HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 I !'
� � �. P g4� 5 � � dr� �
TOWN OF YARMOUTH BOARD OF�A'i.1"�
�� ' APPLICATTONFORLICENSE/PERMIT-`2UD9 � �J, NOV 1 7 2008
...• , r:.. .
* Please complete form and attach all necessary documents by ecember 1
Failure to do so will result in the retum of your applicahon pac . �H DEPT.
NAME OF ESTABLISHMENT: S TEL. #S7� -�5k•(��1a�
' LOCATION ADDRESS � p
� MAILING ADD S: YVl (q �
OWNER NAME: U� TAX ID FEIN r SSN : -
CORPORATION NAME (IF PLIC LE):
MANAGER'S NAME: � Z TEL. # SZXr-3`J SC'L5 G a
MAILING ADDRESS:
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. 2.
Pool operatars must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Caz•diopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a fite 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 tlus application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
� �{ ���?��,r�t� �. d�1!��1!a:� 2.
i
PERSON IN CHARGE:
Each food establishment 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 Hennlich
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 foim. 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
LODGIDiG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE PERMII'# LICENSE REQUIItED FEE PERNIIT r�
_B&B S55 _CABIN S55 MOTEL S55
_INN SSi _CAMP S55 _SWA4NIINGPOOL SSOea.
_LODGE S55 _TRAILER PARK 5105 WfiIRLPOOL 580ea.
� FOOD SERVICE:
LICENSE REQi7IRED FEE PERMff# ACENSE REQUIItED £EE PERMI'I# LICENSE REQIIIItED FEE PERbIIT#
�0-1005EATS S85 JF -b� _CONI-INEN'IAL S35 NON-PROFTL S30
_>100SEATS 5160 / COMMONVIC. 360 1kOq-o13 _WHOLESALE 580
RETAIL SERVICE: —RESID.K71'CH&N 580
LICENSE REQiTIRED FEE PERMIT i? LICENSE REQU[RED FEE PERM[T# LICENSE REQUIRED FEE PERMI'I#
_<SOsq.B. $SO _>25,OOOsq.ft. S225 VENDING-FOOD S25
a25,000 sq.ft. S80 _FROZEN DESSERT S40 IOBACCO 555
�a�cfrnvcE: sio AMOUNT DUE _ $ /y5 .00
•*"'*PLEASE TUR.\i OVER.4i�D CO,'VIPLETE OTAER SIDE OF FORM*****
. , �,
ADNIINISTRATTON ' -
Under Chapter 152, Section ZSC, Subsection 6,the Town of Yazmouth 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
AFFIDAVTI'MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: 1 �
YES V NO
MOTELS AND OTHER LODGING ESTABLIS�NTS
TRANSIENT OCCUPANCl': For purposes of the lixnitations ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transiem occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy sha11 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'vc(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 ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days
pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area urnil 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, prior to opemng, 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 of Yazmouth must notify the Yannouth Health Deparhnent by filing the required
Temporary Food Service Application form 72 hours prior to the catered evern. These forms can be obtained at the
Health Depattmetrt.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuks must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemiit 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 ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited.
NOTTCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RETiJRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER I5, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIIVTING, NEW
EQUIPMENT, ETC.),MUST BE REPOR'IBD TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: ��— �'� � SIGNAT Q�C(i/ �(�� �
PRINT NAME&TITLE: {� r Y�1 � , l� 1 , �� � ��
io�z�%os
l `. . �� \ The Commonweahh ofMassachusetts
Deparbnent of Iadustrial Accidents
M�CI N�
600 R'ashington Street, �'Floor
', Boston,Mass. 02111
Worlcers'Compeesatioe I�seraaee A��vk:Baildiog/plumbing/Ek�yrica�Cootractors
Aealk�t�Uw: p'�e pRIN1'�
I
� name:
i ac4hess: � . .
i siri � state� zio... ohace#
work siM location(full add'essY ' .
� ❑ I am a m�wner perfom�mg all w�k myself. Project Type: ❑New Coostructi�QRemodel
i ❑ I a sole�proprietor and have no one working in anY��P�<<Y• ❑Build'mg Addition
am an�ployer providing workeas'compensati�Tor my employees w on this job.
com - rme: � . .
� ��' � �. dQC�� � . . . . . .
�: � T YYl()�l�'I� �(���� �u C7)c� �St�—� S(o�--
�. �P,r c ,� � �
�. �,�. , � � , � �A.� _��_-,�.
❑ I am a sole propiietor,gweral rneh'seMr,or hameowaer(rirele oue)and have hired H�e conhac[as listed below wlp have
the following wotkeis'compeaSaGon polices:
eomoYv�ane. . . � . . .. . .
ad�r - . � � . . .
Id� . � . � oAereA . . . . . � . .
ie�ea�oe ew � . �d(c'M
� .. . „ _.. . _ . . . r4"""� .._�e�,`:
� enemv u�e-
i �
d�9'. ., . : . . � . . � - ��, - � .
��i . . . . . . . �
�� � � - �die� t
r a�..� , �,.f ... � x�<�t _x .
FaYveOs vea[e emrate��ye/odc9atla�2SAKMGL152euledbNel�palWKalNWpnaNfn��me�pbfl,3N.Nanyer��.
. �Yan'��s�nw�9ndHpenMbielYeforne[aS10rWORKORDERuAt�eKfIB4Nadaya�t�e, laednah�dthta
npy�NhrtatmermybefxwarGWM1AeO�sdlw�NlheDlAtarewmgever�ytlse, � . . . .
/do herrb cer6fy xnder Me petns awd penelNer ofPesjyrY Mid dYe Isfeiwdlon providal eboae h�rne a�Aonrrect .
S�B°alum � // �'_Q�
Printnmie / /�Y � Pho�#_ �UO —3�d�a�I � � . .
oeBdN ose.wy ao ow..rke w thi,,.n M a�moplefN bs.dty.r Nw..mdal . �
eilyar[eiro: . . � P��A flReiM..p�t
❑chMt Nismc8�6e�me b rcqaMM � . � . �Board
. � OSdectseo't O�ae .
oahetpe'Ma: P��: �Rpr�[
t�.+.ce s�.mm�
ORD_ CERTIFICATE OE LIABILITY (NSURANCE oPro P °"�"w°°^� �
reon4c� � DAv�T7-1 02 24 08
� THIS CERTiF�ATE f31S3UED AS A MATTER pP INFORMqTIpN . i
ONLYAND CONFERg NO PoGHTS UPON THE CERTIFlCATE �
, i'he Addia Croup, Ia�, � HOLDER.THIS CERTIFICATE DOE3 NOT AMEprD,EXTEND OR �
�2500 RQnaa.ssaace Blvfl. Ste 100 � � ALTERTHECOVERAGEAFFORpEpBYTFFEPOl1C�SBELOW.
ICinq of Pruasi.a pA 1940fi-2772 �
� Phoae: 610-279-8550 Faa:610-27g-g543 �ptgpRERgpFppRpgdpCpyERqGE
j �� . � NAIC$
� � Davea rt Realtp/ � x+su�n�n �m,c�m se.ez.,.�eo. 46142'
B� �oek Motor �na wa�qete: s,+�a�n,,..n�x�„s.,K.m. 16535
� � c o Davenport geait�. Trust
� � 3 heu Asehettino ustmma �
20 orth Main St.
3onth YB*+��..�. �p, 02664 ��tr
. COVERAGES ��E
. � IHEFOUGESOFNSUR.AtICELfSTL-086.OWFNVEBEEN18St1EDTOlMEWS[AtEDNMEDABOVEFOR7lEPOLICYPQt10DWOICATID.N07WlfHS7M1DWCa
OU �
,' N71'I�QI161BdENT.TEFMORCOPID(f10NOFANYCAMiNCTOR.O'RERWCUBlfWIRiftESPECTTOWFI�ITlBSCEFtiFICATENRVBEBSUmIXt ;
�. ANYPERTAN,T£Pl$URhNCEPFWRDmBY'IFEPW.ICIESOESCR�EDlHtEB718Sc�JECTTOALLTHE7ERMS.EXCLLlSqNSMIDWND(TIONS�SUCx
i �POLICES AGGREGATE LNRS SNOWN MAY WIVE BEEA1 R�IICW BV PAID CLANR. .
LTt TYPE�WSURIWGE FOLICYNURIBEft OR7E
1 c+�"eR"�w�eu'Y uwra
$ $ �aE�i�m, �+��+� el 000 000
G7A8196255 03/01/08 03/O1/09 r�r.�s ,m�e„o. s500 000
� �� ��� . "��Wn�ewsoN t10,000 . '
P�+��+' s 1 000 000 �
j aErn.a�cn�uxrarx�svea
������ a2 OOO� OOD j
�- --- --.--- —___—_. ._ _- _ rRooucrs-cor�ncc_ a2. 000 000---;
-- — �er-- — toe -
aurorom.eweartr j
B �'4VTO BAP8196256 03/Ol/08 03/01/09 �'�1��E� s1,000,000
% xiowrrmnuros
� . BODLYAUURy �
i � SCFEDUIDAvfOS (per�) E . I
R �WN-OWIl�RIITOS �0-�� $ {
g 25� � �
;
R 500 CoZi ��� s
Wsrs�uneenr .
� - � AUTOOIdV-EAACp�ENf S i
ANYAUTO . EN
� pTy1tR7,{11p FAK;C E � j
I AUT001AY: AGG S
EXCE98NI�X91A{J�LI7Y I
��� �C1AG78IdRDE � �H��E s �
aGGREGATE S
DWl1CTIBLE � _
. �RE7aT10H = � - _
� M�ORK9lSCOIPEn34'�ONAlA - S
01PLOYER3'lJA9Ll7Y $ '
' � unaRorRerowa�� 9PC8196024 03/O1J06 03/Ol/09 €.��nccm�r � �
o�c�ntxauoem t l 000 000 �
rtv
s"�ua�iifd�ioruem�. E�o�.E"�- s1,000 000 I
on�ae E�as�nsE_roucr�marr si 000,000 '
f
�t oF overtnimNs��oc�tioxs rv��oazus�oNs nonm sr a�rExri sp�a.weowaor�s
�
, �
i
CERTIFICATE HOLDEit � �C����
� y��'j SHOULDANYOFTXEABOVEDESCItleEDPOUtlESeECANC�LEDBEFORETHEEmIR0.
Towa of Ya=mcuth °A��OF•T�����+`�u�oeawnrornR 30 a,���
ATTN: Permit Dept. rooncerolxecve�cnx�xoeo�tw�amroTxE�a�r.evrFaw�r000sos�wu. �
Routa 28 . nnrosexoom.�caTroworsuneiun�nxraxnuroxrxewsu�RrcsncExrsoR �
S. Yarmouth, NA 02664 pEP�sEM.arn xrs
auni �A '
4
ACORD 25{2067/p6)
� �ACARpCORPORpTI0N1988
i TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-023 FEE: $85.00
In accordance wit6 reg�atious promulgated under authority of Chapter 94,Section 305A and Chapter
II 11,Section 5 of the�ieneral Laws,a permit is hereby granted[o:
I Davenport Realty, 48 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Club Pro Shon
Type of business: Food Service
iTo operate a food estabtishment in: Town of Yarmouth
i Permit expires: December 31. 2009 BOARD OF HEALTH: .�fe�elt Sl�ah. ./�..N., �ai+�nran
' (.1faAcP.ee .`�. JkeGfi�ic.e U'fatxenaa
xFs[[t[cnoxs: Packaged chips,candy,chewing gum only. ./ZO6PIIft S,,�KO[(tft�
� Qlql��C¢¢H�A{[f/F�../V.
i £aefyn 9. ,�Eayeo
�
Novemberl9.2008
Bruce G.Murphy, ,R.S.,CHO
Director of Health
.�, _ . ._. ___.��--------
--
THE COMNiONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTA
PERMTI'NUMBER: #09-013 FEE: $60.00
This is to Certify that Davenvort Realri d/b/a Blue Rcek Club Pro Shon
48 Todd Road, South Yarmouth, MA
IS HEREBY GRANIED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless
sooner suspended or revoked for violation of the laws of the Commonwealthrespecting the
liceasing of common victuallers. This licease is issued in confomuty with the authority granted to
the licensmg authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereo� the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .�Eelwi SAalF .`f2,.rV., CIEai�rnwrt
U'faxlee .�E. �JCe[[ilFex �Jice U'iainnean
✓?a�rt .�. � n, (.jexk
���i6aum.. �J2..Ar-
November 19.2(108
Bmce G.Miuphy, , .S.,CHO
Director of Health
� " � l3wERaacCwB P,eo �'�oP
r�A��^ TOWN OF YARMOUTH BOARp OF HEALTH
S APPLICATION FOR IdGE1�IS�/FEBMTI'-20 �j12 /
� � s � �,;�����"
� *Please complete form and attach all necessary docum ts by December 31, 2007.
Failure to do so will result in the retum of your application packet.
� NAME OF ESTABLISHMENT: l,l e C �j S}`-�- TEL. # SU�f-3Sfl- (�i��
� LOCATION ADDRESS: , �
1 MAILING ADDRES : �� IU , I'`� � a mU� � r 4C1 oa���
I OWNER NAME: � �'� 0 �c r N -
i CORPORATION NAME (IF APPLICABLE):
' MANAGER'S NAME: P b'1 � > � I Z Z i v1 G� TEL. # C0�-�j�-(o i G�
' MAILING ADDRESS: a O N C) � V�-(Cl l� C t d U Q{�I'1't U�2 � � Yh I�d D�l���/
' POOL CERTIFICATIpNS:
' T6e pool supervisor must be certitied as a Pool Operator,as required by�State law. Please list the designated
i Pool Operator(s) and attach a copy of the certification to tlris form.
�
i 1 2
jPool operators must list a minimum of two employees currently certiSed in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please Gst these employees below and attach copies of employee
� eertifications to tlris form. The Health Depert�aent wi0 not use past years' records. 1'ou must provide nen�
copies and maintaiu a fde at your place of business.
I- 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. 'i'he Health Departmept wiFl not use past years'records.
You must provide new copies and maintain a 51e at your establishment.
I. 2,
� PE�tS9N�N��AI�GE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operarion.
1. Z.
HEIMLICH CERTIFICATIONS:
All food service establishcnents 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-chokuig proced'ures below and
I attach copies of employee certifications to tlus form. The Health Department will uot use past years' records.
iYou must provide new copies and maintain a Tile at your place of business.
, �, 2
3. 4.
� RESTAURANT SEATING: TOTAL #
OFFICE USE 011iLY
LODGING:
LICENSE REQUIRF,D FEE PER49T� LICENSE REQUIRED FEE PERbIII # LICENSE REQL7RED FEE PER'KIT=
_B&B S50 _CABIN S50 MOTEL SSO
_INN 550 � � _CAMP S50� - -� _SR'[�I.�4ING POOL S75ea.
_LODGE SSO _7RAILERPARK S10q R7-IIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT i� L3CENSE REQUIRED FEE P£R�417= LICENSE REQtiIRED FEE PER�fIT�
I 0.10(1 SEATS S75 �'(�,� �_CONTRVENTAL S30 NOF-PROFII S25
_>100SEATS 5150 I CO;bLYIONVIC. S50 �<1R—n4C` _µ1-IOLESALE S7i
RETAQ.SERVICE: —REStD.KITCHEN S7i
LICENSE REQUIRED FEE PERMIT= LICENSE REQUIRED FEE PER�SIT= LICENSE REQL7RED FEE PERbII?r
_<50 sq.ft. 545 _>25,000 sq.ft. 5200 VENDING-FOOD S20
_<25,000 sq.it. S75 _FROZEN DESSERT S3i TOBACCO S50
vn_�c�vcE: sio AMOUNT DUE _ $ /2S.o0
*****PLEASE TL'RY OVER?i.\'D CO�iPLETE OTHER SIDE OF FOR�i*"*�^
� ,
ADNIINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now reqwred 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
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of yow pernrits. PLEASE CHECK
APPROPRiATELY IF PAID:
YES �/ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCC[JPANCY: For purposes ofthe 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 princapal place ofresidence elsewheoe.
Transient occupancy shall generally refer to continuous occupancy of not more than thirry (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
dwel6ng unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. a 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
* NOTE: En�tosea Motel Census must be completed and returned w�c�tnis app�icarion.
rooLs
POOL OPENING:All swimming,wading and whidpools which have bcen closed for the sea.son must be' ,
by the Heakh Department prior to opening. Contact the Health Department to schedule the inspection five( days
prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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 of Yarmouth must notify the Yarmouth Health Depaivnent by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. 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 sem to the Health
Department. Failure to do so will result in the suspens�on or revocarion of your Frozen Dessert Pernut 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 ofHealth.
OUTDOOR COOKING: '
_ _� ' , ' piay o€a�€ood produet by a retail or food servi .- —
NOTICE:Permits run aruivally from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
Tf�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISFIlvIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMME�ICEME?IT. REVOVATIO�IS MAY REQUIRE A SITE PLAN.
�arE: / /-/ y-G�7 siGv.aruxE:� Gc-u� 1���,u��� _ Ou� Cc C,�irZ� ���
PRINT�IAME&'IITLE: Cif��9 ` `-� ���1 �7� , !✓�SSf. L�� ��� _
1a?o m
i . ,
' �\ �'!ie Comnronwealth ofMassackusetls
� Depardnent of Industrial Accidents
� NfpM�
600 Waskingtoa Street, 7`"F[oor
Boston,Mass. 011ll
I wu.te.s°compe.satiu■I.seaAee.A�a.vA:soilai�q;/e�.mni■g/Eiectricat cu■hacrors
� � ifu: �tle�w PRIH}T ludhh . ..
� name:
�I add�eys. .
i
� s�te� zio� q_h.rw#
work siM location(full addmssl: �
❑ I am a homeowra perfocming all woik myseif. Project Type: ❑New Cam.stcuctiuo QR�odel
❑ j�am a sole pin�ietor and have no one working in�y capacity. ❑Building Addition
� � I am an employer providing woikeis'com'p/eesation far my�ployces wodcing on this job. .
cemoavme: � il.l� y`�it-1� i� ��t.YJ �V`Zi �-Lf�.� .
d a �
�: �r) �� � G����a���`� l�Y�-� a�-��°i�r• �� - 3� b'- C9 5 l�a-
L���e c� �l l V�1 C,��1 � VYt i��^i C CLYZ ��� C��e W �i'�1 LoOa'��
.. . . . , . .,.,�,�,�wa, .. �._
❑ I mn a sole proprietoy gwad ea�tracter,or Yomeow�er(circle owe)and have buad the co�[actus lis[ed below w1n have
the following wa�k�s'compensation polices:
��ev me:
ad�ess:
e1h' �p'
i�ava�ce ca osllev N
. , . . . . .�. ,__.__�
.. .. . . . . . . . . .. . . . . . .. .. . .. . . . . . .. ,,.,:, > �;
�r�e•
+�d[�-
�' �.S 9-
-_._ _ inva�cea. -_ . . . . _- � -- — - -. _. � . . .._ _
��. .. . . . '2l�.�,. -� - --
Fdhre r axus e�v�e a rcq�6ed odv Satlr 2SA d 1MGL 132 m Isd M IYe I�prlir dai�ial paWe d a me t*!�Z1,SKM adhr..,
••�m�'dr�.�n.�a..a.r�m uev�..ra sror wowc ono�a m.e�.tueu�.a.y.6.me.�. �oa�..e.w me a
e�py Ktlb��y be ferwarded M Nc Omce dlaPe�ef Me DIA hr t�vengeverlenW�.
r lo henay ce.4FJy re%.Me y�.rsa.napen.mea of perf�y d��dYe Gfsnw�ion P.oatd.enve v eve mia cnrmt
Si�_7�..u,> �.(L2/�.P�d�l —�it� �L`�'iG2�G�PiY�-��Dste �/����1/�
Priot name Q-� � �'�{�(� � P6one# �%�' ��}�`�3�-%_3
eBeLl afe ody ds oM wrke 4 th6 am W 6e ar�plued DY dtY�r�xre a��Ll
cHy'x bwn: �a ���g��
❑eYetic HimmaN�!mpeax b�eqahad ❑Sdeel�e�'e O�ee
`ceMactpersoa. �ry �����t
i '
I
`�Q CERTIFICATE OF LlABILITY INSURANCE ��o $ DAiE(MMIDO/YYYY)
DAVEN-1 02 21 07 i
- PRoouc�a THI$CERTIFICA7E IS ISSUED AS A MATTFR OP INFORMATION �
�, .� ONLY AND CONFER3 NO RIGHTS UPON THE CER'fIFICATE I
.. The Addia Gmup, Inc.. HOLDER.THIS CERTIFlCATE DOES NOT AMEND,EXTENO OR i
� 2500 Reaaiasaaca Blvd. Ste 100 AL7ER THE COYERAGE AFFORDED BYTHE POLICIES BELOW.
T[ing of -Pruasia PA 19906-2772
�' Phone: 610-279-8550 Fax:610-279-6543 MSURERSAFFORDaIG COVERAGE NAICif j
aisuaeo waunet� .�merlwn sarim� m�usana Co. 4OZ4Y '
� nea a=t Realty/� �
B ne �ock Motos nn euu�na zuzim su�rivn mwsanw co. �.GS3S :
c o Davenport Realty Trust r�suRaec i
S eohea Aschettino
� South YarmouthStNA 02664 wsursEno-
� NSURER E
� COVERACaES �
i
7HE POUGES OF NSURANCE lJSTE�BROW HAVE BEEN 183UED TO TME WSVREO NAM�N90VE FORIHE POLICY PERIOD k1DICATEU.NDTNRIXSTANUINO
ANY REWIRE6EM.7ERM OR CONDRION OF ANY CONIMCf OR OTHER DOCIRAENT VAiN RESPECT TO NRtlCHTHiS CEftTIFIGATE MFY eE ISSUED OR i
MNY PERiAIN,THE WSURpNCE APFOR��BYTHE POL�IE$DESCPoBED HER6N IS SUBIECTTO hLLT1E 7ERM3 IXCLUSWNS M!D CONDRIONS OF SUCH
PqJC�S.AG6REGniE UNfTS SHOWN MAY XAVE BEEN REWCED BY PM CUeAS �
LTR T'PEOFINSfIRANCE POLIGYNUMBER OATE NW DATE YNVD LIMITS
� GENERALL41Po4TY �.. � FACHOCCURRENCE f]. OOO�OOO I
� B R wnx+Eacu�cc�+Eaa«weiurv GL08196255 03/Ol/07 03/01/08 PRENISES Eaomnenn) s500 000 j
I CUMSMADE ❑$ OCCUR MEDEXP(Myarepxeanj SZO OOO
IPERSONALBADI'INJURY il U00 U0�
I6ENERALAO(iRE6AlE Y'L�OOD UOU i
I GENLnGGREGATELIAIRAPPIAESPER PRODUCTB-COMPIOPAGG EZ OOO OOO
POLICV jE�7 LOC
i ^°TaM°e�E�^eun' coeneweosa�txeurarc yl 000 000 '
� B ANYAUTO BAP8196256 03/Ol/07 03/01/08 �EacGtla"� ' ' i
j R ulovnJEonu'ros . 9ouILr�NJURv `
I " SCHEDULEDAUNS � . ' (PerOwwn) -
�I R MREOAU�0.S 00�9.YINJURY S �
X NOI.ONM�AUTOS (Peracltl�ntl
X ZSO COIDp PROPERTY�AMAGE S !
x 5�0 �.'O11 (PerecodeM)
. GlJNOELMBRRY AUfOONLY.FAACCmENT S i
. �A�� OiHERTHRN �ACC f ;
AUTOONLY: � y �
IXCEESNYf9RELLA LVIBBJTY FACH OCLURRENCE S �
OGGUR �CW�45MADE � AOORE6AlE S
E j
oFnucrre� ' � a
�Nrwx a s �
�
MIORKER$COMPENSR71pNANC X 7ppyLWllS EFt �
A �P����� WC8196024 03/Ol/07 03/Ol/08 EL EAGHACCOEM s 1 000 000
ANV PROPRIETORIPAaTNER1E%ECUiNE
OFFICEFIMEh�EREXCWOW'7 E.LdSEA$E-EAEM�LOY iS�OOO OOO �
s�°°'cw.°esura�8ovis�Bio`Nse.ro�. E.LDISEA9E-POLICYLB.IR sl 000 000 �
OTHBi
UESCRIPTON OF OPERA7KINS f LOGATIONS I VEHICLES!EXCLUSIONS ADDED BYElIDOF6ENENTI SPECW.PROVISIONS
I
I
I
CERTIFICATE HOLDER CANCELLATION
YAMOII—S �OULDANYOFTxEABOVEDEBCRIBEDPOLIdESeEcnNtEILmBEFORETNE!%PIRA7WN !
DATGTXEREOFTHEISSINNGINSURERWILLENOEAWRTOAINL SO UIIYSWRITfEN
� TOiPII of Yarmouth NpTIGETOTiECL-R7IFMATEHOL�ERNIIMEDTOTXELEFf BUTFALURETODOSOSXRLL �
ATTN: Permi.t Da t INPOBENOOBLIGATpNORW1B111TYMANY1aN0UY0N7NEM13URER,ITBAGENMOR i
1146 Route 2B �p �i
3. Yarmouth, I@1 02664 '�""�sE"T"T^�s. '.
AUT ATV I
a j
� ACORD 25(2D07/08) �ACORD CORPORATION 1968
i . .
OF�Y`qR
i
�$ '�� TO�'WN OF YARMOUTH
� y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
���TP�c"`,6`�'� Telephone (508) 398-2231, Ext. 241 — Fax (508) 760-3472
MA�1t0
B O A R D O F H E A L T H
December 6, 2007
Davenport Realty
d/b/a Blue Rock Club Pro Shop
Attn: Mary Purrier, Asst. Controller
20 North Main Street
South Yarmouth, MA 02664
Re: 2008 Permit Application
Blue Rock Club Aro Shop, 48 Todd Road, South Yarmouth
Dear Ms. Purrier,
Thank you for submitting the year 2008 application for yow establishmem's pemvts issued through
the Health Department.
Please note that, since your establishment has a food service license, a '
_ -,:__.
. �_.
for your establishmem was supposed to be submitted with your applicat�on.
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 provide a copy of the above certiScation at your earliest convenience.
If you have any questions on the above, please feel free to comact our office at (508)398-2231,
extension 241. Thank you for your anticipated cooperation.
Sincerely, �
/1'iLx����
Mary Alice Florio
Principal Office Assistant
/maf
cc: file
� � �� Printed on
� � Recycled
Lis Paper
i
. TOWN OF YARMOUTH
BOAi2D OF HEALTH
i PERMIT TO OPERATE A FOOD ESTABLISHI��NT
i
PERMIT NUMBER: #08-058 FEE: $75.00
iIn accordance with reaulations promulgated under authoritq of Chapter 94,Section 305A and Chapter
� 111,Section 5 of the�eneral Laws,a pemut is hereby granted ta
�
Davenport Realty, 48 Todd Road, South Yarmouth MA
Whose place of business is: Blue Rock Club Pro Shon
{ Type of business: Food Service
i
I To operate a food establishment in: Town of Yarmouth
I
Permit e�cpires: December 31. 2008 soARD OF HEnLTH: �SR�aR�, J�Z..A�., C'�uuxenan.
CRaa�Pea .�.��ePli� `Uice C'�aiau►iaic
RESTRtCr[oNs: Packaged chips,candy,chewing gum only. ��.�f9[(1tIL� �
I QfIIE�KPR.!l�Ql{fIt �� .
December6 2007 o-
&uce G.1'vlurphy,j ,R.S.,CHO
D'uector of Health
THE CONIlVIONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #08-044 FEE: $50.00
Tlris is to Certify that Davennort Realtv d/b/a Blue Rock Club Pro Shon
48 Todd Road, South Yarmouth, MA
IS HEREBY GRAN1'ED A
CONIIVION VICTUALLER'S LICENSE
In said Town of Yazmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .�EeBen SRult, J2..N., '�.hauxmart
C'R�a��eee .�E. 7tel[ihex `I1ice '(.ltaiarna�n
J`ta8ext s. `.�3a.acauc, 'C,�eirPi
Clnn , J2..iV.
December 6_2007
Bruce G.Murphy,MP , S.,CHO
Director of Health
r
i
�i{�6'1��`,L_-�°/ $W
t o`:=A'P�s TOWN OF YARMOUTH BOARD OF$EAL�rW Gs �'_ ^ � '� �'? 2 �°
2 � APPLICATION FOR LICENSE/PER14fIT- Z007 U E C 0 � 2006
0 Y
��yv *Please com lete form and attach all neces y C�
P sary documents b Decem �er ��QPFi DEPT.
Failure to do so will result in the retum of your appiication pac
NAME OF ESTABLISFIl�iENT: I ltiE >C{� C����� Yli 41C) � TEL. #CZrtf 3� �iG�
LOCATIONADDRESS: � ' c� _ , � ✓ �r-C�(A��- �a�66�
MAILINGADDRESS: ` r � +Ok �- Od � �
OWNERNAME: � Pc� ' vu � r �
CORPORATION NAME APPLICABLE): —
MANAGER'S NAME: �d� rv� 1� TEL. # ��- �S�-(c 6
�.nvGAvn�ss: � a�Ld ' ar�mo �1 c� ���1
POOL CERTIFICATIONS:
! 1'he pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
{ Pool Operator(s)and attach a copy of the certificatio�to this form.
1. 2.
� Pool operators must list a minimum of two emplo ees currend certified in basic water saf
Y Y ery, standard First Aid and
; Community Cazdiopulmonary Resuscitation(CPR). Piease list these employees below and attach copies ofemployee
' certifications to this form. T6e Health Department will not use past years' records. You must provide new
'i copies and msintain a t'de at your place of business.
1. Z
3. 4.
IFOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fiill-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 Dep�rtment will not use past years'rewrds.
You must provide new copies and maiutaiu a t'de at your establishmen�
I i 2.
PERSONINCI-fAItGE: _ - � -_ __ _ ____ _ _--
Each food establishment must have at least one Person In Charge(PICI) on 'te during hou�s of operation.
i
1� 2.
HEIMLICH CER'TIFICATIONS:
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-chokmg procedures below and
attach copies of employee certifications to this form. The Hea(th Department will not use past years' records.
You must provide new copies and maintain a fde at your place of business.
1. 2
3. 4.
i RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
� LICENSE REQUII2F,D FEE PERMIT# LICENSE REQUIItgD FEE PF.RMI7'# LICENSE REQUIltED FEE PERMIT'#
_B&B S50 . _CABIN E50 _MOTEL $50
1NN $50 _CAMP $50 _SWA�IIvIIIdGPOOL$75ea.
� _LODGE S50 _TRAII,ERPARK $100 _WIIIRI,pOOL $75ea
FOOD SERV[CE:
LICENSE REQIIIRED FEE PER[vIIT# LICbNSE REQUII2ED FEE PF.RNIlT# LICENSE REQUIl2ED FEE PIItMI"1'#
I 0-100 SEATS S95 0�-0 5 _CONTINENTpL $30 _NON-PROFIT $25
_>]OOSEATS 5150 J COMMONVIC. S50 �� _WgOLESALE 575
RETAII.SERVICE: —RESID.KITCIIE,N $75
LICENSE REQUIl2ED FEE PERMCL# LICENSE REQiJII2ED FEE PF.RMIT# LICENSE REQi71RED FEE PERMIT#
_�50 sq.R. S45 _>25,000 sq.ft. $200 _VE[•IDING-FOOD S20
_QS,OOOsq.ft. S95 _FRO"LENDESSERT $35 _TOBACCO $50
NAME CHANGE: S10 AMOUNT DUE _ $1ZS.00
'•"'PLEASE TURN OVER MiD COMpLETE OTHER SIDE OF FORM^^••,
:
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'ved to hold issuance or renewal ;
of any license or pemtit to operate a business if a person or company does not have a Certificate of Worker's
Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�res and liens must be paid prior t renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMCNTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transiem 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 shali 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 ins ed
by the Aealth Department prior to opening. Contact the Health Department to schedule the inspection five(5�ys
pnor to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY: ';
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme�rt by Eling the required i
Temporary Food Service Application form 72 hours prior to the catered event. 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 Pemut 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 Yealth.
OUTDOOR COOKING:
9utdonr rnnkino��r�paration,nr disglay�f any food product by a retail Qr foodservice establishmemis prohibited.
NOTICE:Permits run annually from January 1 to December 3 L TT IS YOUR RESPONSIBILITY TO RETCTRN ,
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. �
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW !
EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COD�IENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. �
DATE: �/,�( -O � SIGNATURE� )CC�9.c-/ /�=�C�'—rit. -GVJC����i�i �I
�, PRIN'P NAME&TTTLE: G r cq P,c�"l"l� �5� CGYI��✓zl ll�✓
iomros
� ' '
i ' ' �
i
! The Comn�oon►vtaltk of Massachusdts
• D�mt�rent of[adxstrial Accidewtc
' � N�N�
60o w���� f"�o,
Boston,Mass. 02111
__. -_.__ Wo�ers'Com tioe Iom�ee AS�vk:Bdl ' 6i��/Eleetrical Ca�trxtars . ._.
, . , _ .. �. <,.. :-�. : _ . . „�„�,,. ..
��:
addrtss:
� S1Iy S18fC: Zta ohmC N
work sih locffiim(fnll addressl:
❑ I am a wnu perfo�ing alt wak myaelf. Project Type: ❑New Cmsavcum�Ranodel
I a sok aod have no one w m� ❑B ' ' Addition
I mm an�ploya lxoviding wadcas'compeffiatim f�my�ploy�.s wa�cing an this job.
,,� a�� �l,le �(?CK- (� ,1l,lJ —�� �� ._ _ --_. — _
.�.: �(� Tr�d�f 2rJ_. � � �
�u,-;S%�r�mo�lti , 4rn14 0��6�-/ .���&�-�3,�� �;��� ��� � �
�,�. Z.t,�v-ic,G� IQuv��ev;cu,�� �v�S C'_.a e.r�.r I,UC �'SI �I�G��IC�I �
� �
❑ I mm a so(e ptopridot,geaxal ewhxtor,or Yomcow�e.r(c�elt owe)and Lave hiad the�tas listed below wln have
iLe following wakas'compen4etion polices:
ao�ar�rrc � .
�
eN.v: � dr�e/: , - .
M
[at�C
�
� �S�:
FaYYe/s+a.e wmqe n'eq�trd uiv BaIMa 2SA dMf�l.lffi m kW Y He I�pdIM da�Ml pmlin�a Le�r ptl SMM aYfe
aee yean'Isptiwamt n wd n eM ptnitls A tYe 6�da 31�0?WORC OHD6R W a me atS1M.M a dry a�t�e. 1 detahW tht•
npy N1�e Naiewt my he t�x�vudW M He Omce dl�at Ik I/1A trewage vWRntl�e.
�do rmeey�e.�fy,wtn Ma y.iws a+v�olo�+Rr uw xYe u,(sn..aro.proatea.soro is ave wa�e�t
s�eusn„e�y�Gr,2c� ��,c (/t2-cf'ir — Cc � �r �.c�l��> nru //� �U-�<o
Printname l�Y/ . PhomN �it�- �7�'�•��7�
.�rLl os wy a..�t w.we r m�...r�r.ee p�d br dh.r w,m.mdJ
�9��� pe'd�feme M De�mt
❑eYed N�ed�k re�eoe b�e9aNed Q4deedn's Oma
❑IkaM�D�p�ml
nWct Pnsw: PYxe/; ❑OWv
t�usa�mml
�
• = Feb. 24. 2006_ 4; 04PM No. 8554 P. 3
qCo,I�D. C�RTIFICATE OF LIABI.LITY INSUkANCE �,��1 �oa"za o6
PRp011 ER � THIS CER7IFlCATE IS ISSUED AS A MATSER OF INFORNATION
' � ONLY AND CONFFRS NO RIGHTS UPON THE CER7IFlCATE
The Addis aroup, Zac. p��7�j�gCOVER�P� E6 AFFORDEDB E�POLICIES�BELOW.
� 2560 R,eaaieeance Blvd. Ste 100
Ring of Prussia EA 19406-2772
� Phoae: 630-279-8550 Fax:610-279-8543 INSURERSAFFOR�INGCOVERAGE N/UCt!
! �°RE° �wsuaEan ...M�n s�Ma mzusa�wo ca. COld2
� 8 ue Roek Club ixsuaae e: �,e�;,,,,_,,,�,��,. 16535
� e o Da 1�ort Realty Ttuat i���G
i S enhen�ABchettino � _ �
� 20 17orth Maia 9t. ��p
� Socth Yaxmouth, MA 0266d .
; r+s�n e
� COVERAGES
� 7HEPOLICIESOFM6URPNCELIS'fED�lAw11AVEBm1I33uEo707HE11L4UREONAMECA80VEFORTHEPOLIGI'PERIODINDICATEo,NO7W1THsfAtAM6
ANY RE�UFiEA1ENf,TFRM OR CONDRION OF 4rv CONianci ax o7HERnOCullEnf mtH RESPECT TO WHICH THIS CERTtFMATE M4Y aE iBS�Eo oR
M4Y PERTAM,n1E WSURnaCE ACFa2oE0 Br'r�vOLICIE3 DE9CR�BEO HEREIN IF SIR.IECTTO ALLiHE 7EW0.s,E](C�IONS ANo wAomON3 OF SIiCH
i PDUGIE3.aGGreEG47EUMrtS�OWNAMYHAtlEeEENREDUCEDBYPAIDCU11M5.
� L7R INSR TYPE OP NJSURAt�cE PoucrNUYBER W MIIID DATE uMRS
�N����� �cxaceuRR�ee sl 000 000
�
8 % c��rscw.cenErsn�unaam GI,p61962550Q 03/01/06 03/OS/07 pq��as „�„m� a500 ODO
' cwwsntnoE QoccuR n�oawnmepmm) E10,000
i
a�soxn�anovN.iukr 51,000,000
GENEwu.nccneoa� S 2 OOO OOO
GEM��G6rtEG47ELrcArtAPPl1E6PER PRODUC'TS-COMP/OPAGO S1 000,000
POLICY Pj� ^ LOC
auroreoeaEw�eam
j s u+rnvro SAPB19625604 03/01/06 03/Ol/07 « B�"� ��rt s1,000,000
7C ALLOWNEUAUfOS � BODILYRINRY
6CHEDtAEOW1r03 (�Pe�^) S .
X nrc�nauros �' � :
eoa�r�wwcr S i
X NON-OWNEDAUfOS ���
' 8 2SO Comp PrtoaErtnoaence '
S 500 C011 (���+U E I
GAR0.0E LWBILRY
AUTDONLY•EAACpoFM E �
. ANYAUTO FAACC !
� OTHERTMnN
� Al1TO0NLY: p�G 6 �
' EXCEiLAIMBRELLALl490.fIY EACHOCCIa+RENCE 3 �
OCCUR �CLaN3�aoE AGGReWrE §
S �
i
� O�UCTBLE � y '
RETEWf�ON E j i
� wORKERSCOaPEN30.TI0NAND X 70RY
j
A ����E��� wa819602409 I 03/01/06 03/Ol/07 E.L,EACNA�CmEM s1,000,000 �
OyFeFleC,�AffA1�REYCLUUEO? ELO�SFw9E-EAEMYLO fS OOO OOO !
SPECW.PRWIs�oN3Celvx ELDI6EASE-POLICYLIANf S1�DOD�OOD i
OTII@R I
i
i
i
OEECRIP710N OF OPexqnpHs�i.ocq7loxslwfiCLeS I IXqJ19i0l19 MDED BY ENDORSEhENi/ePECU1L PROhS1ONS i
�
I
�
CERTIFICATE NOLDER CANCELLATION I
i
yp�_Z 6HWLDANYOFTNbABOVEDqcAmEo►oupE9BEGxCpLLEDBEFORETHEIXPIRATWi ,
� oaieTxve�.n��swxowsurmew�uExoFnvatrowu� 30 oarsx�+
T077l1 Of Yaxmouth xpiK�i0TNE0ERTIFICATEHOLDEtW1uEo7p711E�7,gvfpaLurse700090SwLLL �
AmRN' pex�t Dept� IMPOEENOOBLIWTIONOR�urvoFANYqrqU70NTHEIN911RER,1fSpGENTSOR '
Rnuta 28
S. YAtmouth, bA 02664 �"�6°PiATM� �
RE NT4
ACORD 25(2001N8) OACORD CORPORATION 1986
� . . .
TOWN OF YARMOUTH
BOARD OF HEALTH
' PERMiT TO OPERATE A FOOD ESTABLISHMENT
iPERMIT NUMBER: #07-065 FEE: $75.00
' In accordance with reQulations promulgaYed under autharity of Chapter 94,Section 305A and Chapter
! 11 l,Section 5 of the Z'ieoeral Laws,a panut is hereby granted ro:
i
� DavenEort Reaity Trust, 48 Todd Road, South Yarmouth, MA
i
iWhose piace of business is: Blue Rock Club Pro Shon
'�
Type ofbusiness: Food Service
j To operate a food establishmern in: Town of Yazmouth
�
Permit expires: December 31. 2007 BOARn oF HEALTH: B �s$. �M.$., '
��`s� �rv., v�e��
RFC�cnoxs: rackagea c.hips,c,aody,onewing gum on1y. Radtat 4.B9o[wg � �j
' ' 1'��36B/l�iK� I
� I
January 31.2007
ruce G.Murp , H,RS.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #07-045 FEE: $50.00
Tiris is to Certify that Davenport Rea(tv Trust d/b/a Blue Rock Club Pro Shon
48 Todd Road, South Yarmouth, MA
IS HEREBY GRANT"ED A
COMMON VICTITALLER'S LICENSE
In said Town of Yarmouth and at that place only ande�cpires December thirty-first 2007 unless
sooner suspended or revoked for violation of the laws of the Commonweakh respecting the
licensing of common victuallers. This license is issued in confomuty with the authority granted to
the licensing authorities by General L,aws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: B `�. � M.`�5., C�
���s�, rr., v:�e�
ae6�t4. B�, e�,4
p�k Ma2�,�„�
A�!f R.N.
January 31,2007
Bruce G. urphy ,RS.,CHO
Director of Health
f
I�ppO S1�C ,
; ��FY9��o TOWN OF YARMOUTH
I O - —'a 1146 ROUTF. 28 SOUTH YARMOUTH MASSACHUSETTS 026644451
� MATTI�CMEES �
,��o„� �p�,s-� Telephone (508) 39&2231, Ext. 241 — Faac (508) 760.3472
' . � B O A R�D O F H E A L T H �,-�--_.....�_`
I -"""__
7 " ` ,� 1
To: Yarmouth Board of Health Permit Holders ? , ,J�� i
�
Fmm David D. Flaherty h., RS. ;�D� H�/�LTN DEP7.
Heahh Inspector �
Town of Yarmouth
i
� Re: Federal Ta�c ID Number
i Date: March 22, 2005
�
i The Massachusetts Department of Revenue is now requiring that we furnish detailed information
{ to them regarding all permits and licenses that we issue. One of the detaiLs that they require we
send to them is every establishme�'s Federal Employer ldentification Number(FEIl�otherwise
lrnown as your"Tau ID Number". This is purely for administrative purposes only.
So� businesses use the owner's Social Security Number (SSI� for this purpose. If this is the
case for your establishment, be assured that we will not allow this information to be public
recotd.
Please fill out the fields below and return this letter to
Yarmouth Aealth Departmeut
1146 Route 28
� South Yarmouth, MA 02664
'I'hank you for your anticipated compliance. If you have any questions regazding this �atter,
please do not hesitate to call. The office hours are Monday to Friday, 830 am to 430 p.m. 1'he
' telepho�number is(508) 39&2231,eact.24L
i
� Establishmen OcL- c�D FEIN or SSN: �
��ul�=�Oc.K-G.. f�20 �HZ)P
Location Address: � �� ��
/
� Si�a
i p�: � �J/r!V � �[�{l�i77K� Title: �Vr
I
I
� �� Printed on .c .
