HomeMy WebLinkAboutApplication and WC 4OI EAST JACKSON STREET BOCAR9TON
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GRACE.YANG(�GRAY-ROBINSON.COM September 15,2015 n'ArcEs
ORL,9ND0
VIA FEDERAL EXPRESS TALLAHASSEE
TAMPA
Town of Yarmouth
Board of Health
1146 Route 28
South Yarmouth,MA 02664
Re: Dollar Express Stores LLC d/b/a Dollar Express
31 Long Pond,Yarmouth,MA
Dear Sir/Madam:
Our office is assisting Dollaz Express Stores LLC with permitting new Dollar Express stores in
MA. The date of ownership for this store is October 2, 2015. (This location was formerly a Family
Dollar store priar to October 2, 2015.)
Enclosed please find the following:
1. Application for Tobacco Sales Permit;
2. Copy of the Massachusetts Deparhnent of Revenue Retailer of Cigarettes Permit; and
3. Our firm's check in the amount of$260.00.
If you have any questions,please do not hesitate to contact my office. Thank you.
Sincerely,
iC-(.,� �^-/gr1
Grace H.Yang� `J
Attorney At Law
GHI'/arg
Encs.
G3L�C��O�'i'GDD
SEP 16 2015
HEALTH DEPT.
_ �C�,Gr�OGC�
a TOWN OF YARMOUTH BOARD OF HEA�� �. ' -'_
APPLICATIONFORLICENSE/PERMIT �5 � �.. •:��x � � SEP 162015
*Please complete fortn and attach all necessary documents by December IS.2014.
Failure to do so will result in the return of your application packet. HEALTH DEPT.
ESTABLISHMENT NAME: DOLLAR EXPRESS TAX ID:
LOCATION ADDRESS: 31 LONG POND.YARMOUfH.MA 02664 TEL.#:
MAILING ADDRESS: 7520 E.INDEPENDENCE BLVD.,CHARLOTTE,NC 28227
E-MAIL ADDRESS: �he6rd�mydollarexoresscom �
OWNER NAME: DOLLAR EXPRE55 STORES LLC
CORPORATION NAME(IF APPLICABLE): DOLLAR EXPRESS STORES LLC
MANAGER'SNAME: alcKSILIAKus TEL.#: 984500-9146
MAILING ADDRESS: 7Sp0 E INDEPENDENCE BLVD.CHARLOTTE.NC 28227
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list[he designated
Pool Operator(s)and attach a copy of the certification to this fonn. �
1. 2.
�'� Pool opera[ors must list a minimum of two employees wnently certified in basic water safery,s[andard Firs[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 Heaith Department will
not use past years' records. You must provide new copies and maintain a£le at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS-CERTIFICATIONS:
�y All food service establishments are required to have at least one full-time employee who is certified as a Food
�' T` Protection Manager,as defined in the Sta[e Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Pleaseattachwpiesofcertificationtothisapplicatioa TheHealthDepartmentwillnotusepastyears'records.
You must provide new copies and maintain a Fle at your establishment.
l. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on si[e during hours of opera[ion.
1. 2.
ALLERGEN CERT[FICATIONS:
All food service establishments are required to have at least one ful]-[ime employee who has Allergen certification,
as defined in[he State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this applicatioa The Health Department will not use past years'records. You must
provide new copies and maintain a file at your establishment.
l. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 sea[s or more must have at least one employee hained in the Heimlich
Maneuver on the premises at all times. Please list your employees[rained 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMITN LICENSEREQUIRED FEE PERMITN
6&B S55 CABIN S55 MOIEL S1I0
INN S55 CAMP $55 SWIMMMGPOOL$IIOea.
LODGE E55 TRAILERPARK $105 WHIALPOOL $IIOea.
