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Home My WebLink AboutApplications and WC rs=� ��`�i�� TOWN OF YARMOUTH BOARD OF FIEALTH OCT O`B LU15 APPLICATION FOR LICENSE/PERMIT-2015 * Please complete form and attach all necessary documents by Dece er I DEPT. Fa�lure to do so will result m the return ofyour application pac . ESTABLISIIMENTNAME: Speetlway#244o TAXID: LOCATION ADDRESS: 14 East Main Street,W. Yarmouth, MA 02673-8107 TEL.#: eoa-ns-o9ea MAII,ING ADDRESS:Speedway LLC Attn: Licensing Dept P.O. Box 1580 Springfield, OH 4b541-, E-MAIL ADDRESS:0002440@Stores.Speedway.com; ssowry@speedway.com ;� OWNER NAME: Speedway , LLC ` � CORPORATION NAME (IF APPLICABLE): �� MANAGER'S NAME: Maria Donadio TEL.#: �32425-8965 �,� MAII,ING ADDRESS:14 East Main Street, W. Yarmouth, MA 02673-8107 �� pIS�A� �._ POOL CERTIFICATIONS: The pool supervisor must be certiSed 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. l.NA 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past years' records. You must pravide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ],Maria Donadio 2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ],Maria Donadio 2 ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. ],Maria Donadio 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 file at your place of business. 1.NA 2. 3• 4. RESTAiJRANT SEATING: TOTAL# NA LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUll2ED FEE PERMIT# B $55 CABIN $55 MOTEL �N $55 —CAMP _SWIMMINGPOOL.�110ea. _�.ODGE $55 --TRAILERPARK $105 _WFIIRLpOOL $110ea. FOOD SERVICE: LICENSE REQTUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT t! LICENSE REp UIRED FEE PERMIT# _�100 SEATSS $200 —CON1'INENTAL $35 NON-PRO$IT $30 _COMMON VIC. $60 —WHOLESALE $gp RETAIL SERVICE: —RESID.KITCHEN $SO LICENSEq REQUIRED FEE PERMTT# LICENSE REqQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �QS,OOOsq.ft. 5150 �(o =pROZENDESSERT�$40 VENDING-FOOD $25 �TOBACCO $110 15 , � NAMECHANGE: a15 AMOITNTDUE _ $260.00 "*•*«pLEASE'I'URN 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 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 X OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEDX Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRlATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations 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. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shatl generally be considered Transient. POOLS POOL OPENING:All swimming wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Deparhnent prior to opening. Please contact the Health Deparanent to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heatth Department,or from the Town's website at www.varmouth.ma.us under.Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT[S YOUR RES.PONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, BTC.), MUST BE REPORTED TO AND APPROV6D BY THB BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE IRE A SITE LAN. DATE: � � SIGNATURE: J�' PRINT NAME&TITLE:�aso Cetel by Power of Attomey Rev. I1/03114 � The Commonweallh ojMassachusetts Department oflndustrial Accidents O�ce oflnvesttgations 600 Washington Street Boston,MA 02111 www.irrass.gov/dia Workers' Compens$tion Insurance Affidavit: General Businesses Apalicant Information Please Print Lemblv Business/Otganization Name: speedway, LLc (speedway#2aao> Addtess:Soeedwav LLC Attn: Licensinq Dept P.O Box 1580 Springfieid OH 45501 City/StStO/Zip:Sprinqfield OH 45501 PI70116 #:937-863-6870 Are yoa an employer?Check t6e appropriate box; Business Type(required): 1• x❑ 1 am a employer with 5-10 employees(Full and/ 5• ❑ Reffiit 2.❑ or part-time).