��( Recyded.�s ��Y
r � � Paper
i
' r �,2� ������� c�� �s�P
��e R� � TOWN OF YARMOUTH BOARD OF�I;TH p � GN � p M I� DD
3 � APPLICATION FOR LICENSE/P�RNJIT .-2006
r��� , � DEC 2 0 2005
* Please wmplete fqrm and attach all necessar�dodu�ent`s by De ber 31 2005.
Failwe to do so will resuit in the relvm�oflycslu applicatio �d�L�H D PT.
NAMEOFESTABLIS NT: �jLIQ� �OG1� C�LLt� ��D S}�aP TEL. # J�OB '�JRB•�(oZ
LOCATION ADDRESS: �j.
MAILING ADDRESS: 14-1 i`I fl bZ (o
� OWNERNAME: 1 T or
��
� CORPORATION NAME� �APPLICABLE): �
MANAGER'S NAME: K�N SM I T}( TEL. # Z,
' MaII,�rG ann�ss: �g ,n��7 (Lofl�D s. �l„q-2vVU��Jfu MA�y-
POOL CERTIFICATIONS:
iThe pool supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated
� PootIIperatot�sj and attach a copy ofthe certification to this form.
' i. Td �� SUQPW�1� E �f�►J iN a.
� Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary 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.
1. 2.
3. 4.
i FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service estabiishments 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 roaintain a t'de at your establishment.
1. 2.
!-__ PERSON II�I�HARGE:-- ------
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlb��CH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
iManeuver on the premises at all times. Please Gst your employees trained in anti-choking procedwes below and
� attae}F eopies of employee certifications to this form. The Health Department will not use past years' records.
I You must provide new copies and maintain a t'de at your place of business.
I
i 1. 2.
j 3. 4.
I RESTAURANT SEATING: TOTAL#
�
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERMI'I'# LICENSE REQiJIl2ED FEE PERMI'P# LICENSE REQLJIRED FEE PERMIT#
_B&B $50 CABIN $50 MOTEL � $50
, _INN $50 _CAMP $50 SWAIbIQdGPOOL$75ea.
_LODGE $50 _TRAII,ER PARK S50 WHIItI,POOL $75ee.
i FOOD SERVICE:
I LICENSE REQUIl2ED FEE PERMIT# LICINSE REQUII2ED FEE PERMIT N LICENSE REQiTIRED FEE PF.RMIT#
�0-100 SEATS $75 �6�o CONTINENTAL $30 NON-PROFIT $25
� _>I00 SEATS 5150 �COMMON VIC. $50 �_Sd _WHOLESALE $75
RETAII,SERVICE:
LICENSE REQUIItED FEE PERMIT N LICINSE REQUIItED FEE pERMI1'# LICENSE REQiJIRF.D FEE PERNIlT p
_<50 sq.R. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_QS,WOsq.ft. S75 _FROZENDESSERT $35 _TOBACCO a25
� NAME CHANGE: S10 AMOUNT DUE _ $ 25•00
"""•"PLEASE TURN OVER AND COMPLETE OTNER SmE OF FORM•••"•
1
ADIVIIl�TLSTRATION /
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hoid 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
Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK
APPROPRIATELY IF PAID: /
YES ✓ NO
NOTICE:Permits run a�nualiy from January 1 to December 31. TT IS YOUR RESPONSIBII,ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEIVING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDIITONAL REGULATIONS
POOLS
POOL OPENING:All swimming wading and whirlpools which haue been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TEST'ING: The water must be tested for pseudomonas,total coliform and standazd plate count '
by a State ceRified lab, 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
CONSUMER ADVISORY:
Each food establishment which serves or selis ready-to-eat, raw or undercooked animal products aze required to post
Consumer Advisories.
CATERIlVG POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
_ Fro �este�etramont�dy�asi�by a-State e�ifigd 1akz. -T�s�resultsmus�be sent-to-Yhe�Ioalth
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemtit until the
above terms have been met.
OUTSIDE CAF`ES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeahh.
OUTDOOR COOKING:
Outdoor cooking, preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: Z I(p SIGNAT[JRE:
PRINT NAME&TI E: IS t�! �l �'
o9izsios
.
..� r
`='��
�
� . ,
I ACORD CERTIFICATE OF LIABILITY INSURANCE OPID C �ATE(MhVD�IYYYY)
DAVEN-1 03 02 OS
aaooucen - � -� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
i ` ONLY AND CONFERS NO RIGHTS UPON THE CEHTIFICATE
The Addis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
I � 2500 Renaissance Blvd. Ste 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
King of Prussia PA 19406-2772
Phone: 610-279-8550 Fax:610-279-8593 INSUHEHSAFFOROINGCOVERAGE NNCN
INSUBED INSUREFA: nmevican suzich inaurane. co. 9�142 �
B ue Rock CZLIYI � INSURER 8: zu�icn ao.e�iun x�.��,o�. co. 16535
c o Davenport Realty Trust �--
S ephen Aschettino INSUREflG:
20 North Main St. INSUREfl D:
Sovth Yarmouth, MA 02664
� INSUREP E:
COVERAGES
THEPOLIqE50FINSURANCELISTEOBEIOWHAVEBEENISSUEDTOTHEINSUFE�NAMEDABOVEFORTHEPOIICYPEflIO�INDICATED.NOTWITHSTANDING �
ANY RE�UIflEMENT,TEFM OR CONDITION OF ANY CONTRACT OR OTHEfl DOCUMENT W ITH RESPECT TO W HICH THIS CERTIFICATE MAV BE ISSUEO OR
MFY PERTPIN,THE INSURANCE AFFOflDED BY THE POLICIES DESCflIBED HEREIN IS SU&IECT TO ALL THE TERMS,E%CLUSIONS ANO CON�ITIONS OF SUCH
POLIqES.AGGREGATE LIMRS SHOW N MAY HAVE BEEN REDUCED BV PAID CLNIMS.
LTN NSR TYPEOFINSUHANCE POLICYNUNBER OATE MM/DD/Y E DATE NNIODIY ��RS
GENEFlALLIHBILITY EACHOCCURRENCE SS�OOO�OOO
$ $ COMMERCIFLGENERALLIABILITV GL0819625503 03/Ol/05 03/01/06 PREMISES Eaoaumnce) a 500�Q�Q
CLAIMSMAOE �OCCUP MEDEXP(Myvnapereon) SSO�OOO
PERSONALSADVINIURV 5 S�OOO�OOO
GENEPFLAGGREGATE $Z�OOO�OOO
GEN'LA66RE6ATELIMITAPPLIESPEfL � PRODUCTS-COMP/OPAGG $S�OOO�OOO
POLICV jE�o- LOC
AUTOMOBILE LIABILRY COMBINED SINGLE LIMIT
$ ANYFUTO BAP819625603 03/Ol/OS 03/Ol/06 (EaeccitlenQ E1�000�000
X ALLOWNEDAUTQS BODILYIN.IUflV
SCHEUULEOFUTOS (Pnperson) $
X HIRED AUTOS �
BODILYINJUflY $
)( NONOWNEDAl1T05 (Pe�acddenl)
X Z.r]Q COIDp PROPERTYDAMAGE
Z( 50� C011 (Peraaideni) '�
GAFAGELIA&LRY AIirOONLY-EAACCIDEN� $
I ANYAtf�O EAACC S
OTNERTHAN
AUTOONLY: AGG S
EXCE55/OMBPELLALIABILITY EAGMOCCURRENCE $
OCCUR � CLAIMSMADE AGGREGATE S
j a
I DEDIICTIBLE
E
RETENTION § y
� WOHKEflSCONPENSATIONANU X 70flYLIMITS ER
A EYPLOVEHS'LIABILITV WC819602408 �.3��L�Orj 03/01/06 E.L.EACHACCIDENT SL�QQQ
. ANV PROPPIETOFiPAflTNER/EXECUTNE i OOO
OFPICER/MEMBER EXG W�EDT E.L.DISEASE-EF EMPLOVEE S 1�OOO�OOO
� II yeq describe uMer
SPECIALPROVISIONSbelow E.LDISEASE-POLICVLIMfT § Z�OOO�OOO
OTHEp
DESCHIPr10N OF OPEHATIONS/IOCATI0N5/VEHICLES I EXCLUSIONS ADOEO BY ENOOHSEMENT I SPECIAL PNOVISIONS
� CERTIFICATE HOLDER CANCELLATION
YARM�-2 SHOULD ANV OFTNE ABOVE DESCFlIBED POLICIES BE CANCELLED 9EFORETHE EXPIqATION
DATETHENEOF,THEISSIIINGINSIIPEPWILLENUEAVOPTOMAIL 3O pAYSWPITTEN
TOWII of Yarmouth NOTICETOTHECERTIFICATEHOLDERNAMEDTOTHELEFf,BUTFAILURETD00505HALL
ATTN: Parmit D@IJC. IMPOSENOOBLIGATIONOPLIABILITVOFANYKINDUPONTMEINSIIPER,ITSAGENTSOR
1146 Route 28
. S. Yarmouth, MA 02664 HEPflESENTATIV 5.
AUTH SENTRTIV
4
ACORD 25(2007/OB) . �ACORD CORPORATION 1988
i
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTP TO OPERATE A FOOD ESTABLISHMENT
� PERMIT NUMBER: #06-066 FEE: $75.00
In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter
i
1 I 1,Section 5 of the�eral Laws,a peimit is hereby gramed to:
� Davenport Realty Trust, 48 Todd Road, South Yarmouth, MA
Whose piace of business is: Blue Rock Club Pro Shon
�
Type of business: Food Service
I
; To operate a food establishment in: Town of�armouth
i
Permit expires: December 31 2005 BOARD OF HEAI.TH: B in $. ��., '
�"s� rv., v:�e�.�
�s�cnoxs: Packaged chips,c�dy,chewing gum only. RoGe3t 4. B�, �
n�,���u
; a.���.a.n�.
�
I
� January]0.2006
I Bruce G.Murphy,T ,RS.,CHO
� Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
I PERMIT NUMBER: #06-050 FEE: $50.00
� This is to Certify that Davenuort Realtv Trust d/b/a Blue Rock Gub Pro Shon
48 Todd Road South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualiers. This license is issued in confornvty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affu�ed their official signatures.
BOARD OF HEALTH: B E�s$. G'o+rdok, M.$., G��ci�ux�w
��Sl�lti, Rrv., v�er�
Q�t�. a� et�
P�M�s�t
�� �i� R.N.
J�uazy io_zoo6
Bruce G.Murphy, ,R S.,CHO
Director of Heal
. a�,�oL
a �Fs q1 TOWN OF YARMOUTH BOARD OF HEAL�,w �g� �6 ��$`��
= O
o -'S APPLICATION FOR LICENSE/PERMTT�2i90 �? � 5 �s �� M � DD
� ., .!s �. �
* Please complete form and attach all necessary documents_��ecemb sf�4�ob.5 2004
Failure to do so will result in the return of yow app�''cation pac
� NEALTH DEPT.
NAME OF ESTABLISHIv1ENT� UAE K LU B PRO 1-lOP TEL #�-395'6S152
LOCATIONADDRESS:�IB 1DbD RDAD, ��ll-1 YA�2MOUTI�� , MA �2S�1.1
MAILING ADDRESS•ZU tJ02TN M A1 t� �EFT �ni 1T1-I YA M '�, MA �266�
OWNER/CORPORATIONNAME: DAV NpOR7� 12FALN TI?UST
MANA ER'S NAME: �, # _ _
MAu.irrG Ann�SS: , 5[y.lTl 1 YA 12 MO )TN, M A
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.
i1b �F S�I�PI.,iFh�Of'�NIn/�r 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation �CPR). Please list these empioyees below and attach copies of
empioyee certifications to tlris form. The Healt6 Department wiR not use past years' records. You must
provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
� FOOD PROTECTION MANAGERS -CERTIF'ICATIONS�
; 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. T6e Health Department will not use past years' records.
You must provide new copies and maintain a t'ile at your establishment
1. Z
PERSON IN CHARGE: _ _ _ _ " -
Each food establishment 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 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 t'de at your place of business.
1� 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OF'FICE USE ONLY
LODGIlVG:
LICENSE REQiJIItF,D FEH PERMIT# LICINSE REQiJIItED FEE PERMIT N LICENSE REQUIItED FEE pEgNQT It
_B�B S50 _CABIN $50 _MOTEL S50
_II�N $50 _CAMP $50 _SWIIvIIvIINGPOOLS75ea.
_LODGE . $50 _TRAII,ER PARK $50 _WI-IIRLpppL S75ea.
FOOD SERVICE: �
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIltED FEE pgRAqf p LICENSE REQiJIItED FEE pERbQT p
�0.100 SEATS S75 05�006 _CONT7NEN1'AL S30 _NON-PROFIT $25
_>100 SEATS $150 � / COMMON VICT. S50 � _WI-IOLESALE $75
RETAIL SERVICE:
LICENSE REQiJII2ED FEE PERMIT# LICENSE REQtJII2F,D FEE pEgMiT g I,[CENSE REQLIIItF.D FEE pgI2I�qT q
_60sq.R $45 >25,OOOsq.ft. S200 _VENDING-FOOD S20
_Q5,000 sq.ft. S75 _FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: S10 AMOiJNT DUE _ $�a5.00
'""•'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM^••••
. . y
. ADMINISTRATION
Under Chapter 152, Section 25C, Subsecrion 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's
Compensarion Insurance. THE A1"PACHED STATE WORKER'$ COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yazmouth ta�ces and Gens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�_ NO
NOTICE:Permits run aruivally from January 1 to December 31. TT IS YOUR ItESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THEHEALTHDEPARTMENTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTIl�iG, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO CONINIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, 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
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY•
Anyone w o caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtazned at the Health Department.
I
__ FROZEIV 1iE55ERTS:_ .
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 resuit in the suspension or revocation of your Frozen Dessert Pernut until the
above terms haue been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mnst have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a ret ' r food service establishment is prohibited.
DATE: �l J O �` SIGNATURE:
PRINT NAME&TITLE: `S� • /c �� � ��
10/22/04
1
� '
_� The Coinnmomvealtk ofMassachusdts
- -_—�
=_ Depatwrent of IndxsGrial Accidenls
� _ — �I N�
I - - 60o w�h;��,.� f"F��.
� _ �. Bostwy Mexs. OIIII
i � Worlcas'C��ssaho�Lsea�ee AS�vH: ' ' kelrieal Co�trxrors
:..,, _.. . ...
. � .�rW.. . � ,. . . .
; ��.�7 y �.���+� .��� ' . . ��.,�_ . ... . .. . .
name:
i a�s'
Icitv a.te� an• ohmc N
� work site Imatim ffoll addiessY.
I am a homaowna perfoxming all wak myself. Praject Type: ❑New Cma�xuaion�Remadd
I�a sok aad�ve no me w in� B�ril ' Addition
I am an�ployer pmvidin�wodceds'compeasatim f�my�ployps wo�cing on tLia jpy,�
�....�:_�L.IJF I?OCK CLUF3 Pi20 ��P
' �: 48 TaDb ►2oA�
��-uTN yARMnUTN ��. - 51�-6�2
��A►�IFR►CAN z � � N N �..
❑ I am a sole p[opiietor,8�a1�tracPor,or Yomeow�er(drele owy a�Lave hrted ihe camhracW�s fistad below who Lave
the following wotke�s'comp�ation polices:
��
e�r: olrrl: �
M
�uv ae
�:
dls: �.
FaYae b atene e�aee n�eqdeeA de Sectl�2SA d1MGL L4 en idd b IYe i�He�iW pWn d�ie�p bS13M.M aWw
••�r�'dr��n•oa..a.��duec.r..t.srorwonconoertm.�.rsir.w,a.y.a,�.e. �oee�.wnu,
apy.tm.wde.e.y ee hrwarArd r ne o�e�L�.t1�M,►hrevaqe vet�qwu...
�do 6arsy rnyfy.ede.pye pe8w.et0ena/ab efvM�m+N�dYe iw,�On.�ptoa pnoadaA.eo.e 6 ane.us csmrc
Sigoffiam ( /s �.Qt?1 nmr /) //.s/U�
PriMname HYIn //Ir ��G�{'� P6oce#_JOp'J�/�-a�a2 /.3
.mad.ae..ry a...t wrne r tw,rn b ee p�pl�d br�*s.r w...mrLl
dyrtawa- p�/ ''"'- - pry�n�
❑eYeck H�Be rnpeoe 6 r�qeed ❑��L Haatd
�d�n's O�m
1��. �� �Dept��
TOW1V OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHNIENT
PERMIT NLJMBER: #OS-006 FEE: $75.00
' In accordance with reguIalions promulgated under authority of Chapter 94,Section 305A and Chapter
I 1 I,Section 5 of the Ceneral Laws,a petmit is hereby ganted to:
Davenport Reaky Trust, 48 Todd Road South Yarmouth, MA
Whose place of business is: Blue Rock Club Pro Shop
; Type of business: Food Service
', To operate a food establishmem in: Town of Yarmouth
i
' Permit eacpires: December 31_ 2005 BOARn oF HEALII-I: ,Be��, l�'o+r�o�s,iy�, •
� 1t�s'riucnoxs: Packaged chips,candy,chewing gum only- Rpde3��, ���K
'' �� Sl.�, R.N.
; A�u�lja�rdr�r.�,.R.N.
I'
I
IDecember I 2004
i Bn�e G.M�uplry, RS.,CHO
i Director of Health
i
i
1
i
I
�
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #QS-006 FEE: $50.00
This is to Certify that_ Davennort Realtv Trust d/b/a Blue Rock Club Pro Shon
48 Todd Road South Yarmou MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only andexpires December thirty-first 2005 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confomvty with the authority granted to
the licensing authorities by General I.aws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affuced fheir official sigoatures.
BOARD OF HEALTH: B�$. ��J,$. �.�
p�.H� v:�e��
a�� a.�, e�
��R.N.
_��t�i.z�a
ruce G.Murphy, S.,CHO
Director of Health
� `' � `` � mo673 s r�«,�
� �jAR1 TOWN OF YARMOUTH B rRD OF HEALTH � � � � � � � D
I o_ ` APPLICATION FOR LICE�E/PERMIT -2004 NOV 0 5 2003
r��?
* Please complete form and attach all necessary documents by December H TH DEPT.
Fai lure to do so wi l l resu lt in t he return o f your application packet.
NAMF OF ESTAi3LISHMENT: �L LI .IJR (� .C� TFi # - - �
RE
• 2v A M U
v ,a
� rr v� �
MELNAGER S AMi'• 2
�ING ADDRESS• U 7bDD R(aAn �.ft�l YA12 MDL.1'T�-I T�L. #
' POOL CERTLFICATIONS:
The pool supervisor must be certiTed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(sj and attach a copy of the certification to this form.
i.7D �3E cS1,G��UC� �lll�,l�'r 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this fortn. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
I. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fu(1-time employee who is certified as a Food
Protec5on Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS 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 maiutain a fite 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.
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 rovide new co ies and maintain a file at our lace of business.
P P Y P
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
�.. LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRGD PEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&.B S50 _CABIN S50 _MOTEL S50
_INN S50 _CAMP L50 _SWIMMMG POOL S75ea
_LODGE $50 _TRAILBR PARK S50 _WHIRLPOOL S75ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMtT# LICGNSE REQUIRED FCE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100SEATS S75 O�"��� _CONTINENTAL S30 _NON-PROFIT S25
>100 SEA75 5150 I COMMON VICT. S50 Y'�Gb _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H LtCENSE REQUIRED FEE PERMIT k
_<50 sq.R. $45 >25,000 sy.R. 5200 _VENDING-POOD S20
_Q5,000 sq.R. S75 _FROZEN DGSSI:R'f 535 TOBACCO S25
IYAME CHANCE: S10 AMOUNT DUE _ $ l25 .OO
"••••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM«...«
ADMINISTRATION
Under Chapter 152, Sec6on 25C, Subsection 6,the Town of Yazmouth 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
Compensadon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION 1NSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE:Permits run annualty from January 1 to December 3 I. IT IS YOUR RESPONSIBILITl'TO RETURN
"I'E� COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVAT'IONS 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 SITE PLAN.
A1�DITIONAL RFGULATIONS
POOLS
POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. '
POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count
by a State certified lab, 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
CONSU FR VI ORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATE rN PO I Y:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FRo7.F.x nFccFB � _ --- _ - -_ _ _ _ - - - - __
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 until the
above temis have been met.
OUT4ID . F�: :
Outside cafes(i.e.,outdoor seating with waitedwaitress service),m stu have prior approval from the Board of Health.
OUTDOOR COOIKNG:
Outdoor cooking,preparation,or display of any food p uct by a il or food service establishment is prohibited.
DATE: /� 3 � SIGNATU :
PRINT NAME& TITLE: • N. FO
10/22/03
�
' • �\
i The Commonwealth ojMassachusetts
: Departmen! ojlndustrial.-I ccidents
; Ol/Icea!/eresUast/ais
600 Washington Street
Bnston. Mass. 02111
W'orkers' Campensation Insurance Affidavit
Anolicant informaHon: PlessePRiNTTer0dil
nomc
location: . . .
cit� ehone M
� I am a homecwner penorming all work myself.
� I am a solz proprieror r..,', ha�e no one��orkin_ in am capacit}•
�j I am an emplo�er pro.idin� workers' compensation for my employees wQrking on this job.
comnany namr.(')LIAf. R�\_ � L L�U �� ��O�
adArcss: `'Y) IV L� RlX'l�
tih^c�L.� y/"��I�+HJU11� nhenep�.�-(1���`7U-b`�1107i
insur�nceco.AME��CAIv Z.URICH' �I�SU��NC� eolicyn ��q�2�— � _
� I am a sole proprietor. _eneral contractor. or homeowner(circle onel and hace hired the contractors listed below ��ho ha�e
thz follo«in_ «orkzr :ompensacion policas:
v
address
�n: � phone p:
� insurnncc co polier p
�
� comoany name: - --
� _. _ . .. .. --- --- - -.__ .-- � ---� - ---- -_ _. _ . __ . __ _-___... _. . __ .._ _... _ . . _ . . . .
addrcsr
e�: � � nhoee A•
inenran�n rn. eoll[r M
____ _ ___ __' __ _
. Failure to seeure corenee as requ�red under Seenoo SSA of MGL IS2 u�kad to t�e i�poritiw of cri�inl padlfn of a O�e ep ro 51,500.00��d/or
ooe ye�n'imprisonment u w�dl u eivil pmdHa io�hr(orm of�STO�WORK ORDER asd�Il�e�5100.Op�dq qtio�t m� 1 ndmmd H�t■
eopy of thy sntement may be fonrfrded to the Oliiee of lavati�uioet otMe DU for eovera{e verillutfe�.
� /do�hereby certijp nnder rhr pains and ptrta(lies ojperjury�ha1 the injormation provided above!s but wd rorrtet
3 03
Signaturc �\_�i� Dme �/ /
Printname ��111 /'�� `lP�"�' PhoneA J�Qf-3�P- aa9_3
I . oRcial use onl. do not rrite in�Ais ana to be rompleted by eity ot lowv ollkial
tiry ar rown: y�ODT$ _ permiNfecex M nBuildioe Departmm�
. �Lleemio6 Board
�check if immediarc response ie required . Z61 QSdettmen9 Otifet
�HeN�6 Departmmt �
conutt peraon: phone M;_ �SOH� 398�-2231 eat. nOther
�
. .
THE COMMONWEALTH OF MASSACHUSEI"I'S
TOR'N OF YARMOUTH
PERMIT NUMBER: #04-009 FEE: $50.00
Ttus is to Certify that Davenport Realtv Trust d/b/a Blue Rock Gub Pro Shop
48 Todd Road, South Yazmoutb, MA
IS HIItEBY GRANTED A
COIVIlISON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and �pires December tlrirty-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commomvealth respecting the
licensing of common victualler's. This license is issued in conforntity with the authonty ganted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereurno aff�ed their official signatures.
BOARD OF HEALTH: Beajoyrtn$. (�o+td�c,M.�. �iai�nrf.�s
�,a�� v;�e��
a�t�.�� e�.�
� sr� a.n�.
November19.2003
Bn�ce G.Muzp ,MP , O
DireCtazoff-Iealth
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLIS�NT
PERMIT NUMBER: #04-015 FEE: $'15.00
1n accordance with re�ons promulgated uader authmity of Chapter 94,Saction 305A�d Chapter
1]1,Section 5 of tbe Laws,a�rt is hereby gmmted to:
Davenport Reahy Trust, 48 Todd Road, South Yarmouth, MA
Whose place of business is: Blue Rock Ciub Pro Shon
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yarmouth
, Pemut e�cpires: December 31_ 2004 BOARD oF HEALT�: Bs�«�i+� `.D. l�oadwc, M.`1!. '
�,a�u, v�e�
xes'rlucrioxs: Packaged chips,candy,chewing gum only. Rods9t�. B�, �
d�ls�ac S!uls. R.N.
�
i
I November 19.2003
I Drc�oM�hy� , .,CHO
. ' -'
� . � `/%3 3 �/� !rU B�oE 2occ Cc�9 Prm-SnoP
^� WN OF YARMOUTH BOARD OF HEALTH
' •�` LICATION FOR LICENSE/PERMIT -2002
� ; � ; � I�� ���" � � R ��VI� D
' Please complete form and attach all necessary documents by December 31, 2001. Failu e"Co`do so will result i
the return of your application packet. �(�� 2 7 2o0S
OF ESTABLIS NT: ro - o
� B Tad oud. s
MAIL GAD RE O f�o. (YlGuh a �WmouN1
O e — "r
A R' N a �/ I L. #
��IG ADDRFSS• 4f� Td�� �d So �l�✓moui 1� M A
POOL CERT FI ATIONS•
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form.
1. 2,
Pool operators must list a minimum of two employees cuirently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary Resuscitafion(CPR). Please list these employees 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.
FOOD P �- �T�na.rc•
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 pmvide new copies and maintain a £de at your estabiishment.
1. 2.
PE _. - __ _ _ __ —_
Each food establishxnent must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2
HEI r r�� n T ru�..��c��
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 file at your place of business.
I 1• 2.
� 3 4
1 R�ESTAURA�'��[� '€�'PAL#
' OFFIC . nNi,v
LODGING:
� LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL $50
_1NN S50 � _CAMP $50 _SWIMMING POOL SSOea
_LODGE $50 _1'RAILERPARK E50 _WHIRLpOOL $25ea
FOOD SERVICF•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I O-100SEATS S75 'rFOa-08a _CONTINENTAL $30 _NON-PROFIT $25
_>100SEATS $150 I COMMONVICT. $50 �6�-p$',S _WqOLESALE $75
F.TAII .RVI
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20
_<50 sq.ft. $45 _>25,000 sq.ft. 5200 _FROZEN DESSERT S35
NAME CHANCE• $10 AMOUNT DUE _ $ �oZS.00
, •*•**PLEASE T[JRN OVER AND COMPLETE OTHER SIDE OF FORM*••**
- r. _ . ,.,
ADMINISTRATION "
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 Warker's
Compensation Insutance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID: \ n
ygs � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'I'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TEIE HEALTH DEPAR'TMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
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 REQUIIZE A SITE PLAN.
ennrTi(1NAi RFGULATIONS
POOLS
POOL OPENIIVG:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opemng.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State cercified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swinmiing pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER AAVISORY:
Each food establishment wtuch serves or sells ready-to-eat,raw or undercooked animal pralucts aze required to post
Consumer Advisories.
('ATFRING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Depariment.
--
_—
FumFN nF.SSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Departrnent. 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 waitec'�waitress service),must haue prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparaUon,or display of any food product by a retail or food service establishment is prohibited.
DATE: 11_ v 3 ul SIGNATU . r
PRINT NAME &TITLE: G F , 0'
09/I1/01
,
�,
ACORD CERTIFICATE OF LIABILITY INSURANC�!� PK °"�,M'�°°""'
� VEN-1 03/O1/O1
rnooucea �• � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
� . � ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The Addis Group, Inc. HOLDER.THIS CERTIFICATE UOES NOT AMEND,EXTEND OR
2300 Renaissance Boulevard � ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ki.ng o£ Prussia PA 19406-2772 � INSURERS AFFORDING COVERAGE
Phone: 610-279-8550 Fax:610-279-8543
INSURED INSURERA AR@L1C3Il ZUSICYI
Blue Rock Club msunFxe: �
c/o Davenp ort Realty Trust �Nsurs�ryc:
Kerry Surke
20 I�orth Main St. INSIIRERD:
South Yarmouth, MA 02664
INSURER E:
COVERAGES
TNE iOIJqES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD INDICATED.NOTMTHSTANOING �
ANY REQWREMENT.TEIiM OR GONOITION OF ANV CONTIiACT OR OiNER UOCUMEff�WRN RESPECT TO WHIGX THS CER7IFICATE MAV BE ISSUEG OR
hUY PERTAIN,TIE INSURIWCE AFFORDED BV T!ff POLICIES DESCitlBED HEREIN IS SUBJECT TO ALL THE TERMS,IXCLUSIONS AND CONU1710N3 OF SULH
POIIGIE3.AGGREGATE UMITS SMOWN MAY W1VE BEEN REDUCED BY PAIO CWMS.
