The URL can be used to link to this page

Home My WebLink AboutApplication and WC �� .� TOWN OF YARMOUTH BOARD QF HEALTH J�� j ��a` ' , APPLICATION FOR LICENSE/PERMIT-2017 *Pleasa completa form and attach all necessary documents by December 16 20l . Failure to do so will reault in the return of your epplicanon pac�et ��R�rH DEP��.• ESTABLISHMENT NAME: � - - LOCATIONADDRESS: 0.S�' � � '7 - 9j�� ' MAILIN(i ADDRESS: • � h52. r n E-MAILADDRE :S � ,I1 OWNERNAME: du�r�.�l LLC CORPORATION NAME(IF AP LICABLE): MANAGER'S NAM �� TEL.#: - �/�� MAILING ADDRESS: • r (�� _ POOL CERTIFICATIONS: The pool aupervisor must be certifled as a Pool Operator,aa required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to thia form. 1. /V�f i- 2. Pool operators must list a minunum of two employeea currently certified in standard First Aid and Coaununity Y �:�"` Cardiopulmonary Resuscitstion(CPR),having ono certified employee on premises at all times. Please list the employees below and attach copiea of their certifications to this form.The Health Department wlll not use paet - years'recorda. You must provide new copiea and maintain a 81e at your place of busittesa. � �. NI� 2 : � , ��_ 3. ' 4. �_ FOOD PROTECTION MANAGERS-CERTIFICATIONS: ' • s• All food aervico establishments are required to hava at least one fixll-time employoe who is certified ae a Food � 'ct-- Protection Manager,as defined in the State 5enitary Code for Food Service Establishments,105 CMR 590.000. �`� , . Please attach-co ies of certification to this _ _ _ _ �`".�,, __ . _. .. p application.The Healfh 13epartment wlli not use past years'recorda. You must provida new copiea and maintain a 81e at your establlshment. �. /�� z. PERSON IN CHARGE: Each food establiahment must havo at least one Porson In Chargo(PIC)on site during hours of operarion. 1. N �� , 2. . ALLERGEN CERTIFICATIQNS: . _ _. All food seryice establishmeats aro teqiured to have at least one full-time employee who has Allergen certification, " as defined in tha State Sanitary Code for Food Service Establishmenta,l OS CMR 590.009(G)(3)(a). Please attach copies of certification to this application: The Health Department wlll not use past yeara'recorda. You must provide new Copiea snd maintain a file at your eatablis6men� L I`� 'T I 2: HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or moro must hava at least ona employee haitted in tha Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-cholang procedures below and attach copies of employee certifications to this form. The Heaith Department wlll not use past years'records. You must provide new copies and maintain a 81e at your place of buainesa. 1. ,��' 2. 3. 4. RESTAURANT SEATIN(3: TOTAL# OFFICE USE ONLY LODGINGs LICENSS REQUIRED FEE PERMIT i� LICEN3S RSQUIItED FEH PERMIT# LICENSE REQUIItED FBS PERMTf p B&9 • S55 _CABIN S55 MOTEL 5110 —INN SSS CAMP $55 —SWIIuIMDJCiP00LS110ee. =I.OD(3S SSS =TRAILERPARK 5105 =WFIIRLPOOL S110ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE_ RE4_TIRED FEE PERMTT# LICENSE REQUIRED FHE PERbQT# aioosx�zs sizs _coIVTiNEN AL $35 NON-PROFTf $30 =>I00 SEATS $200 _COMMON VIC. S60 �VHOLE9ALE S80 —RESID.KITCHEN S80 �— RETAIL 3ERVICE: (,� LICE OSE R QUIRED SSa PERMIT# LICE g�E REQ�UIRED Fs'E S PERMTf# LICEN�MQ-U�RBD SES PERMIT# `� /l�/-1 �{ q q /V j��'��1 �<25,OW sq.ft. SI50 � �RdZENDES3ERT S40 �fOBACCO $110 �� _�,i NAMECHANGE: sls AMOUNTDUE _ $ � �(a� **+**PLEA3E TURN OVER AND COMPL&TE OTHER S[DE OF FORMi**** ��'� L S��'I-1 S��' d6I�'6P"��J'�g�J U-0�2. 