* 6. ❑ RestauranUBadEating Establishment 1 am a sole proprietor or partnership and have no employees working for me in any capacity. �� ❑ Office and/or Sales(incl.real estate, auto,etc,) [No workers' comp, insurance required] 8• ❑Non-profit 3.❑ We ara a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have no em lo ees. « 10.0 Manufacturing p y [No workers' comp. insurance required] ' 4.❑ We are a non-profit organization,staffed by volunteers, >>•� Health Care with no employees. [No workers' comp,insurance req.) 12.0 Other Conveniece Store/Gas Station "Any epplicent that checks bax qI mus�elso fill out the sec[ion below showing iheir workers'rAmpensation policy infonnetion. �. ••If the mrporate officers have exempted themselves,but the col�wration has o(htt cmployees,a workers'compensation yo�ic�,is r��$u�� a'ganizntioo should chcck bvx N L � . 7 am an emp[oyet that is providing workers'compensattan insuraace for my employees. Be[ow Ts the policy informruion. Insurance Company Name: Old Republic Insurance Company Insurer's Address: �5 S Moorland Rd, Suite 300 City/State/Zip: Brookfield, WI 53005 Policy€l or Self-ins. Lic.# MWC30512700 7!1/16 Expiration Date: Attach a copy of the workers'compensation policy declaratlon page(showing the policy namber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance covera e verification. !do hereby certify, u t. ins and penalties ofperjury that the injormrstion provided above is true and correct Si n a i �-- n Date: Pho e#: 937-863- �V� � �Sn= YoIA��S A�t� O�cia/use only. Do reot write tn this areo,to be compleled by city or town ojJlclaG City or Town: PermibLicense# Issuing quthority(circle one): 1. Board of Aealth 2. Building Department 3. City/Town Clerk 4.Licensirtg Board 5. Selectmen's Office 6.Other Contact Person: Phoae#: www.mass.gov/die � . ,acoRO� CERTIFICATE OF LIABILITY INSURANCE DqTE�MMIDDIYYYy) ' THIS CERTIFICATE IS ISSUED�AS A MATTER OF INFORMATION ONLY AND�CONFERS NO RIGHTS UPON THE CERTIFICATE HO DER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND�OR ALTER THE�COVERAGE AFFORDED BY THE POLIqES �I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�S�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TNE CERTIFICATE MOLDER � IMPORTANT: If the certifieate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to . the terms and contlitions of the policy,certain policies may require an endorsement A statement on this ceRiflcate does not confer Aghts to the ; certffieate holder in Iieu of such endorsemen s. ', PRODUCER q T � Hylant Group-Cleveland - PHONE . '�� 6000 Freedom Sq Dr,Ste 400 E�q�� - FNC No: ,, Independence OH 44131 ADORES : � INSURERSNFFORDINGCWEHAGE pq��p ' INSURER R. INSUftFD . MARAT3 INSURER B: ��. Speedway LLC wsuners r. ' S00 Speedway Drive , Enon, OH 45323 �N3URER0: I MSURERE: . INSURER F: ' COVERAGES CERTIFICATE NUMBER:376100608 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD �, INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS �, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOW11 MAY HAVE BEEN REDUCED BY PAIO CL41MS. INSR , LlR 1'/PEOFINSURANCE q BR PpLICYNUMBER MMNDY� MM�� LIMITS � GENERqLLWBILITV �' EACHOCCURRBJCE g I COMMERCl4LGENERALLIABILITV A P EM S Ee ocarten S �� CLAIMSMADE ❑p�CUR MFDEXP(Nnyoneperson) g PER�NALBADVINJURY $ . GENERALAGGftEGA'IE g ', GEN'LAGGREGATELIMITAPPLIESPER: PRODUClS-COMP/OPAGG § ' POLICY PR6 L� E AUTOMOBI�E LIFBILITY � ANY AUTO Ea actlCe1g ' ALLONNED SCHEDUIED BODILYINJURY(Perperson) $ ��, AUTOS qUT05 BpDILYINJURV(Peractltle� S ' HIREDAUTOS NON-dAMED .. FUTOS PBOP�DAMAGE s S . UMBRELLALIAB ppCUR � EACHOCCURRENCE E ,,i EXCESS IJAB CLAIMSMADE �. '. AGGREGATE y . DED RETENTION S , q WORKERSCOMPENSATON MWC3051270p $ ��, ANDEMPLOYERS'l1ABILITY ��N 7/7Y2015 7/1/2016 X �STATU- OTM- ' ANV PROPRIEfORIPARTNERiEXECUTIVE � '' OFFICERIMFMBEREXCLUDED9 ❑ NIA E.LEACHACCOENT E5,Op0,000 � j (��aYinNH) Hyes,0esoipeunEx E.L.DISEASE-EAEMPIOYE a5,ppp,000 � DESCRIPTION OF OPERATIONS below ', E.L DISEASE.POLICY LIMR E5,Opp,ppp ,' DESCRIPTION OF OPERAlipNS/LOCATONS/VEHILLES (qk�c�qCORD 101,qtlCHionel Remnks ScheEule,H more space is requimd) � � � .. CERTIFICATE HOLDER � CANCELLATION � SHOULD ANY OF THE ABOVE DESCRIBE�POLICIES BE CANCELLED BEFORE ��. Evidence of Insurence-S eedwa THE EXPIRATION DATE TMEREOF, NOTICE WILL BE DELIVERED M � �� P Y ACCORDANCE WITH THE POUCY PROVISIONS. . � � AyU�T�HpOR/Q�E�D�\REPRESENTPTIVE ,, //K/s.t. �`�� . . ACORD 25(2010/05) The ACORD name and�o o are �7988-2070 ACORD CORpORATION. All rights reserved, . � , . 9 registered madcs of ACORD � . � �}�c�'lh - 1b �asT 11ar,u ;r. FaRrn�c.y E1t3s � Z.lZ4S� a TOWN OF YARMOUTH BOARD OF HEALTH n O �� - -� � APPLICATION FOR LICENSE/PERMIT-2015 ��!� I�� •Please complete form end attach a1I necessary documents byDecembe�IS 2014 - ., � Failure to do so will zesult in the renun of your applicanon F;�j �;j 1�� ESTABLISHMENPNAME: spceawaytzuo � . . LOCATION ADDRESS: ib East Main Street TEL.#: 50&775-0964 ',___.,_.:..�. � '� � _ . _._....._..._. .._..-' MAILING ADDRESS:ATTN:Licensing-P.O.Boz 1580 Sorinufield�Ohio 45501 � � E-MAILADDR�SS: OWNERNAME: HessReWilOperetions LLC CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME:Kyle Rowe �L.*: 1�3zlazs-axs MAILING ADDRESS:ATTN�Ccensina-P O eox 1580 Sorinafieltl.Oh"o 45507 � POOL CERTIF1CATfONS: �. The pool supervisor must be certi£ed as a Pool Operafor,as required by State Iaw. Please list the designated � Pool Operator(s)and attacL a copy of the certification to Hils foxm. �. 2. � Pool operatots must list a minimum of two employees currently cer[ified in basic water safety,standard First Aid and Community Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at ell times. � Please list the employees below and attach copies oftheir cenificauons to this funw TLo fIealth llepar[mcat will uot use past years'records. You must provide new rnpiea und maintain a f5te at your place of busincss. l. 2. 3. 4. FOOD PROTECI'ION MA,'QAGERS-CER"ITFICATIONS: All food service establishments are required to have at least one fiil4[ime employee who is certified as a Food Protection Manager,as defined in the State Sanitazy Code for Food Service Establistimenu, 105 CMR 590.000. Please attac6 copies ofcertification m this application. The Health Department will not use past ycacs'records. You must provide new copies and maiutain a file at your establishment. i. 2. PERSON IN CHARGE: Pach food estsblishment must have at least one Person In Ctisr�;e(PIC)un siu during hours of operatian. 7. 2. ALLERGEN CERTIFICATTONS: All food service establishmenu aze required to have at least one fiill-time employee w6o has Allergen certification, as defined in ffie State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to ihis application. The Health Deparhnent wili not use past years'records. Yon must provide new copies and maintain a file at your esWbtishment. 1. 2. HEIMLICH CERTIFICATIONS: AII food service establishments with 25 seats or more must have at leas[one employee trained in the Hevnlich Manauver on the premises at all times. Please list your cmpioyees hained in anti-chokmg procedures below and attach copies of employee certifications to tlils form. The Health Deparhnent will not use psst years'recorda. You must procide new copies and maintain a file at yaur place of business. 1. 