�. �L� T'PE OF INSURANGE POUGY NUMBER DATE M DATE M �N U�T$
�. GENERALLW&LITY EACNOCCURRENCE S
COMMFACIAL GENERAL LIABILITY. FlRE DAMAGE(My ons fln) f
CWM9 MADE ❑OCCUR M1�ED E%V(My one permon) S
PERSONALBAOVINJURY f
GENERALA6OREGATE S
GEN'LAfiGREGATEl1MITAPPLIESPE PRODUCTS-COMP/OPA('.(3 S
VOLJCY �� lOC
AUTOMO&LEW1&LIiV COM&NFDSINGLEl1Mff s
�A�O . (Ea aulEeirt)
ALLOWNEDAUf03 BOqLY1NJURY s
SGHEWLED AVfQR (Px person)
HIREDAUT03 BODILVINJURV s
NON-0WNED AUT0.4 (Per acc�Aenq
PROPERTVDAMAGE E
(Px axiee�
GARA6E IIAB�UTy AUTO ONLV•EA ACCIDENT S
ANYAIJfO ��n� ��C f
AUTOONIV: (WG S
IXCESSLIA&L1T' � EACNOCCURRENCE E
a�UR � �WMgMppE AGGftEGATE f
S
DEDUCTBLE f
RETEN710N S s
WORKERS COMPENSA710N AND X 7ppy��M�7$ ER
A EMPLOVERS'UABILITV y�g19602404 03/Ol/Ol 03/Ol/02 E.LEACHAGGIDIXf sl 000,000
E.LD�sensE•eno+xrn SS,OOO OOO
ELDISEASE•POLILYLIIAT SZ OOO OOO
OTHER
DESGRIPTION OF OPERA710NSiLOGATIONSNEHICLESIE%LLUSIONS ADDEU BV EHOORSEMENTISVECIAL PROVISIONS
CERTIFICATEHOLDER N �d'�����RED:INSURERLETTER CANCELLATION
Y�_2 SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE 7NE EXRRA710
UA7E iHEREOF,THE ISSUING INSURER N7LL ENDEAVOR TO MAIL 3O UAYS WRITTEN
� NOTICE TO 7XE CERTIFICATE HOLDER NAMED TO TXE LEFT,BUf FAILURE TO DO 50 SMALL
T097I1 of Yarmouth �MP0.4E NOOBLIGATION OR LIABIL7fY OF ANV KIND UPON 7HE INSURER,IT$AGENTS OR
ATTN: Permit Dept.
1146 Route 28 REFRE$ENTATNES.
S. Yarmouth, MA 02664 , � � �
Pamela
ACORD 25S(7/97) �ACORD CORPORATION 1988
TOWN OF YARMOUTH
BOARD OF HEALTH
; PERNIIT TO OPERATE A FOOD ESTABLISHNIENT
j PERMIT NUMBER: #02-082 FEE: $75.00
In accordance with regulationspromu1 gated�mder authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the(ieneral Laws,a pernut is hereby ganted to:
il�avenrnrt Realty�at- 4R Tndd Road_ South Yarmnuth_ MA
Whose place of business is: Blue Rock Club Pro-Shon
I Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit ea[pires: December 31_2002 BOARD OF HEALTH: �iFaal�s� xd!lkea. (�
D. Cj�da.� �C.D.. ?kee
RESTRIC170N5 ff ANY: P8cka8���PS,�dv,�eW�g s��h'• � �• �
�aaeiek�er.AcotL'
S�E. ,��l.
March 14 ,2002
Bruce G.Murphy,MPH, O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER #02-055 FEE: $50.00
This is to Certify that Davennort Realtv Trust d/b/a Blue Rock Club Pro-Shon
4R Tndd Road_ So, h Y rmn rth_ MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yazmouth and at that place only and expu' es December thirty-first 2002 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity v�nth the authority granted
to the licensing authorities by General Laws,Chapter 140,and amendwents thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official sigoatures.
BOARD OF HEALTH: (�jfamlea:� xeUGFoc. �faar.aaK
�D. �jo�o�C. �JlG.D.. q/iee
R�a�t� �. G/o�
P�k��tt
Sl.ak. R.�l.
March 14 ,2002
ruce G. hy,MP .,CHO
Directar of HealU►
r '} ��=v^R TOWN OF YARMOUTH BOARD OF H � ' '�g �-�P
? .- �s � - �� � i ` �
o y APPLICATION FOR LICENSE�' �' ' ,..�,
rC�? cRim� ��� ._� �, Q 6 i i
* Please complete form and attach all necessary do ents by ece er 3.,1;2Q
Fai lure to do so wi l l resu lt in the retum of your application packet. -=.=-__� r'_`
NAME OF T I � G[ � � h rn -S P �L # .�os �s�� -m��a
LOCATION ADDRESS: `1�d Te, c�d 12c�a d , Sov�t.h`1�,�-r rnr�t iLlti
�?o i�lor �h ai n � r
OWNER/CORPORATION NAME• �uuo n �J t 1 i r�S�
' �v � fo mm f 2
MAII.ING ADDRESS: �I� �o d d R c) , `Sn��� G�r mC��lLlti,f�c�
POOL CERTIFICATIONS:
i 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 o�fhe certificaTion to tliis Yonn.—
1. 2.
� Pool operators must list a minimum of two employees cutrently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitadon (CPR). Please list these employees below and attach copies of
employee certificarions to this form. The Health Department will not use past years' records. Yoa must
provide new copies and maintain a fite at your place of business.
1. Z.
3. 4.
FOOD PROTECTION ANA RS - C TIFI ATIONS•
All food service establishments are required to have at least one fuil-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 establishmenl
�
1. 2.
j - �'ER��AI����c - _ _ _
� Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
1. 2.
I
I �yII.ICH CFRTTFT('ATTnN4•
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 certificarions to this form. The Health Department will aot use past years' records.
� You must provide new copies and maintain a file at your place of business.
1. Z,
3• 4.
; RESTA TRA T ATIN : TOTAL#
OFFI . O .Y
1.onr�,ING:
LiCENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
. _B&B S50 _CABIN a50 _MOTEL $50
_A1N $50 _CAMP S30 _SWIIvfMING POOL$SOea �
� _LODGE $50 _'I'RAILER PARK $50 _WHIItLpOOL S25ea
� - --__. - ---
FOOD RVI : � . _ ._-- — ----- .. . _ . _ .. . .. _ . _. . . .
LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIILED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT#
�0-100 SEATS S'75 b 3"08$ _CONTINENTAL S30 _NON-PROFIT S25
_>100 SEATS $150 �COMMON VICT. $50 0 �O _WHOLESALE $75
RF.TA]�i , .�gyl('.�F:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUQLED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$33
N M AN • $lp AMOUNT DUE _ $ I 25.o0
*•'••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•«**
,. .' '
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit ta 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�_
�
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 �/ NO
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMEN'1'FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
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 SITE PLAN. '
tLDDiTiONAL REGULATIONS
POOLS
POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Deparhnent prior to opening. '
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, 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
CONSUMER Ai>VISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
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. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS• �
Frozen desse�mus��e te�ed on a monthiy�asis by a State certified tab. `I'es�resutts must be sent to the HeaTth ,
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 of Health. ,
OUTDOOR COOHING:
Outdoor cooldng,preparation,or display of any food product by a re ' or food service establishment is pmhibited.
i
j
DATE: // /� D� SIGNA
PRINT NAME & TITLE: ��. 5�`7P �J t� ��`C�
10/18/02 I
.
ar ,20• 2002-11 :42AM—THE ADDIS GROUP No .8831 P . 8/14
� c�RA c:Er� � it=1C�► � t Vr ��ABILITY INSURANC��!o ��°�M�
1 oaiaoioa
Pp� TMiB BRT�ICATE IS 15917ED q8 4 M4TTEq OF INFORNA N -
The Addi6 Gxo11q, TriC. ONLY AND CONFERS NO RIGHTS UPON 7HE CERTIplCATE
1,' 2300 Aeaairseace 8onlsvard ALTEBTIiECOVEpAGE FORDEDBYTHEPO�IESBELOW.
� Riag o# Esuaeia 8A 19406-2772 •
Phone: 610-279-8550 Fitxa610-279-8543 . INSURERSpFFORDINq COVERA6E �
�1SURED� � �
INSUREpA Ameriasa Zurich IagurauCe Co.
� 81u. Roak Club iNsuaen a
�e%ot D3Vi73DOYt Realty 2zvst �
i s a m�� k 1�yaia St. kswtER a
i � South Yaxmoath� M7► 02664 �""'`�REa°' �
C�vEqAGE3 iw�neae
� THEPoLICIEBOFINSUp.�NC6L167'FDBELpW11qV�0EEN159UEDTOTHEIN9URmNAMEDA80Vf.FpRTHEPpLf(,WP�qpplNpqA7lp.NOTVITHg7/J.�pIryC
ANY RGOUNiEN6NT�T[AM OP CONORIIXJ OF ANY CON7AqGT OR OTNER DOCUMENT WRH RE$P[-CT TONMICH TNIS CERTIFlCq7H MAV BE 19SUEp ON
MAY PEMTAIfi�TH@ INSl1pMICE AFFOROED BV THE POUCIES DESCRI6E�FIEftE1N IS SUBJECI'7p qll TryE T6FMS,IXCLUS�ONS ANU COryp�7IpNS OF 3UCH
POLICIE$.ApOREGATE LIMIT9 SHOWh Mqy h�qyE BEEN R6WCED BY PAID CLAIMS. M � �
� IYPEOFINSIlN6NCE POLICYNUMBEp �
DATE pp7E �Rq
GENEppL LIAfiILITY
CQMMERCIAL�ENEAALLJPEILITY EAGI9CCURRENCE $
I FIREDPMAqEWryO�xAre) g
F QNbt4MAOE �accUR MEDo[P(anyonePerson) 9
PEFSONu4ADV�NJURY y
I, GBPI'AGGHEGA'f�LWITApp��E$PEti GE��'�Q�� a .
� �� �P �� PpWU0T8-COMPrDPAGG S .
AUfOWOBILE LIA91lAYY
� rwvnvro ��s�a.Na.�njwc�E�anrz S
ALl OWNEO Al1TOS
SCHEOULEo4Ui0e ��p��FlY S
� HIRF_pA{)7'p9 '
I
NON-OWNEOqUTOS �����URY $
)
�P���P7AAQE $
waaceun�un
nuvnuro nuroorx.r-�qccioeNr a
OTHER THrW �M� C
EXCE98LIABIUri NUTOMJIY: dGG S
Ea]10CClWP6NC6 S
OCLUfl �CWMSMAOE Mi6FEGATE
S
OEDUC7IBLE $
Rt1ENTfON $ s
YYOKKERS CqIPENSATION ANO $
� A EMPLOYEX9'L1A&L11Y x tORY RS ER
4PC819602405 03/01/01 03/01/03 E�EacnncaoErrr 61,000,000
ELDI4EqSF-E46MpLpYE 9S�OOOiOOO
p�p s�ois�.ao��cyuMR ;1,OOQ,000
DESCIiPTION OF OPERATION$II.00ATpN$/VEML`�Egrp�C��gpN3 ADUED BY ENppqgQJEry7/8P[t`IAL PfiQVI$IONS
CERIIFICATEHOLDEq ZQ ppp7�pryq��NSUREU:INSIIFEqLEfTER: CANCELLATION
YN{M0�'a SHOULOANTOFTMEpBOVEOE$pq�gEOYOLICIE3BECAHCELLE09EFQqEyryEp�p�q�n�
TOWII Pf YAYldO'IiY.Il DATETHEHEDF,THEI&61MN0�NSUi�AWILLfNOEAVORTOYNl �_DAYSWNITfEN
1►3'TN: ltermit O�DY�. NOTICE TQ TH6 CEpT�FICATE MOIDEq N►Rg0 TO TNE LEA,BUT FlULUpE TO 00 30 gN/y�
1146 Route 2B �MPOSENOOBIIpqT�pNOflWABItJTypF/J1yqNp�pp,�7HE1N3URERRSAGBJTgpq
S. Yaxmouth, IdA 02666 NEPflESEMATJyfi,q,
AUTMORRED pEPpE9plTA714E �i
nCoa�zss(7/9� steven E, col •
�ACOflD CORPORATION 1888
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLLSHMENT
PERMIT NUMBER: #03-088 FEE: $75.00
i
� In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
i 111,Section 5 ofthe General Iaws,a permit is hereby granted to:
i
i Dauenport Realtv Trust, 48 Todd Road South Yarmouth, MA
� Whose place of business is: Blue Rock Club Pro-Shon
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Pernut eacpires: December 31. 2003 soARD oF[-�e.Ar,'['x: �ea;�, ,�dlt�ec, �,c
_ - - _— _ _ _ _ .__
_ ��'e��«�Ct a. C�. 'lJIC.D.. �/iee .
__ _
rs�s'r�ucnoxs Packaged chips,candy,chewing gum only. � '�. '$�waeMc. Ll�oek
. �4�1G�'�mxwott
. .. � s�4+�. ��
Januarv 9 ,2003
ruce G.M�up y, .,CHO
Director of Heahh
� THE COMMONWEALTH OF MASSACHU5ETTS '
TOWN OF YARMOUTH
PERMIT NUMBER #03-060 FEE: $50.00
This is to Certify thai Davenport Realty Trust d/b/a Blue Rock Club Pro-Shop •
48 Todd Road, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yazmouth and at that place only and expues December thirty-first 2p03 unless
- - o ' latiou of the-laws�f the CommoawealE�espeetiug-tk�-
licensing o common victualler's. This liceuse is issued in conformity with the authority granted to
the licensing authorities by General Laws,-Chapter 140, and amendments thereto.
In Testimony Whereb�the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �a s?�, xdli�4oa, �a�a.�
Ga y�c D. C�. 'llll.D.. ?i�ee
,�e6art�. �soa�. �fark
�anr!!ek�or+xeu
�ele« S�uF. ,�?P.
Januarv9 ,2003
ruce . Y, ,
D'uector of Health
-""'1.r' . 13�uc Qo p ttop
,.�._ . � r� � � ue � �
` TOWN OF YARMOUTH BOARD O �,TH �
APPLICATION FOR LICENSE/P 'I�'�.2bp1 ��2j� DEC 2 8 2000
� �-' �� `?ib HEALTH DEPT.
* Please complete form and attach all necessary documents by Decem�r 31, 2000. F�ilure to o so v�n re
the return of your application packet.
-----------------------------------------,---_------------------------------------------------------ - ---------------
i N�1KE_OFESTABLISI�IMENT: 8��t �Poc,C C�u� l�e:c s/foP , # sb6' �y�. GqG7/
LOCATIONADDRESS: f� ToDo QofJO �So. �/,92n�o�JN
', zo o m,4i,v s-. sr. e ��rr1
i OWNER/CORPORATION NAME• �Av�=�/Pa2i Rr� , T2�5r
1 MANA R' N M : iPobe�t i/. MilLc-/' TF # 5D� 3%� G9G �/
1
L�II.INGADDRESS: 4k TU�IA kt%. So �H2MourT/
----------------------------------------------------------------------------------------------------------------
i POOL.CER'I�ICATIONS:
; The pool aupervisor must be certitied as a Pool Operator, as rec�uired by new State law. Please list the
� designated Pool Operator(s)and attach a copy of the certification to tlus form.
1. 2.
i
Pool operators must list a minimum of two empioyees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Heelth Department will not use past yesrs' records. Yoa must
i provide new copies and maintain a fde at yonr place of buainesa.
� 1. 2.
3. 4.
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.
� Yon must provide new copies and maintain a fde at your plsce of business.
i
� 1. 2.
3. 4.
i
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
------��_____________W__--------------------------____ .�__���______�._-------------- �r_�� _�._�.�------
� OFFICE U5E ONLY
i LODGING:
, LICENSE REQUIItED FEE PERMIT# LICENSE REQUIlZED FEE PERMIT#
_B&B $50 _CABIN $50
INN $50 CAMP $50
LODGE $50 TRAILER PARK $50
_MOTEL $50 _SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE: —
NOTE: Per the new 105 CMR 590.000 State Sanitsry Code for Food Establis6ments,the effeMive date for
food protection manager certitication is October 1,Z001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $75 0(- 11 _CONTINENTAI, $30
_>100 SEATS $I50 NON-PROFIT $25
I COMMON VICT. $50 �O - � _WHOLESALE $75
RETAIL SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35
_>25,000 sq.ft. $200
NAME CHANGE: $10 '-
AMOUNT DUE _ $ 12 5.00
:•'•'pLEASE TURN OVER AND COMPLETE OTHER 3IDE OF FORM:•""*
�_. _. .� _. _, -
• ��
_ _ ` . a . . .
;
ADMINISTRATION
I�nder Cha�tez�5�, �ection 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
�_• , .
Sf'aiiy licerise or pernut to operate a business if a person or company dces not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPEN5ATION INSiIRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED X
�
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED
Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_�� NO
NOTICE:Pemuts run annually from January 1 to December 31. I'I'IS YOUR RESPONSIBILTI'1'TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�F�ALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENRJG FOR THE SEASON.
ALL RENOVAITONS TO ANY FOOD ESTABLISIIMENT, 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 SITE PLAN.
ADDITIONAL RF.GUi�ATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been ciosed for the season must be inspected
by the Health Department,and ihe water tested for pseudomonas,total coliform and standard plate count by a State
certified lab,prior to openuig,and quarterly therea8er.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
NEW STATE SrLNITt�RY CODE FOR FOOD ESTABLISHMENTS•
The effective date for food pmtection manager certification is October 1, 2001. As stated in 105 CMR
59U.003(A) 2), food establishments must have at least one person-in-charge who is a certified food pmtection
manager. �s pmvision is effective one yeaz from the date of promulga6on of 105 CMR 590.000.
T6e effective date for consumer advisory is Jxnuary 1,2001. As stated in 105 CMK 590.000(K), enforcement
of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories.
�ATERiNG POLICY•
Anyone who caters within the Town of Yarmouth must nodfy the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtamed at the Health D�artment.
FROZF.N 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 Fmzen Dessert Permit undl the
above terms have been met.
OUTSIDE C�FF:S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mast have prior appmvai from the Board of Health.
OUTDOOR COOKING: '
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: /Z 1 b''•0 U SIGNA
PRINT NAME&TTTLE: �5�—E�'flc�' HSc If ' i Tii� . c_F o
11/16/00
I
; �ac�o CERTIFICATE OF LIABILITY INSURANC�, DATE�MMI�D/YY)
Sva�x�-i os/za/oo
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The Addis Group, Inc. HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
2300 Renaissance Boulevard ALTERTHECOVERAGEAFFORDEDBYTHEPOIICIESBELOW.
Riag of Prussia PA 19406-2772
Phone: 610-279-8550 Fax:610-279-8543 INSURERSAFFORDINGCOVERAGE
INSURED INSURERA: P.7�ei1CdII Zl1IlC11
B�.II6 ROC$ CSUIJ INSURERB:
c/o Davenport Realty Tsust INSURERC:
ESr. George Baldwin
20 North Maia SG. INSVRERD:
i South Yarmouth, MA 02664
INSURER E:
COVERAGES
THE PoLIqES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POLICV PERIOD W�ICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM Oft CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WI7H RESPECT TO WHICH THIS CERTIFICA7E MAV eE ISSUE�OR
MAY PERTAIN,THE INSURANCEAPFORDED BV THE POLIQES�ESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF Sl1CH
POLICIES.AGGREGATE lIM1T5 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYFE OF INSURANCE POLICV NUMBER P LI Y EFFECTI P 1 E%PI
DATE MM/0 UATE MMlDD/`/Y �1MITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIA�GENERALLIA841TV FIREDAMAGE(Anyonefire) 5
CLAIMS MADE ❑OCCUR MED EXP(My one Derson) S
PERSONAL&ADV INJURV S
GENERALA6GREGATE $
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG E
PO�ICY PRO- LOC
JECT
. AUTOMOBILE LIABILITY
ANV AUTO (Fa aBcideO"INGLE LIMIT E
ALL OWNED AUTOS �
BODILV INJURY E
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BO�ILY INJURY a
NON�OWNED AUTOS (Per accidmt)
PROPERN�AMAGE s
(Peraccitlenp
GARAGELIABILITY AUTOONLY-EAACG�ENT S
ANVAUTO
OTHER THAN �ACC $
AUTOONLY: AGG $
EXCESS LIABIIJTY EACH OCCURRENCE $
OCCUR �CLAIMS MADE � AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $ _
WORKERSCOMPENSATIONAND X TORYLIMfTS ER
A EMPLOYERS'LIABILITY yrC819602403 0$��1��� Q$�Q],�Q], E.L.EACHACCIDENT $ ],�QQQ�QQQ
E.L.DISEASE-EAEMPLOVE $ S�OOO�OOO
ELDISEASE-POUCYLIMIT $ 1�000�000
OTHER
DESCRIPTION OF OPERATIONS/LOGATIONSNEHICLES/EXCLUSIONS ADOED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
YARMO_2 SNOULOANYOFTHEA90VEUESCRIBEDPOLICIESBECANCELLEDBEFORETHEEXPIR/1TI0
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN
NOTIGE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SXAL�
Town of Yarmouth �,_
ATTN: Permit DEj�t. �MPOSENOOBLIGATIONORLIAB OFANY UPO HEINSUHER,ITSAGENTSOR
1146 Route ZH REPRESENTATIVES.
S. Yaxmouth, MA 02664
Amie M. McHale �
4CORD 25S(7l97) �ACORD RPORAT
�11I�H 30,to�oattQ
OH� `'. ` dL1I`,Cqd�ny� •rJ aoni
� IOOZ` SN +�
�Q+�L �� .
�. � ��
,,!� � � ��a,,��
�%�/ ��i ��. 1� a"O"%�/
�0�'"'� ��� �?'3 �H.L'IF��H 30 Q2It�Og
•sam1BuSis iei��o iia�pax�}e olvnaiaq an�pa�Sisiapun a�`3oaia�,Cuounlsas uI
' •olaia�s�ua�upuau�pue `Ob I ia�deq� `sn�e� �e,[aua�,iq saquotpne 8u�sua��i a[�o�
pa�ue�,C�uoy;nB a���,u�uuo3uoo ut pansst st asuaoti sn�y s�iai��tn uounuoo 30�ursua�ri
a��uc�oadsai��zamaounuo� a��o sn��i a�3o uonBlotn.[03 paxoriai io papuadsns iauoos
ssaiun IOOZ;ST3-�i�iaq�aoaQ san xa pue 6�o a�id lu�;E pus ylnouuz�3o u,�os p�s uI
�S1�I��I'I S�ZI�'I'IVII.L�IA AIOI�1tL�I0�
d Q�.I,Nd�I�J�IH�2I�-I SI
� ' jd nI x nt E is .L ?I �EQ 3Ey1��ua� ol si sn�y
OS �3�3 0-IO �2I�gY�If1N.LIY�RI�d
H.LIIONRIF 1i,30 NIAAO.L
S.L,L�Sf1H�VSS�I�1I.30 H.L'IV�AAAIOL1IL1t0� �I.L
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NiJMBER: #01-114 FEE: $75.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and
Chapter 111, Section 3 of the General Laws,a permit is hereby granted to:
navennort RPaltv Tmct 4R Todd Road 4o i h Yarmnnt� T��rq
Whose place of business is: Blue Rock Cl b Pm- ho�
Type of business: Foo�Service
To operate a food establishment in_Town of Yarmouth
Permit expires: December 31 ��� BOARD OF HEALTH: �d fK. �et�, �aur�a�c
�� s?�. ZelfuFec. `l/ieee �fai�r�a�
2es7'alcnoNs tF nt�rY: Packaged chips,candy,chewing gum only. ���� �y�qy, ��
. �iClE4Ce � .�
M� s ,2001 �9'
Bruce G.Murphy,MP .,CHO
Director of Health
� -��. 3U,�e �c�G� P�� ���;
_ - _ � Towrr oF YA�ou�ra s ����o��ai.'r� � � � � � N/ � �
li � ' APPLICAITON FOR L���I�T-2000 ►�b V 2 9 1999
� �� ��� � ��� ,
I * Please complete form and attach all necessary do�u�nt3:�3y December 31, 1999. F ',�� t in
� the return of your application packet. �,�
---------------------------------------------------------------------���------------- ----------------_.
NAMEOFESTABLIS�N'T: �lue Qock C.�Jb �ra -Shaa �I, # 5�k 3q� 6�bi
LOCATION ADDRESS• 4 S 1-oc4cf 2�' Sa �an moul'�^
L 2o tlort'in fYltun St. So. ui'(^
N �Guen o�rt �l?a,C T/' -t- �
, . o rf V. �I le✓ #
MAILINGADDRESS: �Ff°dcf oad S� �1�trmou
--------------------_____________�_--------_______-------------W��-------�__�______—�__�.
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to ttus form.
1. n �� 2.
Pool operators must fist a minJmum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitat�on (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 maintaia a file at your ptace of business. µ
8 �.G. l.e,. i� ���
i. �,�� z. ;Iz n.w.�
3. 4.
HEIMLICH CERTIFICATIONS:
All food service estabfishments 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
attsch copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and roaiataia $file at your place of business.
1. V���� 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKIDIG SEATS: TOTAL#� __ _
----_____�----------------------- ----------_______�_MW�-----------------�____________________
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIILED FEE PERNIIT #
_B&B $50 _CABIN $50
INN $50 CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMMIIVG POOL $50ea.
_WHIltLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIILED FEE PERMIT#
LO-100 SEATS $75 y�-27 lCONTINENI'AL $30
_>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 Y2.1_-l� _WI-IOLESALE $75
IZF.TAII. SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.R. $75 FROZEN DESSERT $35
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOiINT DDE _ $ I Z�-�
"••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•"••
' ADMINISTRATION .
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRFA
T0 HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS�'A �
PERS�T�T-flit'�014TPANY 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
�&
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERNIITS. PLEASE CHECK A�PROPRIATELY IF PAID:
YES_� NO
NOTICE: PERMITS RUN ANNUALLY FROM JANLJARY 1 TO DECEMBER 31. Tl' IS YOUR
RESPONSIBII.I1'1' TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISI�Il�IENTS ARE TO CONTACT TFIE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENII�TG FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
C011�NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWIl�A�IING, WADING AND WHIILLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND TI3E WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COLTNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIMIlVG POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WiTHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH
DEPARTMENT BY FILING Tf� REQLTIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT Tf� HEALTH
DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII.URE TO DO SO WII.L RESULT IN Tf IE
SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII.TT�ABOVE TERM_S_HAVE
BEEN MET.
OUTSIDE CAFES:
OiTTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), M[JST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD '
SERVICE ESTABLISHIvIENT IS PROHIBITED.
DATE: II•L6.�1� SIGNATURE:
PRINT NAME& TITLE: �� �c�wm. �i�. �K.�ec , v.�. ,
11/12/99
ACORD CERTIFICATE OF LIABILITY INSURANCE�, °"�`"�'°°""
P����. �VRBDi-1 03/04 99
The A3dis 6sou Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
3uilsa �280' P� ONLYAND CONFERS NO RI6HTS UPON THE CERTIFICATE
HOLDER.THIS CERTtFICATE DOES NOT AMEND,EXTEND OR
100 Ponr �alla Corporate Ctr. ALTER THE COVERAGE qFFOROED 6Y THE POLICIES BELOW.
OOest 4bashohockea PA 19428-2976
Phoaec610-832-2100 8axo610-825-9136 INSURER8AFFORDINGCOVERAGE
IN3URED INSURERA: �e=iCdA Zurich
Hlue Rock Club iruuaeRa
c/o Dave ort Re lty Trust
Mr. Georg� Haldw�n iwuR�xc:
20 North Maia St, irvsuaFno
South Yarmouth, MA 02664
IN8URER E
COVERAGES �
THE POUqES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE AOLICY PERfOD INDICATED.NOTVJITiSTANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY GbNTRACT OR 07HER DOCUNENT WITH RESPECT TO WHICH THIS CER'fIFlCATE MqV BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIGE8 DESCRIBEO HEREM IS SUBJECT 70 ALL THE TERMS,EXGWSIONS AND CONDRIONS OF SUCH
POLICIES.AO6REOATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS.
