000 sq.R. 5225 VENDING-FOOD S25 _<25,OOOsq.R. S30 _FROZENDESSERT 540 I'OBACCO SS> �.��c�vcE: sis AMOUNT DUE _ $ (4�5. b0 "*"**PLEASE'ILR\�OVER A\D CO�IPLETE 07HER SIDE OF FOR�1*'*** � , , ADMINISTRATION • Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal , of any license or petmit 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� OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS � 'I'RANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Aotel 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 ofresidence 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 whirlpools which have been closed for the season must be inspected by the Health Depaztment prior to opening. Contact the Aealth Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area 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 Department three (3) days prior to opening, and quarterly thereafter. POOL CLO5ING: 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 inspecrion three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,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: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. _ __ _ _ - � NOTICE:Perntits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIliED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO CONIMENCEMENT. RENOVATIONS M EQUIRE A SIT PLAN. / / � DATE: l �/j—/C� SIGNATURE�- � �-�� PRINT NAME&TITLE: C L I'I CGr -e� 10 06 10 � I I r _ � i • ` The Cominonwea/th ofMassachuset[s Deparhnent of Indus[rio/Accidents I N/felN� +� 600 Washington Streel, 7`'�Floar I � Boston,Mass, p211/ � Worken'Compensatioa iroaraeee pffldavit; gaildiog/Plombiag/Electrical Contrae[ors I o�: � � add�ess: � � __--.—_—_--______..____.__-_—_----_.-.---_—_ sltY sptc ---__ — zio oho wark site lacation lfiill addiesyF LJ I am a homeowrer perfocmmg all work myself. Pro�ec[Type: �New Construction QRemadel ❑ I am a sole proprietor and have no one wodcing tn any capxity. �gw��g p��on �i [� I arn an employer pmviding workers'compensation for my employees working oa this job. � j .no ..a: Blue Rock Club Pro Sho ��.: 48 Todd Road �ia: South Yarmouth MA 02664 w,..�N 508 398 6962 �.. �o. Zurich American K ❑ [am a sole proprietor,ge�enl eo�tractor,or 6omeawner(.arck ou)and have hired the contracco�s listed below who�have the following workers'compensation polices: eomoaov�e..• add►esf• cth• oYose B iesvaeee to. M ad�ar eitv: o�e.s M ir n�rr.++r.■�i..cr.....i ° F�B�te o�scvs e�aec n�eqrrM�idv 9MM�2SA d MGL 132 eu kad b tle I�ptilY�d�d . . . . . °�Yti�+'ImPrYw�nt a wN n dH pemNb i�Hc fu��f a 3TOf WORK ORDBR ui a eee MSIO�.MP��e d�6e 7 0�i1.3M.M atlhr npy d N6 tta6eueu vy be ferw�rded 6s tse Odke dl�ef the DIA far ave'a�e verNutlN. Y iP�ee. 1 aedenh�d t4t a /fo her�eby nreFJy�wnder Me pinx and pe (eter oJyerjpry IArt fhe lwfenwm(on provlder ebope(t trre iwd cerrect s��'"„` c//T�'��'Z` l �-'�'� ?� �,K 11-19-2010 Pr��,a,a_ Mary Purrier (as aQent only) P�,K,y508-398-2293 et8c�1 ax oety do oa wrke Ia this�rn to be ooP��S�Y�4wn a9kW � . . dty ar tawn: P�Nmme p �Bnidh�e Dcpar�en[ ❑c6edc 1(ismcd�t req�eme is rtqd�ed �IJaea�Bwrd �`,�avnL(Msee nafatt penec QNnNY D�ar4�s1 l�..�u sqa zum� pse�e M �01Yv ' � .aCORo CERTIFICATE OF LIABILITY INSURANCE OPID EE DATE(MM1VDD/YYYY) DAVEN-1 03 02/10 PROOUCEP THIS CEFiTIFICATE IS ISSUED AS A MA7TER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE The Addis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2500 Renaissance Blvd. Ste 100 ALTER 7HE COVERAGE AFFORDED BV THE POLICIES BELOW. Kinq of Prussia PA 19906-2772 . Phone: 610-279-8550 Fax:610-279-8543 INSURERSAFFORDINGCOVERAGE NAIC# - . INSUNEU INSUREflA: mm�ican su:ieh xn.�:.�ca Co. 4�1A2 Davenport Realty/ Bl,ve Rock Motor Ynn INSURERB: iuzich wm�i�� :o,��„��, c,. 16535 � c/o Davenport Realty Trust w � Step hen Aschettino � iNsunEec 20 Forth Main SY.. INSURERD: South. Yarmouth, MA 02669 INSURER E: � COVERAGES � THE POLICIES OF INSURANCE LISTEP BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW RHSTANOING ANY REOUIREMEf�f�,TERM OF CONDITION OF ANY CONTRACT OR OTHER OOCUMENT W ITH RESPECT TO W HICH THIS CEqTIFICATE MAV BE ISSUED OH MAY PERTAIN,iHE INSURANCE AFFOflOED BV THE POLICIES OESCFIBED HEREIN IS SUflIECT TO ALL THE TERMS,EXCLUSIONS ANU CONDITIONS OF SI1CH POLIQES.AGGREGATE LIM11T5 SHpWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. LTP NSfl TYFEOFINSUHANCE POL�CYNUM9EN DATE M�.VDOIri PDATE MM/OD/YY LIMRS GENEHALLIABILRY EACHOCCIIRRENCE $ 1�OOO�OOO $ X COMMERCIFLGENERALLIABILITY GL08196255 �3�01�1� �3��.�11 PREMISES�Eaoavrenca) 85�0��00 � CLAIMSMAOE �OCCUR MEDE%P(Myoneperson) $SO�OOO j PERSONALBADVIWUPV SZ�OOO�OOO GENERALAGGREGFTE E Z�OOO�OOO GEN'LAGGREGATELIMRAPPIIESPER: PRODUCTS-COMP/OPFGG $Z�OOO�OOO POLICV PPP L� JECT � AUTOMOBILELIABILITY COMBINEDSINGLELIMIT y1�OOO�OOO � B ANVFUTO BAP8196256 03/Ol/10 03/Ol/11 jEaacade1tj i � X ALLOWNEDAl1T05 I BODILVIWURV $ SCHEOULED AUTOS �P��"'O�) I X HIREDAUTOS BODILV INJIIRY E X NON-OWNEDAIf�05 (Peraccitlenp X 2$� CORIjJ PROVERTVUAMFGE a i X .$�0 CO11 (Peracciden�� GAqAGELIABIIRY AUTOONLV-EAACCIDENT $ FNVAlITO EAACC E i OTHERTHAN AIJrOONLV: qGG $ E%CESS/UMBFELLA LIABILRY EACH OCCUBRENCE $ OCCUR � ClAIMS MAOE HGGflEGATE $ $ �FDUCiIBLE 5 REfEMION $ E WORKEHSCOMVENSATIONAND X Tpqy�IM1T5 ER A EMPLOVENS'LWBILIIY WC8196029 03/Ol/10 �3�01�11 E.L.EACHACCIDEM 51 �00 0�� ANYPROPqIETOM'AflTNEFIEXECUTIVE � � � OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1�OOO�OOO SPECIALSPROVISIONSbelow � E.LDISEASE-POLICVIIMIT $Z�OOO�OOO OTHEH DESCPIPTION OF OPEPATIOfiS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENOORSEMENf/SPECUIL PflOVI310N5 CERTIFICATE HOLDER CANCELLATION YARMO—O SHOULUANYOFTHEABOVEDESCHIBEOPOLICIESBECANCELLEDBEFOflETHEE%PIRATION UATETHEPEOF,THEISSUMGINSURFRWILLENDEAVORTOMAIL 3� DqYSWHATEN NOTICE TO THE CEATIFICATE HOLDEfl NAMEU TO THE LEFT,BUT