HomeMy WebLinkAboutApplication and WC p���- (3�F I��i�- � �ya z� ��
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+ TOWN OF YARMOUTH BOARD OF HEAtiT�I �.
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��� APPLICATION FOR LICENSE/PERMIT-2017
` *Please complete form and attach all necessary documents by December 16.Z016.
Faiiure to do so will result in the return of your application packet.
ESTABLISI-IMENT NAME:S t-S e - -.3��(c �l4 z2
LOCATION ADDRESS: ., �. � -a� �` S. h� �� TEL.#: .5"!� -- � - .�3�
MAILING ADDRESS: �s u� G � s<<.,-
E-MAIL ADDRESs: Q� � ,.- � a/ -
. OWNER�AME: �Sy-.�D + SL�n� S',�n•e f�.�„.E s(��-- �:e. L.L. �
COR.PORATION NAME(IF APPLIeABL ): `� �'
MANAGER'S NAME: �ca'�'� G u, l ry�c, s� TEL.#: �'f �39 Sl 1" 3 y
MAILING ADDRESS: S a �- ,' �•2 �.,`C���S�'-� ��.,p,(
POOL CERTIFICATIONS: �
The pool supervisor must be certified as a Pool Operator,as r�u' ed by State law. Please list the designated
Pool Operator(s)and attach a eopy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in standard�'irst 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 wi}1 not use past �
years'records. You must provide new copies and maintain a file at your place of business. m E =^ �
1. 2. � _ �?
3. 4. _ �,�. �
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FOOD PROTECTION MANAGERS-CERTIF'ICATIONS: � -' �
All food service establislunents 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 590A00.
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 establis'hment. �
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
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1. a�T �U� `/n��� 2. � _°;
ALLERGEN CERTIFICATIONS: �`
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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 Hesith Department will not use past years'records. You must O
provide new copies and maintain a file at your establishment. �
1. ��� � C.a�t l �'7 4 h 2. :
HEIMLICH CERTIFICATIONS: ���� �
All food service establishments with 25 seats or more ust 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL# ���
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT N LICENSE REQUIItED FEE PERMIT#
B&B S55 CABIN S55 M07'EL 5110
INN SSS CAMP S55 SWIMMING POOL$110ea
_LODGE S55 =TRAILERPARK $105 _WHIRI.POOL S110ea
FOOD SERYICE:
LICENSE REQ[1IIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FERMIT#
0-100 SEATS $125 _CONTINENTAL S35 NON-PROFIT S30
>l00 SEATS 5200 COiviMON VIC. $60 —WHOLESALE S80
— — —RESID.KITCHEN S80
RETAIL SERVICE:
L10EN$E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# '
<50sq ft. S50 / >25,000 ft. 5285 ��9 ...VENDING-FOOD S25
<25,0(IOsq.R 5150 =FROZEN�ESSERT S40 ,.r COBACCO SI10
NAME CHANGE: S15 AMOUNT DUE _ $ �S'rJ•OO
**•**PLEASE TURN OVEB AND COMPLETE OTHER SIDE OF FORM•*'**
�
ADMINISTRATION '
Under Chapter 152,Section 25C,Subsecrion 6,the Town of Yannouth 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
Compensafion Insurance. TI�E ATTACHED STATE WOItKER'S COMPENSATION INS�JRANG�
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHEI3 -
OR / -
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED t/
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � N(�
MOTELS AND OTHER LODGING ESTABLISHMENT�
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall h�
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 demonsirate that they maintain a principal place of residencc
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)d"ays,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 OPE1vING: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 Deparnnent to schedule the inspection three(3)
days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool azea until the pool has been
inspected and opened.
POOL WATER TESTII�TG: 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 I
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 Yazmouth 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.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 CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health
OUTDOOR COOHING:
i Outdoor cooking,preparation,ar display of any food product by a retail or food service establishment is prohibited.
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NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTTY TO RET[JRN
; TI�COMPLETED dtENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ' ;
!
ALL RENOVATTONS 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 I
' TO COMMENCEMENT. RENOVATIONS MAY REQUIItE A STTE PLAN.
DATE: " '%• �2-�(IL� SIGNATURE: , � �CG�-��--
PRINT NAME&TITLE: / I S 'y E. ��!��a._c��, �.,i. r���5�!,t: ���r,�,�,s�
. Rev.10/12/I6 � '
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; The Stop &Shop Supermarket Company LLC �
�,� _ _ _ - , _ __ o Comp(iance Department
,��'����;��'��t� ' Ahold USA Retail
. 1385 Hancock St, �
, � Quincy, Mass 02169 �{�������
• � � ' t�}��f��%1 r�. e' »f^�a9
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Date: HEALTH DEPT.
Dear Agency Representahve,
My name is Ashlye Brennan, I am the Licensing Manager for The Stop&Shop S�permarket
Company LI,C. The purpose of this letter is to submit a renewal (s)to your agency for our �
store location. We ask that all fiiture communications regarding licensin�pe�itting for our
store Ioca.tion(s)be addressed to my attention at the address below.
Should you ha.ve any questions now or in the fut�are,please feel free to c.onta.ct me at 617-770- �
8708 or ashlve.brennan(�a,ahold.com. � �
I appreciate your help with this transition.
• Sincerely,
Ashlye Brennan .
Manager,Licensing
The Stop &Shop Supettnarket Company LLC
1385 Hancock S�
Quincy,MA 02169
617-770-8708
617-689-4061 fax
617-770-6980 fax �
ashlye.brennan@ahold.com .
10/19/2016 Fwd:[storemanager]License Renewal for 2017-bgrize@ahold.com-Ahold Delhaize Mail
From: Florio, Mary Alice <MFlorioCc�yarrrrouth.ma.us>
Date: Tue, Oct 18, 2016 at 2:34 PM
Subject: [storemanager] License Renewal for 2017
To: "Stop & Shop Supermarket#022 lssne.store.0022.storemanager(tr�ahold.com)" <ssne.store.0022.storemanager(a7
ahold.com>
Good afternoon.
Attached are the Town of Yarmouth license renewal application and workers compensation insurance affidavit for 2017. Please
print out the forms for your establishment, complete them fully, and return them to our office with the fee at your earliest
convenience.
Stop &Shop Supermarket#022: Retail Food Service = $285.00 total
Please note that your current Health Department licenses expire December 31st
If you have any questions, please feei free to contact our office.
Thank you. •
MaryAlice Florio, Principal Office Asst.
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
508-398-2231, ext. 1241
https://m ai I.google.com/mai I/u/0/#inbox/157dd0103cb4d274 1/1
� The Commonwealth oflGlassachusetts �
Department of Industrial Accidents
��ce of Investigations
' " I Congress Street, Suite 100
Boston,NfA 02I14-2017
, _
� www mass gov/dia .
Workers' Compensation Insurance Affidavit: General Businesses
Apulicant Information Please Print Legibly
Busi.n.ess/Organization Name:The Stop& Shop Supermarket Company LLC
Address: �385 Hancock Street
City/Sta.te/Zip: Quincy, MA 02169 Phone #: $00-288-8415
Are you an employer? Checl�.the appropriate boz: Business Type (required):
l.�■ I am a employer with employees (full and/ 5. � Retail
or part-time).* 6. ❑ RestaurantlBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estate, auto, etc.)
employees worlang 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.❑ 1Vlannfacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Hea.lth Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy infoxmation.
**If the corporate officers 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 employer that is providing workers'compensation insurance for my employees Be1ow is the policy information.
Insurance Company Name: MAC RISK MANAGEMENT, INC. (TPA)
Insurer's Address: 1385 HANCOCK STREET
City/Sta.te/Zip: QUINCY, MA 02169
Policy#or Self-ins. Lic. # 576 Expiration Date:August 1,2017
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimi.nal 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is irue and correct
SiQnature• l ,( h �'.1(.t L���� Date• �D��ZC�� t�._v
Phone#:617-770-8708
Official use only. Do not write in this area,to be completed by city or town official:
City or Town: Permit/License #
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person• Phone#:
www.mass.gov/dia
�JE �D1Y[It[Dlt�1C� Df ��8'AL�JQ�P.tt� License No.
576
Seriai No. y 1 g�j$ DEPARTMENT OF INDUSTRIALACCIDENTS
�
��ji� i$ tD ((���(tp �j� AHOLD AMERICA'S HOLDINGS, INC. AND ITS' SUBSIDIARIES
1385 Hancock Street, Quncy, MA 02169 -
o.f ,having confornQed with the provisions of
sub-parao aph( 2, b )of Section 25A of Chapter 1�2 of the General Laws is hereby licensed
to be a
SELF-INSURER
F I R S T
This license is effecfive for a period of one year from the day of
A U G II S T ZQ 16 at 12:01 f1.M., unless sooner revoked.
- � - � � � DEP�4utENT OF 1 STRIAL GDENTS �
. i
D 2 R E C T 0 R
- � THIS UCENSE MUST BE POSTED ATTHE LOCATION THE BUSINESS