FOOD SERVICE:
LICENSEREQUIftED FEE PERMITM LICENSEREQUIRED FEE PERMITk LICENSEREQUIRED FEE PERMITX
0-I00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>1005EATS 4200 COMMONVIC $60 WHOLHSALE $80 ��
—RESID.KITCHEN $80
RETAILSERVICE:
LICENSEREQUIRED FEE PERMITN LICENSEREQUIRED FEE PERMITk LICENSEREQIDRED FEE PERMIT#
<50 sq.fl. $50 >25 000 sq.$. $285 VENDING-FOOD $25
�XQS,OOOsq.R. SI50 �� Tp� _FROZENDESSERT S40 x TOBACCO $110 �I`5�637
NAMECHANGE: $IS AMOUNTDUE � S 260.00
euaapLEASE 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 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 TO BE PROVIDED UPON RECEIPf DURING
W EEK OF 9/21/2035.
. CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance ofyour permits. PLEASE CHECK
APPROPRIATELY IF PAID: YES ✓ ��"u: Ou5 i r1�5�� ria -hc.yc�S c��.tf y e.� �
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENTOCCUPANCY: ForpurposesofthelimitationsofMotelorHoteluse,Transientoccupancyshallbe
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 [ha[ they maintain a principal place of residence
elsewhere.Transient ocwpancy shall generally refer to wntinuous oceupancy of not more than thir[y(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. Ocwpancy that is subject[o the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior ro opening. Contact the Health Departmen[to schedule the inspection three(3)
days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until[he pool has been
inspected and opened.
POOL WATER TESTING: The wa[er must be tes[ed for pseudomonas,[otal 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 wi[hin seven(7)days of
closing.
FOODSERVICE . �
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by[he Heal[h Department prior to opening. Please contact the
Health Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who ca[ers within [he 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. These forms can be
ob[ained a[[he Health 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[hereafter,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 mek
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress 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 esfablishmen[is prohibited.
NOTICE:Permi[s run annually from January l ro December 3 L IT IS YOUR RESPONSIBILITY 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,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMEN EMEN . RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: � I � S SIGNATURE: ��
PRINT NAME&T1TLE: RACE YANG,ESQ.,A jy RRE GENT
Rw.11/03/14
� The Commonwea[th ofMassachusetts
Department oflndustrial Accidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apnlicant Information Please Print Le¢iblv
BuS1nCSs/OrganiZahOn Name: Dollaz Express Stores LLC dba Dollaz Express
Address: 31 LONG POND
City/State/Zip:SOUTH YARMOiJ1'H,MA 02664 phone #: 845-356-8390 x 121
Are you an employer? Check the appropriate boz: Business Type(requ'ved):
1.❑X I am a employer with 4 employees (full and/ 5. X❑ Retail
or part-time).* 6. ❑ RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales (incl.real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment
theu right of exemprion per c. 152, §1(4),and we have 10.❑Manufactiu-ing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑ Health Caze
with no employees. [No workers' comp. insurance req.] lz•� Other
*Any applicant that checks box#I must also fill ou[the sec[ion below showing their workers'compensation polity infoimation.
•'If the corporate officers have exempted themselves,but[he colporation has other employees,a workers'compensation policy is required and such an
organizatio¢should check box#1. �
I am an employer that is providing workers'compensation insurance for my employees. Below is the po[icy informatdon.
Insurance Company Name: ACE American Insurance Company
Insurer's Address: 1601 Chestnut St Ste 1
City/State/Zip: P�ladelphia,PA 19192
Policy#or Self-ins.Lic.# �R C48594815 Expiration Date: 10/31/2016
Attach a copy of the workers'compensafion policy declaration page(showing the palicy number and expiration date).
Failure to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposition of criminal penal6es of a
fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalries in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against tUe violator. Be advised that a copy of tlus statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerkJ'y, under thepains andpenalties ofp¢rjury that the information provided above is true and correct
Si�ature: ��/1 I��/lfY /YI i�n nn e n Date 10/7/2015
Phone#: 845-356-8390 x 121
Official use only. Do not write in this area,to be completed by city or town offtciaL
City or Town• . Permit/License#
Issuing Authority(circle one):
1.Board of Health 2,Building Department 3. City/'Fown Clerk 4.Licensing Boacd 5.Selectmen's Office
6.Other
Contact Person• Phone#•
www.mus.gov/dia
Massachusetts Department of Revenue 2014 - 2016
Cigarette and Tobacco Excise Unit
Retailer of Cigarettes, Cigars and Smoking Tobacco
ooa
This Temporery Voueher must be posted and Wsible at all fimes. Sales W persons under 18 years of age are prohibi[ed by law.
Applicatlon Number. AL545
Federal Identification or Social Securiry Number:
Mailing address for license: Sale locatlon
DOLLAR EXPRESS STORES LLC DOLLAR EXPRESS STORES LLC
7520 E. INDEPENDENCE BLV 31 LONG POND
CHARLOTTE, NC 28227 YARMOUTH, MA 02664
This document signifies that the business location listed above has iequested a license to sell tobacco produGs. This con�irmation voudier shall
only be used uMil the receipt of the permaneM license,at which point ihis documenl is null and void.
Massachusetts
Department of Revenue
PO Box7004
Boston,MA 02204-7004 �
DOLLAR EXPRESS STORES LLC
7520 E. INDEPENDENCE BLV -
CHARLOTTE, NC 28227
DOLLAR EXPRESS STORES LLC'S
LIMITED POWER OF ATTORNEY
FOR RETAIL TOBACCO
AND PERMIT PURPOSES
WI�REAS, DOLLAR EXPRESS STORES LLC ("Dollar Express") is a
Delaware limited liability company with a principal address of 7520 E. Independence
Blvd., Suite 100, Chazlotte, NC 28227 and is duly authorized to conduct business and
operates pursuant to Federal Employer ldentification Number 47-4165211;and
W1I�REAS, Dollaz Express has retained the law fum of GRAYROBINSON,
P.A. ("CnayRobinson") to serve as its regulatory wunsel for retail tobacco licensare in
various local and state municipalities. .
WFIEREAS, RICHARD M. BLAU, ESQ. {"Richazd Blau") and GRACE H.
YANG,ESQ.{"Crrace Yang")are shareholders at GrayRobinson.
WFIEREA5, Dollaz Eapress desires Richazd Blau and Grace Yang to act on its
behalf, as attomeys-at-law and as attomeys-in-fact, to secure Doilaz Express' good
standing as a licensee qualified and authoxized to sell tobacco products at its associated
Dollaz Express retail operations.
NOW, THEREFORE, Dollar Express hereby appoints and empowers
Richard Blau and Grace Yang 4o act as Dollar Express' true and lawful attorneys-in-
fact for licensure purposes relating to Dollar Ea�press retail locations located in:
Alabama, Arizona, California, Colorado, Connecticut, Delaware,Florida, Georgia,
Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New Mexico,
New York,North Carolina,Ohio;Oklahoma,Pennsylvania,Rhode Island,Tennessee,
Texas, UtaL, Vermont, Virginia, West Virginia, and Wiscunsin. Pursuant to this
, appointment,Richard Blau and Grace Yang are authorized to represent,request,and
file informafion; sign license applications(either paper or online application filings);
submit payments; receive licenses and permits; and act on behalf of Dollar Express
� and in the name of Dollar Express.
Tlus Limited Power of Attomey shall extend to actions before any office of any
local or state regulatory agency associated with the issuance of retail tobacco licenses or
permits related to Dollar Express'retail business.
It is the specific intent of Dollar Express that the power conferred on its attomeys-
in-fact will be exercisable by Richard Blau and Grace Yang from the date of this instrument
KE 37623321.1 �
,
, and shall continue in fiill force and effect until Mazch 31,2616 or if ternunated eazlier by
Dollar Express in writing. �
IN WI'INESS W�REOF, Dollaz Expxess' duly authorized representative has
executed tl5is PoweX of Attomey for Licensure and Pernut Purposes on tlris�day of
September,2015.
For: DOLLAR EXPRESS STORES LLC
f,
By:ii�,�.�� ���
Bruce Efir
Chief Execurive Of&cer
Vr.RIFICATION
STATE OF NORTH CAROLINA )
) SS:
COUNTY OF NIECKLENBURG ) ,
The foregoing insh'ument was acknowledged befoxe me on this � day of
September, 2015 by Bruce Efud, who is personally known to me or who praduced
_/� ��f�P.1(� �S �--1 C�2.Ir1 S � as proof of identity.
. .�-C�S
Notary Public
NOTARIAL SEAL
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