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Home My WebLink AboutApplication and WC f a�c��od�o `�r9� , �� a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2016 u t�' C � 1��5 " *Please com plete form and attach all necess a ry documents b y ��'• �-~ � Failure to do so will result in the return of your application pac et A `T� � �. f t� ESTABLI SHME NT N A M E: A D V A N C E A U T O P A R T S#7 1 9 6 T A X ID: �:,�_ � 3�1-� ��j LOCATION ADDRESS:447 STATIO�{AVE TEL.#:508-258-1030 �� MAILING ADDRESS: PO BOX 2710 ROANOKE VA 24001 E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME(IF APPLICABLE): ADVANCE STORES COMPANY INC MANAGER'S NAME: TEL.#: 540-362-4911 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 operators must list a minimum of two employees currently certified in 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 provide new copies and maintain a file at your place of business. L 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 Aepartment 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. i. 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 Hea(th Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ' 1. 2. HEIMLICH CERTIFICATIONS: - All foad service establishments with 25 seats or more must have at least one employee trained in the Heimlich i Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and i attach copies of employee certifications to this form. The Health Department will not use past years'records. f You must provide new copies and maintain a file at your place of business. 1. 2. i 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 �SWIMMING POOL$I IOea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: , ' LICENSE REQUIREA FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFI7' $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE E T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<5�sq.R. $50 ( >25,000 sq ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $150 a�� _FROZENDESSERT $40 _TOBACCO $I10 NAMECHANGE: $is AMOUNTDUE = S 50.00 *****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 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 AFFIDAVTT 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. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the 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 principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of nof 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,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. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the ' Health Deparkment 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 Deparhnent,or from the Town's website at www.varmouth.ma.us under Health Aepartment, Downlciadsble�orms. 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 COOHING: Outdoor cooking,preparation,or display of any faod product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 3 L 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 A PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY EQU A S LAN. DATE: 12-18-15 SIGNATURE: PRINT NAME&TITLE: JO H LOUIS-AGENT Rev.10/01/IS �� I ! ! The Commonwealth ofMassachusetts ��,�.,, ' Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation�nsurance Affidavit: General Businesses Anplicant Information Please Print Le i�blv_ Business/Organization Name:ADVANCE AUTO PARTS Address:447 STATION AVE City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail ' or part-time).* 6. ❑ RestaurantBar/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] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing ' no employees. [No workers' comp. insurance requiredJ* ll.� 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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an emp[oyer that is providing workers'compensatian insurance for my employees. Below is the policy information. Insurance Company Name:SEE ATTACHED Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Sectian 25A of MGL c. 1 S2 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 Office of ' Investigations of the DIA for insurance coverage verification. I do hereby cert' , der the pai nd penalties of perjury that the information provided above is true and correct. ' Si ature: Date:12-18-15 ' Phone#:513-394-6161 Official use only. 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.gov/dia � � � � DATE(MM/DD/YYYY) ACORL7� CERTIFICATE OF LIABILITY INSURANCE o5�zsrzo�5 t.�..--. 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 AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES 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 endorsed. 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 CONTACT NAME: Marsh USA inc. pHpNE FAX Three James Center n�c wo: 1051 East Cary Street,Suite 900 A DR�ESS: Richmond,VA 23218-1137 Richmond.CertRequest@marsh.com INSURER S AFFORDING COVERAGE NAIC# J32008--GAWU5-15-16 iNsurtert n:ACE American�nsurance Company 22667 INSURED INSUReR B:ACE Property And Casualty Ins Co 20699 Advance Stores Company,lncorporated 5008 Airport Road iNsuReR c:See Additional Page Roanoke,VA 24012 INSURER D: INSURER E: -- INSURER F: COVERAGES CERTIFICATE NUMBER: CtE-6od8t0�5-o3 ��fi WSIONfittJM8Ei2: -- - - ' THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHICH THIS I N E AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURA C EXCLUSIONS AND CONDIT�ONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OP INSURANCE POLICY NUMBER MM/DD/Y`!W MMI DlYYYY A X COMMERCIAL GENERAL LIABILITY XSLG273J3536 06/01/2015 06I01/2016 EqCH OCCURRENCE 3 1,500,000 CLAIMS-MADE �OCCUR PRMM SE T E oNccurrenc E 1,500,�00 X Self-Insured Retention 500,000 MED EXP(Any one person) t PERSONAL 8 ADV INJURY $ 1,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE a 10,OOb,000 X POUCY❑PR� �LOG PRODUCTS-COMP/OP AGG $ $,500,000 , JECT $ OTHER: A AUTOMOBILE LWBILITY ISAH08857192 06I011Z015 06I01/2016 COMBiNED SINGLE IIMIT g 5,000,000 a accident _ X ANY AUTO BODILY INJURY(Per person) $ A�l OWNED SCHEDUIED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTpS X AUTOS Per accid nt $ B X UMBRELUI LIAB X OCCUR XOOG27832507 O6N112015 0610112�1F) Eq�H OCCURRENCE $ 5,40�,� EXCESS LIAB CLAIMS-MADE AGGREGATE 3 5�� DED RE7ENTION$ E C WORKERS COMPENSATION SEE ADDITIONAL PAGE OFi/0112015 06/0112016 X PTAT �RH AND EMPLOYERS'LIABILITY � ANYPROPRIETOR/PARTNER/EXECUTIVE Ya N�A E.L.EACHACCIDENT � �,OOO,OOO .. OFFICERIMEMBER EXCIUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under �Qpp ppp, _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT S ---- - DESCRIPTiON OF OPERATIONS/LOCATIONS/VEHICLES {ACORD 101,Additlonal Remarks Schedule,may be attached if more apace is required) CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN li ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE � of Marsh USA Inc. Susan B.�gnone ��,.4 /j, ��,e-,t,,c„ O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD