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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH � �� ' APPLICATION FOR LICENSE/PERMIT-2016 �' *Please comrlete form and attach all necessary documents by December 15 2015. Failure to do so will result in the return of your applicatton packet. ESTABLISHMENT NAME: ADVANCE AUTO PARTS#7196 TAX ID: LOCATION ADDRESS:447 STATION AVE TEL.#:508-258-1030 MAILING ADDRESS: PO BOX 2710 ROANOKE VA 24001 E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME(IF APPLICABLE): VAN T R M INC -r -�� TEL.#: 540-362-4911 � ````3 MANAGER'S NAME: :,� n � , MAILING ADDRESS: �_� � �'v POOL CERTIFICATIONS: �A_ � �,� The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designate ;;� �v ``-'.., Pool Operator(s)and attach a copy of the certification to this form. -� o � i i. 2• _� � � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community ,_� Cardioputmonary 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 n�w copies and maintain a file at your place of business. ' � 1. Z• �.� 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 Department will not use past years'records. uy«�� 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. L 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 Health Department will not use past years'records. You must provide new copies and maintain a�le at your establishment. i, 2. HEIMLICH CERTIFICATIONS: 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-chok�ng 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. z• 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 l0ea. LODGE $55' _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 —>I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE T LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50sq ft. $50 ��1��_>25,OOOsq.ft. $285 VENDING-FOOD $25 _<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S 50.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'"`* (ZO�^(��G lF� 1J 6 6'�� 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 AFFIDAVIT 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 elsewliere.Transient occapancy shall generally refer to continuous 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 inspectecl 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 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 requtred 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 Health Department, Downloadable 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 wiil 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 COOKING: 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 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY IRE A SIT . DATE: 11-29-16 SIGNATURE: PRINT NAME&TITLE: J H LOU15-AG T . Rev.10/OI/15 '� � DATE(MMIODMlYY) ACORO CERTIFICATE OF LIABILITY INSURANCE os�o��20,6 �— THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTtFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PpLICIES 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 Marsh USA Inc. NAnae: PHONE F� Three James Center ac No: 105t East Cary Sheet,Suite 900 E-MAIL ADDRE : Richmond,VA 23219 Attn:AdvanceStores.CertRequest@ma�sh.com INSURER S AFFORDING COVERAGE NAIC# J32008--GAWG16-17 API wsurtert n:ACE American Insurance Company 22667 INSURED iNsuReR e:�Addi6onal Page Advance Stores Company,Incorporated 5008 Airport Road INSURER C: Roanoke,VA 24012 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-004523868-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR'1'HE 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. �LTR ADDL UBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABIUTY XSLG27854400 0610112016 06I01/2017 EACH OCCURRENCE $ 1,500,000 CLAIMS-MADE �OCCUR PR AI ET EREccu ence $ 1,500,000 X Self-Insured Retentbn 500,000 MED EXP An one person� $ PERSONAL 8 ADV INJURY $ 1,500,000 GEN'L AGGREGATE lIM1T APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY❑PR� �LOC PRODUCTS-COMP/OP AGG S 3,500,000 JECT OTHER: $ A AUTOMOBILE LIABILITY ISAH�42490 �N11/2016 �/�1/2�117 COMBINED SINGLE LIMIT g 5,�00,0�0 Ea accideni X ANY AUTO BODILY INJURY(Per person) $ AlL OWNED SCHEDULED BODI�Y INJURY(Per accident) $ AUTOS AUTOS NON-0NMED PROPERTY DAMAGE $ X HIREDAUTOS X AU70S Peraccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION E $ B WORKERS COMPENSA710N SEE ADDITIONAL PAGE O6/Ot/2016 06I01/2017 X PTR ORH- AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y� N/A E.L.EACHACCIDENT 5 1,000,000 OFFICERMIEMBER EXCWDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIP710N OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Additional Remarks Schedule,may be attached i(more spaee is required) CERTIFICATE HOLDER CANCELLATION Advance Stores Company,Incorporated SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 5008Airport Road NW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Roanoke,VA 24012 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA7IVE of Marsh USA Inc. Diana Holsinger O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2074/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: J32008 LOC#: Richmond ACO� ADDITIONAL REMARKS SCHEDULE Paye 2 of 2 �.,..--�- AGENCY NAMEDINSURED Marsh USA Inc. Advance Stores Company,Incorporated 5008 Airport Road POLICY NUMBER R08�Ok@,VA 24012 CARRIER � NAIC CODE EFFECI7VE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers'Compensation policies: Policy Number.WLRC48605448(AOS) Cartier.Indemnity insurance Company ofNorN America _ — --- -- — —._ Effective Date:06IOt12016 Expiraiion Date:06I01/2017 Policy Number.SCFC48605461(WI) Carrier.ACE Fire Underwriters Ins.Co. Effective Date:O6I01I2016 Expiratan Date:06I0112017 Policy Number.WLRC48605473{TN) Carrier:Agri General Insurance Company EffecGve Date:O6I01120i6 Expiration Date:O6I01/2017 Policy Number.WLRC4860545A(CA,MA) Carrier.ACE American Insurance Company Effective Date:06IOt12016 Expiretion Date:06ro112017 Policy Number:WCUC48605436(OH) Cartier.ACE American Insurance Company EffecGve Date:O6/Ot/2016 Expiration Date:06101/2017 SIR:$500,000 ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD