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Home My WebLink AboutApplication and WC � �,a TOWN OF YARMOUI'H BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December 16 20I6. Failure to do so will result in the return of your application pac cet. ESTABLISHMENT NA � � LOCATION ADDRES • � I$ ' e,cf TEL.#: ��5!' MAILING ADDRESS. I cc�,.g E-MAILADDRES : ' �.: a1 �lC i c+oOTL�INp�TDf� OWNER NAME: t'l— CORPORATION NAME IF APPLICABLE): MANAGER'S NAME:�Gt„�;, ��t� TEL.#: MAILING ADDRESS: �' POOL CERTIFICATIONS: � G�. ; The pool supervisor must be certified a a Pool Operator,as required by State law. Please list the designated r-. ' Pool Operator(s)and attach a copy of the certification to this form. i � � � �. r.�. 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 `=a` years'records. Yoa must provide new copies and maintain a file at your place of business. i es'i� 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 g �. Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Q Please attach copies of certification to this application. The Health Department will not use past years'records. Op You must provide new copies and maintain a file at yonr establishment. � � J 1. 2. , � � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. `� 1. 2. ALLERGEN CE1tTIFICATIONS: 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 ��p copies of certification to this application. The Health Department will not use past years'records. You must o provide new copies and maintain a file at your establishment. ,� 1 L 2. � HEIMLICH CERTIFICATIONS: �Q All food service establishments with 25 seats or more must ha.ve at least one employee trained in the Heimlich � Maneuver on the premises at atl 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. �O You must provide new copies and maintain a file at your place of business. (N 1. 2, 3. 4, RESTAURANT SEATING: TOTAL# Loncnvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B�B $55 CABIN $55 MOT'EL SI10 INN $55 CAMP $55 �SWIMMING POOL$l(Oea. _LODGE $55 TRNLERPARK $]OS WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $I25 _CONTINENTAL $35 NON-PROFIT 530 >l00 SEATS $200 _COMMON VIC, $60 —WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# <SO sG.R. �50 >25,000 sq.ft. $285 VENDING-FOOD �25 �<25,OOOsq.ft. $150 ��'a =FROZENDESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I�a V� ***•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** 1 r ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewai 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 COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SICNED,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 i�� MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shail 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 generaliy refer to con6nuous occupancy of not 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 CLO5ING: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 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 Heaith Department, Downloadabte 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. Failwe to do so wi(1 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: 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 RESPONSIBILI'TY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ; � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOAR.D OF HEALTH PRIOR � � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL� ' DATE:^(()'a�—/�,o SIGNATURE: J�: `-+�'•�.��.,.C�',�-�' PRINT NAME&TITLE:(��(�ac� �• �"D�Qs.,�,.��c: . �I° i�c �r eS��,.