HomeMy WebLinkAboutApplication and WC " ..- - . - _- o, t o..r{ � 0.', '
�' TOWN�F YARMOUTH BOARD OF E�EAI:,TH
APPLICATION FOR LICENSElPERMiT-2d17
�'"� *Please complete form and attach all necessary documents by December l6.z016.
FaiTure to do so will result in the return of your apptication packet.
ESTABLISF�IENT NAME: S=fn.�S � � e2Gl� TP�x iD• C')LI:3c�(� L(y z�
LOCATION ADDRESS:�7Z��S�r��--i�,=� v2' �: �,r.�a c�1� TEL#• .�[�S'��1�/.-�y I
MAII.INGADDRESS: l_35�SNcnr�r_G 5-�- ��:+�`.�r v ,�21/'� O.�/���J L��P.�s<<„< ���C�-
E-MAII.,ADDRES�: c7�C� - � ��, .���, ' �
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COR.PORATION NfiME AI'PLIeABL ): `` �'
MANAGER'S NAME:__ ��� ,.d L. ,�v,c_G, TEL.#: �,�{�'--=s9�1-r5 t1.3/
AlIAII,ING ADDRBSS: S �a, t c�c- G -S�-. ��,�1�c .. r�l�..� �..�//�<I L i C-�'nS ;-79��A,[
POOL CERTIFICATIONS: /`,� �
The pooi supervisor must be certified as a Pool Operator,as r�uifed by State law. Please list the designated -
Pool Operator(s)and attach.a eopy of the cerfification to tliis form.
L 2.
Pool operators must list a min;m�of two employees currentty certified in standard�irst Aid and Communi
Cazdiopulmonary Resuscitation(CPR),having one certified empioyee on premises at all times. Please list th
employees below and attach copies of their certifications to this form.The Health Department will not use pa z �
years'records. You must provide new copies and maintain a file at your place of business. � � y �`C1
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: -� � 0
All food service establishments aze required to have at least one full-time employee who is certified as a Foo
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.fl00.
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.
f '".:y'.,
1. �C�� i � L-�l-1`'?C �'� 2.
PERSON IN CHARGE: -
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. "
1. �a �.?� �.., �� i',, 2. ��
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ALLERGEN CERTiFICATTONS: w� �
Ali food service establishments aze required to have at least one full-time employee who has Ailergen certification,
as defined in the State Sanitary Code for Food Service Bstablishments,105 CP.�IR 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. C� l,% I � L.--t-f � � 2. O
HEIMLICH CERT'IFICATIONS: �-��� � U\
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. 2.
3. 4
RESTAURANT SEATING: TOTAL# � j;
� l-� �---�--
LODGWG:
OFFICE USE ONLY
LICENSE REQU[RED FEE PETtMIT# LICENSE REQU[RED FEE PERMIT f! LICENSE REQUIRED FEE PERMIT#
B&B CABIT7 $55 MOTEL $110
ass
_� $55 —CAMP =SWIMMING POOL$1 IOea
_LODGE $55 _TRpILERPARK $$OS _WHIRLPOOL S110ea
FOOD SERYICE:
LICENSE REQU[RgD FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE RERMIT#
�l00 SEA S �200 —CONTINENTAL $35 _NON-PROFIT S30
— _ _COMMON VIC. $60 WHOLESALE $80
RETAII,SERVICE: —12ESID•KI7'CHEN S80
L2CEN�SE R QUIRED $50 PERMIT# _L�I—CE SSE�REQ�UIItED $285 P� LICVENDING�FO�OD $25 PERMIT H
_QS;�sq.ft $150 _FROZENDESSERT $40 �TOBACCO $]10 ���
NAME CAANGE: SIS AMOIINT DUE _ $ 3����
"***•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 renewai
of any Iicense or permit to operate a business if a person or company does not ha.�e a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INS�TRANCE
AFFIDAVIT MUST BE C�OMPLETED AND SIGIWED,OR
CERT.OF INSURANCE ATTACHED
OR /
WORKER'S COMP.AFFIDAVIT SIGNED AN�ATTAC'HED V
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your�ermits. PLEASE CI�ECK
APPROPRIATELY IF PAID: .
YES � ND
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Trdnsient occupancy shall b�
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel.and hotel use.
Traasient occupants must have and be able to demonstrate that they maintain a principal�lace of residenc� -
elsewhere_Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)d"ays,_and
an aggrega.te of not more tban 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 ailowed to sit in the pool azea until tfie pool has been
inspected and opened.
� POOL WATER TESTING: The water must be tested for pseudomonas,totai coliform and standazd 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 swimxning pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPEMNG:
All food service establishments must be inspected by the Health Departrnent prior to opening. Please contact the
Health Depaztment to schedule the inspection three(3)days prior to opening,
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Applicarion 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,
Dovmloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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:
Oufside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heaith.
j OUTDOOR COOKING:
i Outdoor cooking,prepazation,or display of any food product by a retaii or food service establishment is grohibited.
i
' NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR R�SPONSIBILITY TO RET[JRN
TF�COMPLETED.RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 16,2016. �
i
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i_e., PAINTING, NEW I
�, EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SIT'E PLAN.
DATE: (D�ZZ1 I I l.a SIGNATURE: A C� P r,t��L
f' 1 �1� } �, - !`F ���`t4�-�.� .
PRINT NAME&TITLE: J-�S I� 4`E �J t�= �f��ti c-. � ��F� ��
Rev.10/L2/16
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, I
10/19/2016 Fwd:[storemanager]License Renewals for 2017-bgrize@ahold.com-Ahold Delhaize Mail
-------- Forwarded message -------_
From: Florio, Mary Alice <MFlarioCcr�varmouth.ma.us>
Date: Tue, Oct 18, 2016 at 2:36 PM
Subject: [storemanager] License Renewais for 2017
To: "Stop & Shop Supermarket#2422 (ssne.store.2422.storemanager(�a ahofd.com)" <ssne.store.2422.storemanager(a�
ahold.com>
Good afternoon.
Attached are the Town af 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#2422: Retail Food Service ($285); Tobacco Sales ($110} _$395.00 total
Please note that your current Health Department licenses expire December 31st
If you have any questions, please feel free to contact aur office.
Thank you.
MaryAlice Florio, Principal Office Asst.
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
50$-398-2231, ext. 1241
https://mail.google.com/mail/u/0/#inbox/157d930f7a99ba81 1/1
� The Commonwealth of`7Glassachusetts
Department of Industrial Accidents
Office of Investigations
' ' 1 Congress Street, Suite I DO
` Boston,MA 02II4-2017
" www mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organi.zatioll Natile:The Stop &Shop Supermarket Company LLC
Address: 1385 Hancock Street
City/Sta.te/Zip: Quincy, MA 02169 Phone#:800-288-8415
Are you an employer? Check.the appropriate boz: Business Type (required):
1.0 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 Sa1es (incl.real estate, auto, etc.)
employees worlang for me in any capacity.
[No workers' comp. insurance required] 8• ❑ Non-profit
3.❑ We are a corporation and its offlcers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Nlanufacturing
no employees. [No workers' comp. insurance required]** 1l.❑ 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 employees,a workers'compensation poIicy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees Below 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 poIicy number 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 tha.t 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 of perjury that the information provided above is true and correct
SiQnature: / ,(��1 �'l:�f.t ��'�^-�-� Date� i t7I Zr>C I l_o
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
�� �DUIIitDTI�1E� Df �Ag�cfiL�tl�P.ttf� License No.
576
Seriai Na 11g58 DEPARTMENTOFINDUSTRIALACCIDENTS
�
��i}� �}� �D �Q�.#p �� AHOLD AMERICA'S HOLDINGS, INC. AND ITS' SUBSIDIARIES
of 1385 Hapcock Street, Quncy, MA -02169 -_ , havingconfarmedwith theprovisions 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 effective for a period of one year from the day of
A u G U S T 20 16 at 12:01 A_M., unless sooner revoked
DEP� ENTOFI STRIAL DENTS
;
D I R E C T 0 R
THIS UCENSE MUST BE POSTED ATTHE LOCATION 0 THE BUSINESS