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Home My WebLink AboutApplication and WC �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 JAN 13 Z017 *Please complete form and attach all necessary documents by December 16 2016. Failure to do so will result in the return of your application pac et. HEAL�H DEPT. ESTABLISHMENTNAME: w 3 � LOCATION ADD�tESS: u 4� TEL.#: 7`7S— 3 MAILING ADDRESS: i e ri n p 1 E-MAILApDRESS:5�5-Fev�S c�Sr.�arl u�c��l Lv v►1 OWNER NAME: � t�: l_ CORPORATION NAME IF APPLI ABLE): � �,c9 2..L MANAGER'S NAME: ,�n"f'Orl i �. � OV TEL.#: 5D �^ a-(� MAILING ADDRESS: • L � �� POOL CERTIFICATIONS: The pool supervlsor must be certitied ns a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certificarion to this form. �. Nt� z. �.�� :. 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 Heaith Department wilt not use past �� years'records. You must provide new copies aad maintain a�31e at your place of business. �" �. NI � 2. � � 3. 4. �,:� �� ,� FOOD PROTECTION MANAGERS-CERTIFICATIONS: �"--O All food service establishments are required to have at least one full-dme employee who is certified as a Food Protecrion Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach oopies of certification to this application. T6e Health Department wlll not nse past years'records. ` You must provide new copiea 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 operarion. 1. 2, ALLERGEN CERTIFICATIONS: All food servi�e 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 yeara'records. You must provide new copies and maintain a file at your establishment. L Z; HEII�ILICH 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-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 tile at your place of business. L �1 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMTT tl LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# B&B $55 CAHIN $55 M01'EL 5110 � S55 —CAMP S55 =SWIIvIMIN(3 POOL$1 I Oea =LODGE S55 _TRAILERPARK SI05 _WHIRLPOOL SilOee. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REpUIRED FEE PERMIT# 0-100 SEA'1'S 5125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _WMMON VIC. $60 �VHOLESALE $80 RETAIL SERVICE: -RESID.KI1'CHEN E80 �_ �{� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT!f LTCENSE REQUIRED FEE PERMiT# 2 � � /'��..J �<25,000 sq.ft, S$50 �SQ— =FROZEN DESSERT�$40 �TOBACCO_F�$I 10 ��I7�7/✓ NAME CHANGE: sis AMOUNT DUE _ $� '�,(oO• *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**** ,2 11��C��,,,02 r��' � F��4�tP-tS-�}tS3--OZ 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 limitarions 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 � elsewhere.Transient occupancy 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 whirlpoois 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 unril 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 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent,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 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 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 anaually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANI' FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME CE ENT. RENOVATIONS MAY REQU SIT LAN: DATE: 1 �I SIGNATURE: � PRINT NAME&TITLE: Ronald L. Eclmiston, Treasurer for Speedway LLC Rev.10/12/16 . � �� The Commonwealth ofMassachusetts �;��?r��t:Farcri=�;;� Department of Industrial Accidents Office oflnvestigations ` 1 Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaplicant Information Please Print Le�iblv Business/Organization Name: ��d �0.`.i L L C. n.) Inct. �,�es#c�� J ;�.y�� ► � Address: 4 y ( /�/{�„-, �-� , City/State/Zip: �1,f�.�r�,,�12/�j�q Dalo73phone #: (.�� R7'7,S � I�jv.3 Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with�employees (full and/ 5. [�Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working 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. l 52, §1(4),and we have 10.0 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.❑ 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 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 ' the policy information. Insurance Company Name:��G� RP �u ��1 ��' � In S.L.� rc�h r P � (Z_ /�"L/ �G>c f'1 �' �f7�l�p� � Insurer's Address: �0 b(� �--r� � p �� , r r. ��-�� ,�[> City/State/Zip: .J r,r��P.v�� P��r� . (�!� � y ��.1 Policy#or Self-ins. Lic. #� � (� � I(�Q Expiration Date:_��) — ,�,(� � '� 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 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 certify, the p 'ns and penalties of perjury that the information provided above is true and correct. Si nature: Date: 1 I / Rona d L. miston, reasurer or pee way , Phone#: - 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 , ACO� DATE(MM1DD/YYW) �,,.- CERTIFICATE OF LIABILITY INSURANCE 1/11/2017 THIS CERTIFICATE IS ISSUEp AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TMIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AITER 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 hoider 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 Melissa Love Hylant Group, Inc. -Cleveland P"o"E ,216-447-1050 F"X .216-447-4088 6000 Freedom Sq Dr, Ste 400 E-MAIL Independence OH 44131 INSURER S AFPORDING COVERAGE NAIC# INSURERA:OICI Re ublic Insurance Co 24147 INSURED MARAT-3 INSURER B: Speedway LLC INSURER C: 500 Speedway Drive INSURER D: Enon, OH 45323 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2126647423 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 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. �LTR NPE OF INSURANCE INSD WVD POLICY NUMBER MM/ODIYYYY MMIDDY� LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR DAMA E TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY� PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITV $ Ea accitlent ANY AUTO BODILY INJURY(Per person) $ AUTOS NED AUTOSULED � BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED PROPERTYDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERS COMPENSATION MWC30801100 7/1/2016 7/1/2017 X PER OTH- AND EMPIOYERS'LIABILITY y�N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5,000,000 OFFICER/MEMBER EXCLUDED7 � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLpYEE $5,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5,000,000 DESCRIPTION OF OPERATIONS I LOCA710NS I VEHICLES (ACORD 101,Additlonal Remarks Schetlule,may be attached if more space is required) In regards to: Speedway Store #2438 at 441 Main Street, West Yarmouth, MA Speedway Store #2440 at 14 East Main Street, West Yarmouth, MA Speedway Store #2445 at 1353 Route 28, South Yarmouth, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1 146 Rt.28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth MA 02664-4451 AUTHORIZED REPRESENTATIVE �� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD