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Home My WebLink AboutApplication and WC � �� TOWN OF YARMOUTH BOARD OF� ` � APPLICATION FOR LICEN��[��1$1$T`y�2tl'1 �O� �� D . * Please complete form and attach all n��"'d�n�s by� �Q� Qp/j�009 Failure to do so will resuk in the ref�rn of your applicataon p ��M utr�• 'NAME OF ESTA$LISHMENT: Blue Rock Pro Shop TEL. # 508-398-6962 LOCATION ADDRESS: 48 Todd Road, South Yarmout , MAILINGADDRESS: 20 �rth Mttin Street , South Yarmouth, MA 02664 OWNER NAME: Daven on rt ealty TAX ID (FEIN or SSN): CORPORATION NAME (IF APPLICABLE): MAIVAGER'S NAME: Diane Kin man TEL. # ' - MAILING ADDRESS: 20 North Main Street, South Yarmout , MA 02� 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 certificarion to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commmrity Cardiopulmonary Resuscitation(CPR). Please list these employees 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. i. a. 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 Protecrion 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 Heahh Department will not use past years'records. You must provide new copies and maintain a file at your establishment. L . . ' j 2. PERSON IN CHARGE: - --- -- — - - _ _ EacI�food estabGsfiment must have at least one Person In Charge (PIC) on site during hours of operation. 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 all times. Please list yow enployees trained in anti-cholang procedures below and attach copies of employee certificarions 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQLTIItED FEE PERM[7'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI# _HBcB $55 _CABIN $55 _MOTEL S55 _INN $55 _C^.I� $5c _S:17.'�II.�Il^IGPOOL S86za _LODGE $55 _TRAILERPARK $105 _WI3IRLPOOL $SOea. FOOD SERVICE: UCENS$REQURiED FEE PERMIT# LICENSE REQUIItED F$E PERMIT# LICENSE REQUIItED FEE PERMIT# �P�100 SEATS 885 ��Q��Y_lS _CONTINENTAL S35 _NON-PROFIT S30 >100 SEATS St60 I COMMON VIC. S60 d-00 _WgOLESALE $80 REiA1L SERVICE: _RESID.KITCHEN 880 LICENSE REQiJIRED FEE PERMfT# LICENSE REQUIRED FEE PERM[T fi LIC£NSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 _>25,OOOsq.ft. 5225 _VENDING-FOOD 825 _QS,OOOsq.ft. � $80� � � _FROZENDESSER7 $40 _TOBACCO S55 NAME CHANGE: S15 AMOUNT DUE _ $ /'{S.00 ••""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•*"• T ... .. . . .... r .. ADMINISTRATION Under Chaptec.152, Section 25C, Sabsection 6,the Town of Yarmouth is now required to hold issuaace or renewal ` of any.lic�ense or perinit 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 V ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' Town of Yarmouth taxes and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELX IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHIVVII�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Iiotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of rassiidence 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 s'vf(6)momh period. Use of a guest unit as a residence or ' dwelling unit sha11 not be considered tzansient. 