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Home My WebLink AboutApplication and WC _ pcc�1N S+f1��t3 , �, � _ _ �� 'ob�Cof;�#'ZO6 � TOWN OF YARMOUTH BOARD OF HEALTH ; � � � APPLICATION FOR LICE�?�iS�E�PE I fi'- i ��'t + � �� ' e..• ' - � � _ _ * Please complete form and attach all n��'essar,�d��nen s y;' �e ` ber.�.5.-� 201 S _:�.-,,- ' Failure to do so will result in th�;�tur�=o�-3�ur app�ication p�i�et.-- � - - �� ---�------r Ocean State Job Lot of S. Yarmouth, Inc. E�TABLISHMENT NAME: Ocean State Job Lot #206 TAX ID: LOCATIONADDRESS: 1080 Rt. 28, Yarmouth Plaza TEL.#: 508-394-1386 N[AILING ADDRESS: 375 Commerce Park Road, North Kinastown, RI 02852 E-MAIL ADDRESS: Permits@OSJL.com OWNER NAME: Ocean State Jobbers, Inc. CORPORATION NAME (IF APPLICABLE): ', MANAGER'S NAME: Diane White TEL.#: 508-394-1 386 ' MAILING ADDRESS: 375 Commerce Park Road, North Kinqstown, RI 02852 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. ' _ - ----__ ------ __ t 1. ___ _ 2. Pool operators must list a minimum of two employees currently certified in standaxd 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 y�ars' records. You must provide 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. 1. 2. ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. --- 1• n;anP _Wh i i-P��_— � �. 2•! �Ia.u��s �I��a � ALLERGEN CERTIFICATIONS: AII 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. 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-chokmg 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# -- �r.�Trr rrrr ��Tr v-- -- --- --' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$1 l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 ' _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' <50 sq.ft. $50 >25 000 sq.ft. $285 VENDtNG-FOOD $25 �<25,000 sq.ft. $150 �2�'j =FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $is AMOUNTDUE _ $ /Sb.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ` a , 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED X Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be t 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 i an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or � dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy � Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ' POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected ' by the Health 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. ..�,_��r_�� -�_,�.A,�_��r�._ _ .:_.�_��______ --- _------- -_ FOOD SERVICE ; SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING 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 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, , Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results ! submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen k 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 IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. 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. DATE: 11 -5-2 015 SIGNATURE: , � � ' PRINT NAME& TITLE: Elaine M. Gagne, Licensinct Manager Rev. 10/O1/15 � I �I The Commonwealth of Massachusetts i � , Department of IndustYial Accidents Office of Investigations ' 600 Washington Street Boston, MA OZIII ` �� www.mass.gov%dia �� Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/OrganizationName: ocean state Jobbers, Inc. Address: 375 Commerce Park Road City/State/Zip: North Kingstown, RI 02852 Phone #: 401 —295-2672 Are you an employer? Check the appropriate box: Business Type(required): � 1.� I am a employer with 4 5 0 0 employees(full and/ 5. �Retail or part-time).* 6. ❑ Restaurant/Bar/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 officers have exercised 9. ❑ Entertairunent their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other empioyees,a workers'compensation policy is required and such an organization shouid check box#l. I arri an employer that is providing workers'compensation insurahce for my employees Below is the policy information. Insurance Company Name: Safety National Casualty Corp. Insurer's Address: 1832 Scheu�z Road City/State/Zip: S t. Lou i s, MO 6 31 4 6 Policy #or Self-ins. Lic. # LDC 4 0 4 7 2 2 3 Expiration Date: 1 0/01 /2 01 6 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 forwarded to the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Si ature: � Date: I I—S l S� Phone#: 401 —295-2672, Ext. 2764 Official use on[y. Do not write in this area, to be completed by city or town officia� City or Town: Permit/License# ' Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6. Other Contact Person• Phone#: www.mass.Qov/dia I Client#: 77587 OCEANSTA33 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10I01/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF iNFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFiCATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDEO BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DO�S NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endo�sed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Sa11CI�/B@tl1g110 Starkweather&Shepley P"o"E 401 435-3600 ^ 4 ,vc No exe: nrc No: 07-431-9678 PO Box 549 E-""^'� sbeni no starshe com � ADDRESS: g � P• Providence, RI 0290'I-OS49 INSURER(S)AFFORDINGCOVERAGE NAIC# 401 435-3600 iNsuRER A:Catlin Insurance Company, Inc. 19518 INSURED INSURER B;S8f@t�/N8t10118I CaSU1I�l CO�p. Ocean State Jobbers, Inc. iNsuReR c:Employers Mutual Ins 21415 375 Commerce Park North Kingstown,RI OYSSZ INSURER D: INSURER E: iNSURER F: COVERAGES CERTIFICATE NUMBER: REVI510N NUMBER: � TMIS IS TO GERTIFY THAT THE POUClES pF INSURANCE LiSTED BEIOW HRVE BEEN fSSUED TO THE INSURED NAMED ABOVE FOR THE PO!!CY 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OF iNSURANCE ADDL SUBR POLICY EFP POLICY EXP LIMITS LTR INSR VWD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A �( COMMERCIAL CaENERAL LIABILITY LLC6842290316 3/01/2015 03/01/201 EACH OCCURRENCE $'I OOO OOO CLAIMS-MADE aX occuR ��"MISES Ea o��°�� a 1 000 000 MED EXP(My one person) $ PERSONAL 8 ADV INJURY a 1�OOO�OOO GEN'L AGGREGATE IIMIT APPLIES PER: GENERAL AC�GREGATE yZ�OOO�OOO POLICY�ECT �LOC PRODUCTS-COMPlOPAGG $Z�OOO�OOO OTHER: S (�` AUTOMOBILELIABILITY SBZG3O9�G 3/01/2015 03/01/201 EaaccdeDfSINGLELIMIT ,�,000�000 �. X ANY AUTp 5Z2630916(MA) 03/01/2015 03/01/201 BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HiRED AUTOS X NON-ONMED PROPERTY DAMAGE $ AUTOS Per accident 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS IIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERSCOMPENSATION LDC4O47ZZ3 10/01/2015 10/01/201 X PER OTH- AND EMPLOYERS'IIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE Y�N E.L.EACH ACCIDENT 3') OOO OOO OFFICER/MEMBER EXCLUOED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $� �00�� DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $� OOO OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Additional Ramarks Schedule,may be attaehed if more space is required) CERTIFICATE HOLDER CANCELLATION Ocean State Jobbers,If1C. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFpRE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 375 Commerce Park ACCORDANCE WITH THE POIICY PROVISIONS. ' North Kingstown,RI 02852 AUTHORIZED REPRESENTATIVE �W�/�� Qo. V LV i/•Y/`-�+ti�t O 1988-2014 ACORD CORPORATION.Ail rights reserved. ACORD 25(2014/01) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S734719/M734586 SSB