2. i. 4. RESTAURANT SEATING: TOTAL# OFFiCF.USE ONLY Loncnac: LIC6'NSEREVUIRFD FEE YGRMIT# LICENSGREQUIREU PEE PERMITk WCENSEREQUIRED PF.E PERMIT# B&8 S55 CABIN 555 MOTEL SI10 IMI f55 CAMP S55 SV.'IMMINGPOOLSIIOex —�.ODGE S55 _TRAILERPARK 5105 WHIRLPOOL SllOea FOOD SERYICE: LICENSERL•OUIRED fEE PEIiMITR LICENSEREQUtAED EF.E PERMII'M I,ICENSEREQUIRED FEG PERMITN 0-IWSEAI'S 5725 _CANTINEMAL S35 NON-PROFIT S30 _>IOOSFATS 5200 COMMONVIG 560 �'HOLESALE S80 ' --- — — —AESID.KRCHEN 580 RETNL SERVICE: WChNSEREQUIRED F$H PEM71Tk LICENSEAEQUIRfD FEE PF..RMITY LICENSEREQUIRED FEL' PERMCf9 <50sq ft. E50 >25,000 R. 5285 VENDIMC-FOOD S25 �QS.00Osq.ft. SI50 �Z �ROZEN�ESSERT540 �7'OBACCO SIIO �,`1�� NAME CHANGE: S15 AMOIINT DUE _ $ I S.OO •••••pLEASE TURN OVER AND COMP6E7'E OTF7ER SIDE OF FORM•'"" � . . ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insarence. THE A1"CACFiED STA1'E WORKER'S COMPENSAI'ION INSUI2ANCE AFFIDAVIT MIJST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED_ OR � WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED_ � Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuauce of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � MOTELS AND OTHER LODGING ESTABLI5HMENTS 1'RANSIENTOCCUPANCl': ForpurposesofthelimitacionsofMotelorHoteluse,Transientoccupancyshallbe - limited to the temporary and short te[m occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they tnaintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more dian tl�idy(30)days,and an aggregate ofnot more tk�an ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling uoit shall not be considered transient Oaupancy 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 generelly be cons�dered Traasient POOLS POOL OPENING:All s^^mrn�,w�ding and w6irlpools which have been closed forthe season must be inspected by the Health Depariment prior to opemng. Contact the Health.Depaztment to schedule the inspection three(3) days prior to opening.PLEASE NOT'E:People are NOT allowed to sit in the pool area until the pool has been inspec;ted and opened. POOL WATER 1'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Heaith Department ttuce(3)days prior to openiug,and quar[erly thereafter. POOL CLOSING:Every outdoor in ground swimming pool mus[be drained or covered within sevea('n days of closing. FOODSERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Depar[ment prior to opening. Please contact the Health Department to schedule the inspection tluee(3)days prior to opening. - CATERING POLICY: Anyone who cate7s within the Town of Yarmouth must norify the Yarmouth Health Deparlment by filing ihe . requued Temporary Food Service Application form 72 hours prior to the catered event. These fomis can be obtained at the Health Department,or from the Town's website at www yazmouth.ma.us under I-Ieakh Depachuent, Dovmloadable Fonns. . FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening snd montlily thereaRer,with sample resu(is submitted to the Health Depsrtment Failure to do so will result m the suspension or revocation of your Frozen Dessert Peanit unril the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaihess service),must have prior approval from ihe Board of Health. OUTDOOR COOHING: Outdoor cooking preparation,or display of any food product by a retail or food secvice establishment is prohibited. NOTICE:Permits run annually from January 1 to Decetnber 31. TT IS YOUR RESPONSIBII.11'Y TO RETtJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PATNTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPR VED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVAI'IONS Y 2E A PLAN. ��DATE: �-Z,y -�, SI AT[JRE� PRINT N &TITLE: ohn Ha �s ower of Attome rs�.urosna