-r- Rev.10/12/t6 Corporate Officers and Directors of Maxi Drug, tnc. fncorporated in the State of Delaware on 11/28/1990 Federal/D#042960944 Kenneth Black, President Office Address: Fiite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone:717-214-2550 Home Address: 1710 Revere Drive, Mechanicsburg, PA 17050 Home Phone:717-728-962�,SS#: 334-58-4992 � Michael Podgurski,Vice President I Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone: 717-975-5888 Home Address:200 Turtle Creek Circle, Oldsmar, FL 34677 Home Phone:727-784-1270,SS#:233-76-2921 Susan Lowell,Vics President Office Address: Rite Aid Corporation, 200 Newberry Commons, Etters, PA 17319 Office Phone:717-975-5744 Current Address: 114 Clover Lane, Elizabethtown, PA 17022 Home Phone:717-367-6166,SS#: 151-58-1052 Ghislaine Lespinasse-Bond,Vice-President Office Address: Rite Aid Corporation, 30 Hunter Lane,Camp Hill, PA 17011 Office Phone: 717-975-5768 Home Address: 17 Adams Drive, Burlington, NJ 08016 Hame Phone:609-239-2828,SS#: 119-46-1958 Daniel Miller,Vice President&Secretary Office Address: Rite Aid Corporation,30 Hunter Lane,Camp Hill, PA 17011 Office Phone: 717-214-2541 Home Address: 1921 Monterey Drive, Mechanicsburg, PA 17050 Home Phone:717-695-0298,SS#:207-42-4454 Matthew Schroeder,Vice President&Treasurer Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011 Office Phone:717-214-8867 Home Address:8 Wheatland Drive, Mechanicsburg, PA 17050 Home Phone:717-766-8106,SS#: 197-50-6528 '+�'� 17r� L'r»>r�iruu�v��tltlt r,1',�/u,s�rrrlrr�sett.c — De�l�nrtnrritt r�j(�r�lrrslrlril;•I crirlE��rl.s �r L,�,�}„� �' U11Jc� vf!�►vrsti�alivirs � h�10 {Yuslriilgton Slreet - r'� ` l�usron, �Lt.l 011l� `" �'� ivw�v,massgav/rlia tiVorkers' Cc�mpensution lnsur�nce�ifficlavit: Ceneral E3usinesse9 :1 pplicant Information Plense Print LeaiblY �� Business/Or�anizatian Name: ��-�c_ {��,=� i� ��1� { ' ��cJJress: �I�S �t n �'�e� (_014 City/St�te/Zip: o �e.�+ I�Y1 U��honc!#: �J��S— �Zv�—� l /tf � e ynu an emplayer Check the�ppropriate b�a: t3u ines�'typs(requfreJ): I.� [ am a empioyer with �� E" 4mployee�(E�II��cil 5. �Ret3i1 ��r part-tima).• 6. ❑ Reataursn��HariEating Establishment Z.(] t �m a sola propcittot or partnership and have no 7, [�OfTtce�nd/or 3atea(incl.re�)estate� auto��te.) �mployees working far me i»�ny capaciry. 8. Non- rofit �O WOlICCIl� comp. insuranca required) ❑ P 3.❑ We aro s corporation�nd ib ot7Tcers hava exercised 9. ❑ Entertainment � rheit right of excmptfoa per c..i 52, 31(4)�and we havar 10.Q Manufacturing � no cmployee�. (Nn warkers' comp. insurance reyuiredj• �� Q FteaJth Cua �t.❑ �Ve ara�norrprofit organi2ation,statfed by volunteers„ �vith no employee�. (No wo�ken'comp.iruurancenq.j 12•Q Other ' ',\ny applicant that checltt box M1 muft alsa flQ out�hs stNion bslow showin`theit wo�kay'compentsl(oe poliry inAxmalloe,' ' ,•lf the aaporst�oflTeers hsv�exd»ptsd ihemxlre�,but�h�uxponUan ha�o�he�r en�ployea.s worlcsti'aompsnwlo�poltry b eequired snd sueh aR �rqanizalk��houla checii box NF. �urn nn emp/oyEr/hot Ls provlr �wa�ktn'co�+p adon inraroncsfo�my emp/oyte� Bdow 1t lJtt pv/lcy infoima�lon. nsurance Company N�une: C V�.-�� ✓ ` �- nsurer'�AJ�res�: � ;ity/Statcl'Lip:,... , __ . ,_ oficy�or Self-ina. Lic.� 1 l ,�-�+..i�.�j��—�� tG Expir�tion Oate: �� "�� tt.�ch� capy nf thr workery'compen�attare puller�teelaraNan pa�s(�hawin�tht polley�iurn6er and eiplca#!ort J�te). �itrare ro sccure cuvenga as requirad unJer Section 25�1 of 1�tG�.c. l52 caa tea+!to ths impusition of crimin�!penaltie��f� :ie ��p!o Sl,SQU.OQ;�nd/ot ont-year imprisonment,.�s�vrll.is eivii pCnaltiaa in iha f�rm of a 5"i'�P 1V�RK URDER 1nd 3 fina 'r�� to S2S0.00 a �1�y:�gainst tha viotains, f1a;tc4vise�thaf a capy o�this stat�cntent nsay ba fqt�v;trdet�tt�ths f?FffeQ aF , vesti�;�tians uf tha Dt,t far insur;tnce cr�vCraga verificntion, to l�rrrby rrrN/ji, und�rhs�n �r ptrrullle!v�ptrJury thct ths in/'orrnotion psavrJed�rbdv�r z�►rrus�xd corrsct 1��_ � `�' ` oare: I v—ai—i� , ��e 1!� ,. U/'fFci�ti us�t wrly. !lo nut wri�t in Ihi�nrea, Iv Sr c•vinptattJ hy c�i1y ur town d%fFClu� f i Ci ry�►r Cu�vn: i P�rrr�it�i.ice��sa�t � -----.. _ 'tiv�iin� .\irlhn�ify (cir�lt nrta►: � l. 11��rr� ��f tle:ilfh '. Itnil�liu� 1)e��.►rt�n�nt }. C�ty�'fn�rit i ►rrk t, f.ic��in; tin.�r�l i. ��Iectmen'� 1?ftiee i. !)Ih�C '��nt.tct f'crt�in: -._- - - -_--- _._ __._ ._ 1'hnrre /�: � � � � DATE(MM/DDIYYYY� ACORD CERTIFICATE OF LIABILITY INSURANCE o,�osrzo,s ��, 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(fes)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 NTA MARSH USA,INC. NAME: FAX 501 MERRITT 7 PHONE N A/C No: NORWALK,CT 06856 E-MAIL Attn:Norwalk.certrequest@marsh.com I Fax: 212-948-0929 ADDRESS: INSURER S AFFORDING COVERAGE NAIC# 416752-DRUG-GAWU-16-17 E01 GLIX iNSurtertn:ACEAmericanlnsuranceCompany 22667 � INSURED iNsuRER e:Travelers Properiy Casualty Company of America 25674 RITE AID AND AFFIL�ATES PO BOX 3165 iNsuReR c:ACE Property and Casualty Insurance Company 20699 HARRISBURG,PA 17105 INSURER D: � INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-008214205-08 REVISION NUMBER:11 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. �L� L 6 POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDDlYYYY MMIOD/YYYY A X COMMERCIAL GENERAL LIABIIITY XSL G27403803 01/01/2016 01101/2017 Ep,CH OCCURRENCE $ 4,000,000 A CLAIMS-MADE �OCCUR PREMISES Ea occ rtence S 2000000 X DRUGGIST LIABILITY iNCLUDED SIR•$3,000,000 MED EXP(Any one person) g EXCLUDED X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,000 POLICY❑ PR� � LOC PRODUCTS-COMP/OPAGG $ 15,000,000 JECT i OTHER: $ AUTOMOBILE LIABILITY OMBINE SI LE LIMIT $ Ea accident i ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ X UMBRELLA LIAB X OCCUR X00 G27939375 001 01101I2016 0110112017 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X RETENTION$25 000 $ B WORKERS COMPENSATION TC2JUB-7442L10A-16 (AOS) 01/0112016 0110112017 X STATUTE ERH AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNERlEXECUTIVE Y� N�A TRKUB-7442L111-16 (AZ,MA) Ol/O1IZOIF O1IO�IZO17 E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 2,000,000 It yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTiON OF OPERA710NS/LOCA710NS/VEHIC�ES (ACORD 101,Additlonal Remarks Schedule,may be attached if more space Is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION RITE AID AND AFFILIATES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE PO BOX 3165 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HARRISBURG,PA 17105 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Nancy Kalbfell vx,w.�,y, �o..e.�-e-G. O 1988-2014 ACORD CORPORATION. All�ights reserved. ACORD 25(2014I01) The ACORD name and logo are registered marks of ACORD � � , r Tana Sweigart From: Florio, Mary Alice <MFlorio@yarmouth.ma.us> Sent: Tuesday, October 18, 2016 2:22 PM To: Tana Sweigart Subject: License Renewal for 2017 Attachments: 2017 License App and WC Affidavit.pdf s Good afternoon. i ; 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 i your earliest convenience. Rite Aid#10194: Retail Food Service=$150.00 tota! Please note that your current Health Department licenses expire December 315t If you have any questions, please feel free to contact our office. ,, Thank you. Mar Alice Flori Prin ' y o, apal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231, ext. 1241 1