FAILUNE 70 DO SO SNALL TOIPIl of Yarmouth IMPOSENOOBLIGATIONOflLIA81LRYOFANYKWOUPONTHEINSUHEfl,RSAGENf50H Route 28 South Yarmouth MA 02664 HEPNESENrATIVES. auni serranv 4 ACORD 25(2001/08) m ACORD CORPORATION 1988 �� OP ID: EE ACOR�s OATE(MMIOD/YYYY) '�� CERTIFICATE OF LIABILITY INSURANCE o,nan, 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 CERTIFICA7E OF INSURANCE DOES NOT CON3TITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED j REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. � IMPORTANT: If the certifleate holder is an ADDITIONAL INSURED,Me poliey(ies)must be endo�sed. If SUBROGATION IS WAIVED,subject to � the terms and conditlais of the policy,certain policies may require an endorsement A sUtement on this eerfifiwte does not confer righls to the � certiftwte holder in lieu of such endorsemen a. � �� 670-279�550 N�ECT The Addis Group,inc. 610-279-8543 PNONE �a�c Na: 2500 Renaissance Blvd.Ste 100 E.� � King of Prussia,PA 19406-2772 P��R i Jeffrey A Grebe c DAVEN-7 INSURE S AFFORpNG COVERIIGE NpIC� i IN&IRED DavenpoR Really Trust �Nsun�re�:American Zurich Insurence Co. 40742 I dba Blue Rock Golf Course wsurtEne:Zurich American Insurance Co. 16535 Stephen AschetNno ix��. 20 NorUi Main St i South YarmouM„MA 02664 ixsunerto: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CWMS. . � L� TYPE OF INBURANCE POLIGY EFf POLICY EXP POLICYNUNBER MMN M lJMR3 � ��WB�TM EACHOCCURRENCE E ��OOO� B X COMMERCIALGENERALLIABI�RY L08196255 0�/0�/�� 03/��/�2 pREMI S Eao¢urterre S $��.�� CLAIMS�MAOE � OCCUR MEDEXP(M oneperaon) f �O. � PERSONALSAUVIWURV S �.UOO�UO GENERALAGGREGATE S Y�OOO� GEMIAGGREGATELIMRAPPLIESPER PRODUCTS-COMP/OPAGG S ��OOO�OO POLICY . PR0. �� f AUTOYOBILEIU&LffY C01.�INEDSINGLELAAR s ��OOO�OO B ,wrnuro BAP8796256 03/OtH2 O3/ot/12 �E'�� BODILY INJIIRV(Per perwn) $ X ALLOWNEDAUTOS 80DILY INJURV(Per aa�ltlenl) f SCHEDULEDAUTOS X HIREOAIROS PROPER7VDAMAGE f . (Per aotidern) X NON-0WNEDAUTOS f X 2b0 Comp s UNBRELLA W1B ��R , EACH OCCURRENCE S EXCE88 WB CLAIMS�MqDE AGGREGI1iE E OEDUCTIBLE Y RETENrION E _ WORKERS COMPEN&11fON VJC STATU- 07H- AND EMVLOYERS'WBWTY X A ANYPROPRIETORiPMTNERIE%ECUTIVE Y�N C$'I!IGOY4 O$/OI/'I'I 03/O'IMY E.LEACHACCIOENT f 'I.00O�OO OFfICERMEMBEREXCWDE09 � N/A (MnM�bryinNH� � E.LDISEASE-EAEMPLOYE f ��OOO�OO rcy�msa�e uM�r DESCRIPTIONOFOPEPAilONSDeIav E.LDISEASE-POLICV�IMR S ��OOO.00 UEBCPoPTION OF pPEpq7pN3/LOCA710NS l VEHICLES(AR�c�ACORD 107.AAMtlon�l Ramrtb SCMEu4.M mae ap�es b�pukeE) .. . . . ' JAN 2 4 2 011 CERTIFICATEHOLDER CANCELLATION ��- �� `��--� � �"�-�- ' YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANCELLED BEFORE TOWII Of Y2�fIlODU1 TME EXPIRATION OATE THEREOF, NOTICE WILL BE DELNERED IN Route 28 NCCORDANCE NIITH THE POLICY PROVISIONS. South Yartnoufh,MA 02664 ,wTMo��xrnmre T�� 1888-2009 ACORD CORPORATION. All righffi reserved. ACORD 25(2009/09) The ACORD name and logo are regiatered marks of ACORD