L T'�OF INSl1RANCE pOIJCV NUMBER pA� ��
GENp2AL I.�p9��J}y EACH OCCURRENCE S
COMM�tpAL GENERAL UABILIIY FlRE DAMAOE(Any one fin) $
CLNMS MA�E ❑OCGUR MED DCP(Any one pe�cen) $
PERSONALB A�V INJtIRY S
GENERqLA00pE0A76 S
GEMLAGGRE6ATELIMITAPPLIESPER: � pRO0UCT6-COMPlOPAGG S
POIACV j� LOG
AU(OMOBILE W81lIiY
COMBINED 3INGLE fJMR
ANyAUTO �e�q�nU S
ALL OW NED AUfQ4
SCHEDULEDAl1TpS �DILVINJURV g
(PM Person)
HIRED qUTQS
60�ILY INJURY
NON•OVJNm AUT0.S (pm aaldenq S
PROPERTV�AMAGE s
(Per acclEa�y
GARAGEUABILITY AUTOONLY-EAACLYOENf f
ANY AUTO
07HER7HAN EqACG g
AUTOONLV: AG6 S
EXCESSLIABILITV EqGFiOCCURRENCE S
OCCUR �CLqIMSMADE AO6REGATE $
S
OEDUCTBLE
a
RETENfION ;
S
WORKERSCOMPENBATIONAND X TORVLJMfTS ER
A EMPLOVERS'L�q&LfiY y�819602402
03/01/99 03/O3/00 E.LEACHACCIDENf s1,000,000
��.o�sensE•�a�r.+P s1,000,Q00
onaea
e.�.oisEnse•aoucvurtar s 1,000,000
OESCRIPTION Of OPERnTION5ILOCA7pµgryp{�LE&IXCLUSION6 AODED 6y ED�ppRSEMEM/SpEC�AL PROVISIDNs
CERTIFICATEHOLDER Y qODITIONFI.IN3URED;INSUR62L�TER; CANCELLATION
YARMO-2 ���A��TMEAfiOVEDESCR�BE�pOLICIESBECANCELLEDBEFORETFEE�IRq7�ON
DATE iHEREOF,THE 155UING INSURER VJ�LL ENOEqVOR TO MAIL 3 O DpVS Wp�7'7Ery
TOWII o£ Yarmouth �nCE T0 TF{E GERTIFICA7E HOLOER NAMm TO THE LEFT,Bvf FA&l1RE 70 00&O SF{q�L
j�'j"j'j1; pe�j�t DeSt, IMP0.SE NO OBUGATION OR LIA D U IN6VRER,115 qGENTS pR
1146 Route 28 ���rnnvEs.
S. Yarmouth, MA 02664 AUf11DRHEDREPR nvE
ACORD 25S(7l97) �ie �• McBa
" ACO ORPORA 1
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-27 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
1 I],Section 5 of the Genernl Laws,a pertnit is hereby gan[ed to: .
Davennort Realtv Truc 4R Todd Road Snnth Yarmo � h_ MA
Whose place of business is: Blue Rock Club Pro-Shop
Type of business: Food Service
To operate a food estabiishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:� �P/. �et�//a, C'�a�.�qq„ q� n
�oan G. �nuClivan�n�a /1.� Vice l.�ir
ttEsix[c17oNS �F astv: Packaged chips,candy,chewing gum only. �o6erE a.g�nC7rowAn, C.[e�r/�
a�r/iel[s6 Ja�/ll��y/-�Jdaa�
ichaeC dou9kCin
December 3 , 19 99
Bruce G. Murphy,MPH .S HO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOI7TH
PERMIT NUMBER: Y2K-16 FEE: $50.00
This is to Certify that Davenport Realtv Trust d/b/a Blue Rock Club Pro-Sho�
4R Todd Road South Yarmouth_ MA
, IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. Tlus license is issued in conformity with the authonty ganted
to the licensing authorities by General Laws, Chapter 140,and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their oi�'icial signatures.
BOARD OF HEALTH: ��I�.+�Btt�p/, C�q�/., q , /
�oart.G. �'uCCivaR, �/l•, Vic6 C.'�ai.n�an
o6�.t/�/ nd3�„g�, C�,�
a6ri/eCleg Ja�OU�y-�/ oo�
' hasl O o �Lin
December 3 , 1922 mce G.Murphy,MPH, S. O
Director of Health
,
, �,..� � .. � --- l�w�k(P,c 5���4�,
`� , 4 . .. F, t ..� � '� `� 1.� �� S�� �y n
IJ
TOWN OF YARMOUTH B�O�}+d�+'�1`E�ALTH DEC 1 7 1gg7
APPLICATION FOR LICENSE /PERMIT -�998
��, HEA!.TH DEPT.
" Please Complete form and attach all necessary documents by December 31, 1997. Failure to do
so will result in the retum of your application packet.
--------------------------------------------------------------------- -------------------------------------------
NAMF {�F ST T4F�MFN'�'• a�U2 QA� C(1,I0 �ro -1ho� TEL # 5Dg�3�8 696Y'
AADRESS; 4B �OcfcQ �6 .So (.tor.vmoul�In
G Zv (1 D . a.tn t . 5 . �hurw�ovrL+
O�ORPORATIOrT AT MF• i i)O n na�t Trus�i
ivfAIVA '-:R•, 1V MF: fLOt]P.✓t U mI l�.Z� T T �, sCiJN.e--
1�II.ING ADDRES�� sc�,rnk.
-----------------------------------------------------------------------------------------------------------------
POOT RTIFI ATIONS:
Pooi Operators must list a minimum of two employees currently certified in basic water safety,
standard first aid and Commuoity Cardiopulmonary Resuscitation(CPR).Please list these
employees below and attach copies of employee certifications to this form. The Healt6
Department will not use past years records. You muat provide new copies and maiatain a
file at your place of business.
nl� �
1. 2.
3. 4.
HFIMLICH CERTIFICATION�
All food service establishments with 25 seats or more must have at least one emplayee trained in
the Aennlich Maneuver on the premises at all times. Please list your empioyees trained in anti-
choking procedures below and attach copies of employee certifications to this form. The Health
Department wili not use past years recorda You must provide new copies and maintain a
file at your place of busioess.
_ 1. h��� 2.
3. 4.
RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL#
----------------------------------------------------------------------------------------------------------- ---
� OFFICE USE ONLY - ---
i ODGING:
� LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT#
' _B&B $SO _ CABIN $50
i
._INN $50 �CAMP $50
� _LODGE $50 _TRAILER PARK $50
� _MOTEL $50 _ SWIM POOL $SOea.
,
I
_ VVHIRI.POOL $25ea.
, FOOD SERVIC�F;
� LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT#
�0-100 SEATS $7 qg"Sl _CONTTNENTAL $30
I _>I00 SEATS $ 0 _NON-PROFIT ___ _$25_
� 1 COM. VICT. 50 gQ�3S WHOLESALE $75
� —
$�a
����
LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT#
_<50 sq. ft. $45 _TOBACCO $20
_<25,000 sq. ft. $75 _FROZ. DESSERT $35
._>25,000 sq. ft. $200
Sep�rate payment is needed for y, �
liquor or entertainment licenses AMOUNT DUE _ �J
Y , �
^ i
ADMINISTRATION
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS
NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSB OR PERNIIT
TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A
CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACAED
STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE
COMPLETED AND SIGNED.
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR
ISSUANCE OF YOUR PERMTTS. P,LEASE CHECK APPROPRIATELY IF PAID:
YES �� NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS
YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIOI3(S) AND
REQtJIRED FEE(S)BY DECEMBER 31, 1997
SEASONAL BSTABLISHIvIENTS ARE TO CONTACT'�HE HEALTH DEPARTMENT FOR
INSPECTION 7-10 DAYS PRIOR TO OP�I�iING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOb ESTABLISf�fENT,MOTEL OR PdOL (i.e. ,
PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TQ AND APPROVED BY
THE BOARD OF HEALTH PRIOR TO COMIviENCEMENT. RENOVATIONS MAY
REQLTIRE A SITE PLAN.
AT,DITIONAL REGULATI4 1�S
POOLS
POOL OPENING: ALL SWIMMING, WADING AND VJHIRLPOOLS WHICH HAVE BEEN
CLOSED FOR THE SEASON MUST BE INSPECTEb BY TF� HEALTH DEPARTMENT,
AND 'THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO
OPEI�IING.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIbfING POOL M�TST BE
_ -DRAINED12R�0YEREI2VIITHII�i-SEYEN�I�I)AYS-OE_CLQSA�I�.- - ---. _ ____- -- -- ---- - -__
FOOD 5ERVICE
��RiNC'�Oi.ICY:
ANYONE WHO CATERS WITHIN THE TOWN OP YARMOUTH MU3T NOTIFY THE
YARMOUTH HEALTH DEPARTMENT BY FILING'I'HE REQUIRED`I'EMPORARY
FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf�CATERED EVENT.
TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT•
FROZEN DES�FRTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE
CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTI�NT•
FR07.EN DESSER PERbIIT UN"I'IL TI�ABOVE TERMS HAV BEEN MET. OF YOUR
�rrsmF caL�s:
OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),
MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH.
ozrrnoox coo�r��: '
OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A
RETAIL OR FOOD SERVICE ESTABLISF�vfEEN'T IS PROHIBITED.
DATE: �Z' �b�� SIGNATURE; �,
�"C\�2�/
PRINT NAME &TITLE:����Idi.u�'1. J�• �KCC. l�. 1 •
10/97
page 2 of 2
,
�_ .������',`�;�'�������:�� ������s�_� �1 a� ',
;
p� .. .. ... . ,;: ...��THIS CERTfFICATE i3 ISSUm AS A NAFTER OF NFORIIATION
Ths 11d8is 6roup. Iac. ONLY AND CONFERS P�RIGHTS UPON THE CERTIFICATE
Suite S00 F�LDER-71i►SCERTWCATEDOE8MOTAMEND,EXiENDOR
100 lour Halle CoYporata-� CCr. ALTERTF#ECOVERACiEAFFORDED.6YTF�PQLICIES�LOW-
Nast Lbaahohocicaa Ba 1942 8-2 97 6 COiYIPAHIESAFFORDINGCOVBRA(�E
ShaNn R. Rnachtel, ARll, CIC �p� �=iaea Zurich
pnv.wo. 10-832-2 � �rr.6 0- 2 -9 36 ,
� ��. cawarv .
8
Davenport Reslty Truat °O"APAD1'�
llr. 6eorga Si118�rin ; C
ao ��n xasa st. �,,,,v,.,
souraz :a�th, w► oa6ca o
_ , ; , _. _ ...
rws�BrocElttiFrnMriNEPW.IC�EsoFwBUn.wce��srEue�.owNnveeEEN�ssUEoronleNlsuqEonnMEOABav6FaRlf�voucv.rERroo �. . � ..
P01U1TE9.IiO7UVITF16TAt�iNHYRE�UFBE.MT.IEPIR OR CONOff10N OF 7iP1Y CANNfRPiCT ai OilERDOCUMCaIi'bYllli/�APECf T�V�RYq{7FII8
CERTIFICATEMAY BE ISSUEO'bR AMV PERTAIN.Tfff MBUMNCE AFFORDE�BYlFi-PoLICES OESCRIBED HEREIN IS SUBECT TO ALl7Hc TEFMS.
FXCI.USbNS MIDCON01710N8 OF SUCN POL�CfE&LlY7S SHONW MYY HAVE BEEN REDUCED BY PAID CG/YA�.
t'�IR T'PEOFttiSURRNCE POLICYNUMBER MTE�YIMNDfl'Y) a�l�Y) LIMII9
OENFRALLNBIIATI . BENEWILnG(aFEW7E t
C�CIALOENERKL15BRliv vRO0UCT8-CO�iAv,1G[i S
cur�sewne �ocam . . _ r�a�ovx+nxtv e
`..n OYMIER'86CONTNACY$H'SPROT �"�. . . EaL710CC11RRENCE 6
�oawi�l�nw*t`.1 i
� MEu�tvWwarep.mm> s
.AIIfO11�811::ELYNILITY .
a rrae
canex�osa�c�uMrt 3
urr,wta
ntE awx�n wros eoo�r w.tin+r
sc�owEn�uros �r"°.r°n'� •
�owros . e�v�r
r�oN.owamwros _ _ _ _ _
� PROPERiV�M�WGE .S . . . - . . . ..
WRKiEWlM.RY':-::. . ....... AUIOO�AY-EA/VCCI�ENT S . . .
NIYI4Uf0 � - D7FIER77NHAUfOO/LY
........ :. .... ... .. _.
ERCFINCCIOENf i..-. .
AO(iREG47E .�.._. ._ . .
E%CR�bi.611fiRFI'/ . I . ' . _ . � EACNOCCURRENCE i .._ ..
UMB�LIAFONM �GGREONTE 3
OlXER7w�N iR6REW FORM i
YrOM(BM�B181i710N NID $ A �-' ' ;:?
. .._ .-.s....._.,,.�.._.,
E�L41ER8'W9LOY _ KEACNACCIUENf � SS•000•000 �.-
1l �P�� E �x 1(C81960240Q O7/OS/97 03/O1J98 �o�nse-ro�crw�r s1,000,000
o�sr� Fxc� �o�wse-�wa�.or� a1,000,000
an�
� �� '.. - �� . ��. ��� . . , . . . . - : .
ossaaanowaFareunorsa.or.wnona�Nie�ma�.� �s
_ #1�I�CICR �F.�l�1: _
__ .,. _ , . ,. . .�:. _
. :
__ ____. _., Y�_3 srromn,unoFn��eoveoescweFnPouapeecrwce��fieeror�n� _ _
;.._ o�nen�rowoare�.nxroeur�eao�v.wrMw.�exoew+iaeroeuu�_.._ _...
. ... �.-, . 30 o�n�r�+rancEron�c�mFlea��narmronE�::�__.
�« �e91ib�'�of Yarmauth BtRFMWRE70WN.&ICNNOiCEeN11LLWPOBEN00&.190.i1�NAR�umm.__...
.., _ 7CR`4'Ai "�lraiE 11ipE.
' 1146 Routr 28 ov�wr�aauwd�xe�Mr.��nsaeRer�r�mrea
AUTiOPoffD R�8lNTA7NE / . ...
;., S. Yatuoutta, 1fl4 07664 //� c/��! ..
� Shavm R. 7Caechtal. �iCIC""'��Y
� ' �-" � 1$�:.
,
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: 98-35 FEE: $50.00
This is to Certify that Davenport Realty Trust d/b/a Blue Rock Club Pro-Shop
48 Todd Roadr$rnrth Yarmrnrth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 1998 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: ���(/.� �natt0see, C�ia(��.,�,,/��+an / /J/
iSEATIIJG: �/�oa/a C�.�J7u/�lli�an�/KJp./l.� Vice l-h�irman
� Kob/er� J. i>rowen� (�[�/r/�
� abrie��a�roG��rtf�ldooPed
� • �a�0' ���:,�
January 2 . 19 98 -
i ruce G. Murphy,MPH, .5., HO
Duector of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTl' TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 98-51 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 395A and
Chapter I 11,Section 5 of the General Laws,a permit is hereby granted to:
naven,�n,nrt Real y Trus 48 Todd Rnad South Yarmouth MA
Whose place of business is: Blue Rock Club Pro-Shon
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 1998 BOARD OF HEALTH:�d�l. �ett��, C�+t...+an
SEATING: �oan��7snuee�a�, ,��, v�e ctia�.,�n
xEsriuc'rioNs tF nt�: Packaged c6ips,candy,chewing gum only. �o6e�t BJO .[O,�rowon, C�er�x
� a�rielle Ja�rol��iy-�aaPea
�;��e o('ou�l�PR �
Januat�, 1998 � � ti=-
Bruce G. Murphy,MPH, .5., O
Director of Health