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 swunnung,wading and whirlpools which have been closed for the season must be m' sp� ' by the Health Departmentpnor to opening. Contact the Health Depazhnem to schedule the inspection tlu�ee(3)days pnor to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has baea inspected , and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totat coliform and staadard plate coum by a State certified tab, and submitted to the Heakh Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town ofYarmouth must notify the Yarmouth HealthDepartmentby Sling the required Temporary Food Service Application form 72 hours prior to the catered evern. These forms can be obtained at the Health Department. ' FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit wrtit 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 ofHealth. OUTDOOR COOI�NNG: _ Outdoor_�oking,_greparation,or dispiay of any food product by a retail or food service establishment isprohibited. _ � NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILYl1'TO RET'tJRN TI�COMPLETED RENEWAL APPLICATIOIV(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTFI PRIOR ', TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. ' DATE: ��/�/( Q � SIGNATURE i�QiLI� ��ti.ltil�c-�iL� PRINT NAME&TITLE: I�� u.l�/" i ev G9S5�. CGYZ-�YD l�� 0925/09 �\ The Commonwealth of Massachusdtr Department oflndustria[Accidents NBqN�1�tl11f 600 WashingTon Street, 7`"Floor Baston,Mass. 02111 Worlcers'Compessatioa Iasvance At6davk:Baildiog/PlembisglEleetrital Coutraetors • Anadea�t�tin: Please PRi[yT k�Alv oame: address: c� s1aM. . zin.. nhme N . . wodc site locatia�(full addressY. �� ❑�I�a homeowaer perfoxmiog all w�k myself. Projed Type: ❑New Cons4uction QRemodet ❑ I�a sole-�eopaiAor and have no oue wodcing in m�y�capxity. ❑B�rilding Addition �I am an�ployer�oviding waicas'compeasation fce my empbyees workiog�tltis job. . �.�..,o�: Blue Rock Club Pro Shop ,dm�,,. 4S Todd Road �.. South Yarmouth, MA 02664 ��; 508-398-6962 � Zurich American Ins : Co. WC8196024 '�`r r,�. : : ::_.R,sxa „ r...>�r.- rF�i3Y�'34i :a.e:a� ❑ I am a sote p[apriefor,gaersl eo�lraeter,or homeewwer(drde one)and�have hired�the cont�acWis fistod below who have the folbwing wakas'compeasation polices: - . wnonv�ane• -. ' . . � . . . _ � . . . . a_d_dttaf. . . - . . . � . . . . 'I19: � . . . - . . . . . . . . . ��t- . . ... . . . . � . . . l�aa�ae cw � . . . . -° ...m..g . � . . . . . . . . �_,f..'�c�: . -, . ... . .. _. _ . . ...a- . v:-p^- > .fK'S .:s5a* �i�l:'..��4.'2 �� •. •. ' . . . . . . . . - .. �O��Ol�' . .. . , - . . . . _ _ . . . . _ —_.. _ __. . _ . . _. ._. . ___ _ ._ _ _ _ _ __ ..--. __. . . � Fi�RCr1RfC - tl `n.,.._.�< �, : . �.•, A.' .;yF. u5' -..a'S`aa��'S �m$i.i3T'.. A .'�`.. f'�', n . ; ��5' . cNvaee rt9ibdv3celir2SAdMGL152n�WdqlYei�IMdui�IWpeWesdaLe�MSl,3N.MoY�f . e�e Yen'I�p6abt a wd n eM pcullln Is f1e��a S'1'Or WORIC ORDBR ud�6e dS1M.N a My apWt�e. 1�dqahW HN a tMy�[IWfWeaetmybehew�MdbNeOmeelL��f1YeDlALrp�lge�. � - . � � � - �lo seney x�e.alieprbu alveH+�r atar Nu iwfe�w.mbu proddel abaoe 8 aYe al o.n+rcc- . . � . , y � �[�t.c9 ,�� c�o a,r�� // — �/-D�i e�� Ctl- 1� �-ri � rn�a Sd$-3�J�-��S�i �Inewy da�efwtkeilWarnYhepo�efed6YdlYerMn.a�tid . . . . . . ay.raw.: pe�.tdro�s n�.n� pa��.k.�..xb,ry.�a �°.ua . aSdxlwYOem . _ 0�� i•ds�iam �s' � I ACORD_ CERTIFICATE OF LIABILITY INSURANCE OPID J onre�w.voorvrvn DAVEN-1 03 06 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGNTS UPON THE CERTIFICATE The AddiB Group, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2500 Renaissance Slvd. Ste 100 ALTER THE COVERAOE AFFORDED BYTHE POLICIES BELOW. Riag of Pruasia� YA 19406-2772 Phone: 610-279-8550 Fax:610-279-8543 INSURERSAFFORDIN�COVERAGE NNCA Nsuneo INSURERA: rwzie�n sarieh mnu�ne� Ce. �IOZ42 Daven rt Realty B�ue �ock Motor nn INSURQiB: g�u;p�iican Sa�ac�nc� �,. 16535 - c o Davanport Realty Truat INSURQiC: , S ePhen Aschettino 20 North Main St. INSURERD: South Yarmouth, MA 02664 ' INSUftER E: COVERAGES � THE POLICIES OF INSUMNCE LISTm BELOW HqVE BEEN ISSUED TO THE INSURm NAMED ABOVE FOR TNE POLICV PERIOD INDICATED.NOTWITHSTANDING ANY flE9UIqEMEM,TERM OR COPIDITION OF ANY CpMqqCT Ofl OTHER OOCUMENT W RH pESPECT 70 W HICX THIS CERTIFICATE MAY BE ISSUED Oq MAV PERTNIN,THE INSUflANCE AFFORDED 6V THE POLICIES DESCFIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOW N MHY HNVE BEEN REOUC�BV PAID CLAIMS LTR P TYPE OF NiSUqANCE POLICY NIAlBEP DATE GUDD/Y �ATE YM�00 �RS OENFAAL LIABIIJTY EACH OCCURRENCE S 1�OOO�OOO $ }[ COMMERCIALGENERALLIABILIT' GL08196255 03/Ol/09 �3��1�1� PqEMISESEaomurerce S$0�� CLAIMS AUDE X�OCCUR MED IXP(My ane pa�son) E 1 O�OOO reasor+n�snoviwui+v a1,000,000 GENEFUTAGGqEGATE S'j�QQQ�QQQ GENIAGGREGATELIMITAPPLIESPER: PpO0UCT5-COMP/OPAGG EY�OOO�OOO POLICY JECo-T �� pUT01A�8RE WB1I.ITY COMBINEO SINGLE LIMR g S OOO OOO B FNVAUI'0 BAP8196256 03/Ol/09 03/Ol/10 ��BLOdB1�� ' ' X ALLOWNEDAUf05 BOOLLVIWURY SCNEDULED AtlrOS (�Ve�s�) $ X HlqmAllTOS ' BODILVIWURY S X NOlIOWNEDAtlr0.S (�aWEeril) X 250 Comp pqOPERTYDANAGE X 500 Coll m•��q � E 6AflRGELIRBRRY AUTOONLV-EAACCI�EM E ANY RUTO O7HER7XAN EnACC S AUTOONLV: p�G S E%CESSNNBPELIALIpBILITY EACHOCCURRENCE S OCCUR �CLAIMS MhDE AGGREGA7E E a DmUCTIBLE S HEfENTION $ s WORKERS COIl�N5ATI0N AND X TONY LIMRS ER EIAPLOVEqS'11pBILRY A ANVPNOPHIEfOiVPARTNEiLD(ECUTIVE �C8196024 03/01/09 �3��1�1� E.L.EACHACCIDENT E1�QQQ��OQ OFFICERIMEMBEREXCLUDED7 ELDISEASE�EAEIAPLOYE SL OOO�OOO - . ttyes.Eescn6e untler � SPECNLPROVISIONSbelow E.LDISEASE-POLICVLIMIT EZ�OOO OOO OTHER DESCqIPipN OF OPEpATqNS/LOCpT10N$/VEHICLES/EXCLUSIONS AUDEO BY ENDOpSE1AENf/SVECWL PXOVISWNS CERTIFICATE HOLDER CANCELLATION Y�0_3 SNOULDANYOFTHEABOVEGESCpiBEDPOLIpESBECANCELLFDBEfOHETHEE%PdiRT10N DATETHEflEOi,THEI35UIN6WSURFAWGLENDEAVOIiTOGWL 3O DAYSWPRTEN TOfPIl of Yarmouth NOTICE TO THE CEfl71FICATE XOIDER NAYEU TO TXE LER,BUT FAILUHE TO DO SO SHALL ATTN: PeTllllt D9E1t.. MPOSE NO OBLIGATION Ofl LIABILRY OF ANY KIND UPON TXE INSUIIEIi,RS I1GENf8 Op Route 28 S. Yarmouth, FA 02664 REVRESENTA RUT ENTATI 4 ACORD 25(2001/OB) O ACORD CORPORATION 7988