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 purgoses 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 • 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 whirlpools which have been closed for the season must be�inspected by the Health Department prior to openmg. Contact the Health Department to schedule the inspectlon t6ree(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 CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Ail 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 Applicadon form 72 hours pzior 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 h$ve been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor searing 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 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 BOARD OF HEALTH PRIOR TO COMME�iCE ENT. RENOVATIONS MAY RE A S PLAN. DATE: C/�� SIGNATURE: ^ PRINTNAME&TITLE: Ronald L. Edmiston, Treasurer for Sp�dway LLC Rev.10/12/16 � -,, � ��, . : � The Commonwealth of Massachusetts ' � �� Department of Industrial Accidents Offrce of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: J�p��v L L�. � I�C;c_. �,p��d c,c)Q Lj o2,c�c.�(� Address: I'-E �QS.�' ,/l1�G�I Vl ��-} City/State/Zip:�.�-j-' `�Gi.t�v,�n .c-��,��i ��r13Phone#: �� % '7S—�`�lCo� Are you an employer?Check the appropriate boz: Busi ess Type(required): 1.� I am a employer with_�' employees(full and/ 5. Retail or part-time).* 6. Restaurant/BarlEating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity., � [No workers' comp:insurance requiredJ 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]* 11.0 Health Care 4.❑ We are a non-profit organiza.tion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applicant that checks box#1 musf also fill out the section below showing their workers'coarpensation 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�S providing workers'compensation insurance for my employees Be w is the policy informatton. Insurance Company Name: (�-l�C �/'�y� n C Insurer's Address: O��' F r t 0' -'-� ��Q City/State/Zip: • � Policy#or Self-ins. Lic.#��(��,�(��/�b�� Expiration Date: �.�/=� �—�'�l '� 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,under p ins d penalnes of perjury that the informatdon provided above is true and correc� Si ature: Date: f/ `� l Rona . iston, _reasurer or pee w � Phone#: — Officdal use only. Do not write in this area,to be completed by city or town of,f�cia� 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 ACORD� DATE�MMIOD/YVYY) �. CERTIFICATE OF LIABILITY INSURANCE 1/11/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVEIY 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), AUTHpRIZED 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�A�� Independence OH 44131 INSURER S AFFORDING COVERAGE NAIC# INSURERA:OIC� RE ublic Insurance Co 24147 INSURED MARAT-3 �NSURER B: Speedway LLC INSURER C: 500 Speedway Drive Enon, OH 45323 INSURER D: 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 PERIOO 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 7ypE OF INSURANCE POIICY EFF POIICY EXP LIMITS LTR INSO WVD POLiCY NUMBER MMIDDIYYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITV EACH OCCURRENCE S CLAIMS-MADE �OCCUR PREM SES�a occur ence $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY� PR� � LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ AUTOS�E� AUTOSULED BODI�Y INJURY(Per accident) $ HIREDAUTOS NON-0WNED PROPERTYDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERSCOMPENSATION MWC30801100 7/1/2016 7/1/2017 PER OTH- AND EMPLOYERS'LIABILITY x STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ N�A E.L.EACH ACCIDENT $5,000,000 OFFICER/MEMBER EXCLUDED7 (Mandatory in NH� E.L.DISEASE-EA EMPLOYE $5,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5,000,000 DESCRIPTION OF OPERATIONS/IOCATIONS/VEHICLES (ACORD 701,Addidonal Remarks Schedule,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 1146 Rt.28 ACCORDANCE WITH THE POIICY PROVISIONS. South Yarmouth MA 02664-4451 AUTHORIZED REPRESENTATIVE f/a./�.WC.�`V`�� OO 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD