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Home My WebLink AboutApplication and WC � TOWN OF YARMUUTH BOARD OF HEALTH j � APPLICATION F4R LICENSE/PERMIT-2017 *Please complete form and attach alI necessary documents by ecember 16 201b. Failure to da so wiFl result in the r�t�un of your applicauon pac ek E.STea►�T,IS��NT N�ET�cean State Job lot of S.Yarmouth,Inc.d/b/a Ocean State Job Lot#2�.�ro: 11-3656��5 • LOCATION ADDRESS: rmouth Plaza TEL.#:508-3941 MAILING ADDTtES5:375 Commerce Park Road Q �Z � $-MATY.ADDRESS: �amatn rni�eil r�.�m OWNER NAME:�.P n Stat_Jobb r . Inc. CORPORATION NAME(IF APPLICABLE): _ �. � MANAGER'S NAME: Diane White TEL.#:503��8-7123 � �' � MAILING ADDRESS: r- �` () = t�; � POOL CERTIFICATIONS: �'" The pool supervisor must be certifed as a Poo!Operator,as reqaired by State law. Please list the designated m� "'� � Pooi Operator(s)and attach a capy of the oertification to tlzis form. � c= � � � � 1. Z• Pool operators musi list a minimum of two employees currentiy certified in standard First Aid and Commanity Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees beIow and attach copies of ttxeir certafications to this form.The Health Department will not use past years'records. You must provide uew copies and ma_intain a file at your place of business. . �• 2' �:vc�, 3. 4. ,� �.�,� FOOD PROTECTION MANAGERS-CERTIFICATIONS: � All Food service establishments are required to have at least one fiill-time cmployee who is cerGfied as a Food �:_� Protecrion Manager,as defined in the State Sanitary Code for Pood Service Establishments, 105 CMR 590.000. � Please attach copies of eertification to this application. The Health Department wiEI not use past years'records. t�jy` .� You must pravide new copies and maintain a file at your establishment. � �''" �� „'� 1. 2. . �� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l. Diane White Z,Kenneth Cowap ALLERGEN CERTi�'1CATIONS: All food service establishmeats aze required to have at least one full-tirne employee who t�as Allergen certi�cation, as defined in the State Sanitary Code for Food Service fistablishments,105 CMR 590.Oo$(G)(3)(a}. Please attach cogies of certification to this application. The Health Depardment wllt not use past years''records. You must provide new copies and maintain a file at yonr establishment. . 1. 2. HEIMLICH CERTIFICATTONS: All food service estahlishments with 25 seats ox more must have at leass one empIoyee trained in tiia Heimiich Manenver nn the premises at all iimes. Please list your employees trained in anti-chokuig procedures below and � attach copies af employee certifications to this form. The Heslth Department wi11 not use past years'records. You must provide ne�v copies and maintain a fie at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE UNLY LODGING: LICENSE REQDIRED FEE PERMFT# LICEIVSE 12EQUIRED FEE PERMIT# LICENSE REQU[RED FEE PBRMiT# B&B $55 CAB[Id $55 MOTEL gll0 �NN $55 GAMP S55 =SWIMMENG POOL S110ea. �,ODGE S55 1'RAiL6RP.ARK $105 �WHIRi.POQL S1l0ea F�OD SERVICE: LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PHRMIT# __._aioo ssa�S 3125 _CONTINENTAL S35 AION-PRQFIT $30 >100 SEATS $Z0p COMMbN VIC. S60 "-'WHOLESALE S80 � —RESii1.KiTCHEN S80 RETAIL SERV7CE: LICEidSE REQUIRED F$E PERMCf# LICENSE R&QUII2ED FEE PERMCf# LICENSB REQi3IRED F6E P£1tMIT# �38sq ti. $3Q >25,000 sq.ft. S2BS VENDING-FOOD S25 25,00(?sq.ft. SlSO ��j =FROZENDESSERT$90 !-'I'OBACCO $1 0 rraHiscErnivcE: $�s AMOUNTD'[7E _ $ �'""+PT.EASE TURN OVER AND COMYLETE OTHER SIDE OF FORM""""* b0��-��j�r2�4-�Z ADMINISTRA'I'ION Under Cl�apter 152,Section 2S C,Subsection 6,the Town of Yacmouth is now required to hold issuance or reaewal 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 C011�ENSATION INSURANCE AFF�DAVIT MUST BE COM�'LETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED X OR WORKEFt'S COMP.AFPIDAVII'SIGNED AND ATTACHED X Town of Yatimouth taxes and liens must be paid prior to renewai or issuance of your pezmits. PLEASE C�ECK ' APPROPRIATELY TF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limita6ons ofMote]or Hotel use,Trensient occupancy shalt be limifed to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants �ust have and be able to demonstrate that they maintain a principal place of residence _,._ ___ _ . eJsewhere.Tzansient accupancy shall generally refer to continuaus occupancy of not more than thiriy(30)ilays,and an aggregate of not more than ninety(90)days within any six{6)month period. Use of a guest unit as a zesidence ox dwelling unit shall nat be cansiderec!tzaasient. Occupancy that is subject to the collecfion of Room Occupancy Excise,as defined in M.G.L.c.64G or 83�CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been clvsed for the season must be inspected by the Health Department pr�or to opening. Contact the Health Dep ent to schedule the iasp�tian three(3) ciays prior to opening.PLEASE NOTE:People are NOT allowed to�sit in tho pool area until the pool has been inspected and opened. � i POOL WATER TESTING: 7he water must be tested for pseudomonas,total cotifortn and standard plate count , by a State certified lab,and submitted to the Health Departnient three(3)days prior to opening, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pvol must be drained or covered wikhin seven(7}days of closing. FUOD SERVICE � SEA3QNAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Healih Depariment prior to ogening. Please contact the ' Health Department to schedule the insgection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yazmouth mus#notify the Yarmouth Hea�th Department by ft(ing the required Temparary Food Sezvice Applicatian form 72 hours prior to the catered even�. These forms can be� obtained at the Health Departruent,or�from the Town's website at www.yartnou#h.ma.us.under Health DeparGnent, Downloadable Forms. — FROZEN DESSERTS: Prozen desserts must be tesfed by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Departnnent. Failure to do so.will result in the suspension or revacauon of your�'rozen Dessert Permit until the abave terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seafing with waiter/waitr�ss service),must have prior approval from tt�e Boa�+d of Health. � OCJTDOOR COOKING: � O�tdoor eooking,preparation,or display of any food prodact by a retail or food service establishmeni is prohii�ited. � ; . ; ATOTICE:Permits run annually from January 1 to December 3 i.IT IS YOUR RESPONSIBILTTY TO RETURN , THE COMPLETED RENEWAL APPLICATiQN(S)AND REQUIRED FEE(S)BY DECEMBER 16,201b. ? f ALL RENOVATI�NS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL {i.e., PAINTING, NEW i � EQI3IPMENT,ETC.),NNST BE REPORTED TO D APP OVED BY HE BOARD OF HEALTH PRIOR � TO COMMENGEMBNT. RENOVATIONS MA Q A SI?'E DATE: �O �1 (�p SIQNATU PRiNT NAME&TITL , �u'e Am Real Est e dministrative Assistant �(��JLu 1 Rev.I O/1)1[6 i � � The Commonwealth of Massachusetts Depar�ment of Industrial Accidents O�ce of Iavestigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: ��.Q.Yl �� l7� �� Address: 3�� l.,{)rnm�r� �i�(� � City/State/Zip: 1 CU2852Phone #: ��-�q,�j -�(_p�2 Are you an employer?Check the appropriate boz: Bu�sm Type(required): 1.�I am a employer with�t� }�employees(full and/ 5� lSl.Ketail - ar part-nme).* - 6: ❑ ResfaurantBar/Eatmg Establishment 2.❑ I am a sole proprietor or partnership and have no �, � O�ce andlor Sales(incl.real esta.te,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑ Non-profit 3.❑ We aze 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 required]* 11.[]Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 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 corporadon 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 Below Bs the policy information. Insurance Company Name: Insurer's Address: g3 f 1 City/Sta.te/Zip: �� L�l,,l.i � �� (.Q,�j��( o Policy#or Self-ins.Lic.# �-D�i,1--�(Z��l�� Expiration Date: �� l� Attach a copy of the workers'compensation policy declaration page(showing the policy number and egpiration 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby ce tify, nder the pain d penalties ojperjury that the information provided above is true and correct. Si a Date: � Phone#: 1--� � - 'Z 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 Client#: 77587 OCEANSTA33 DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 10/18/2016 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 NAMEACT Sandy Benigno Starkweather 8�Shepley PHONE 401 435-3600 F'� 401-431-9678 PO Box 549 �A Lo eXt: ,vc,No: AooRess: sbenigno@starshep.com Providence, RI 02901-0549 401 435-3600 INSURER(S)AFFORDING COVERAGE NAIC# iNsuReRa:Catlin Insurance Company,Inc. 19518 iNsuRen iNsuReR s:Safety National Casualty Corp. Ocean State Jobbers, Inc. iNsuReR c:Employers Mutual Ins 27415 375 Commerce Park North Kingstown, RI 02852 INSURER D: . INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: fiAl�-I�T6 CERTIFYTHAT THE PaLICfES �F INBlJRA1VCE L7STED BEL61N HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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 EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A �( COMMERCIAL GENERAL LIABILITY Y Y LLC6842290317 3/01/2016 03/01/201 EACH OCCURRENCE $��Q�Q00 CLAIMS-MADE a OCCUR PREMISES Eaoccu ence $�,0��,�0� X Required by Contract MED EXP(Any one person) $ or Written Agreement PERSONAL&ADVINJURY $1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $Z�OOO�OOO POLICY�JEC�T � LOC PRODUCTS-COMPlOPAGG $Z�OOO�OOO OTHER: $ (`, AUTOMOBILE LIABILITY 562630917 3/01/2016 03/01/201 COMBINED SINGLE LIMIT ,� o00 000 Ea accident $ � r C X ANY AUTO 5Z2630917(MA) 3/01/2016 03/01/201 B�DILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERSCOMPENSATION LDC4047223 10/01/201610/01/201 X PER OTH- AND EMPLOYERS'LIABILITY T T TE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $'I�OOO OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $��,�� If yes,describe under --' PTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $'I,OOO,OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addltional Remarks Schedule,may be attached if more space is required) Re: Store#206-1080 Route 28,South Yarmouth, MA Boston Super Markets Associates Limited Partnership and KeyPoint Parnters, LLC are included as additional insured's with respects to all policies except Worker's Compensation. CERTIFICATE HOLDER CANCELLATION BOSt011 SUp@I'MB�I(etS ASSOCIBteS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Limited Partnership ACCORDANCE WITH THE POLICY PROVISIONS. c/o KeyPoint Partners, LLC One Burlington Woods AUTHORIZED REPRESENTATIVE Buriington, MA 01803 � �, ��k� O 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S872724/M865552 SSB