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Home My WebLink AboutApplication and WC :, � � �G / OWN ARMOUTH BOARD OF HEALTH � � 1�,',�r�,�.Z � ��3� �� APPLICATION FOR LICE S ERM T -�2017� ;buk��ar��^,�a 2G6y ''° �� * Please complete form and attach all necessary documents by December 16 201 Failure to do so will result in the return of your application packet. � ��b ESTABLISHMENT NAME:Dollar General Store #17767 TAX ID: LOCATION ADDRESS: 447 Route 28, West Yarmouth, MA 02673 TEL.#: (615) 855-4361 MAILING ADDRESS: Tax Licensinu, 100 Mission Ridge, Goodlettsville, TN 37072 E-MAIL ADDRESS: tax-beerandwinelicense@dollargeneral.com OWNER NAME: DG Retail, LLC CORPORATION NAME (IF APPLICABLE): DG Retail, LLC MANAGER'S NAME: Jean Duval TEL.#: (802)272-6910 MAILING ADDRESS:Tax Licensing, 100 Mission Ridge, Goodlettsville, TN 37072 POOL CERTIFICATIONS: Q�� The pool supervisor must be certified as a Pool Operator,as required by State law. lea�e" at Pool Operator(s) and attach a copy of the certification to this form. �jAY '� � 2��1 1. N�p' 2. HEAL.TH DEPT. Pool operators must list a minimum of two employees currently certified in standard First i an om y 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 years' records. You must provide new copies and maintain a file at your place of business. � 1. N�p' 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: II 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. You must provide new copies and maintain a file at your establishment. l. N/A -- No Service 2. PERSON IN CHARGE: Separate Payments Each food establishment must have at least one Person In Charge (PIC) on s Please Returrr Chec�fo: 1. N�A -- No Service 2• i (Vla �"'��.ec�Gt�,�� 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 co i f ifi i n ' p es o cert cat o to this application. The Health Department will not us�a�_t vears__records. You_must ___ provide new copies and maintain a file at your establishment. Vendor#352773-- 1 N/A -- No Service 2 Invoice#20171776704BL3 � / Batch#13532/� $ 150.00 ' HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one ��,�.,y,,,, «u...,,u ... ��.,, ..,,�..��,;�� 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 file at your place of business. - -- _ _— - - -______. 1 N/A -- No Service 2 3 4 Vendor#352773 �" Invoice#201717767TOBCITY4 � � RESTAURANT SEATING: TOTAL # � Batch#13532 � $ 110.00 � 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$1 l0ea. _LODGE $55 _TRAILER PARK $]OS 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 ; _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 �� RETAIL SERVTCE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.fr. >25,000 sq.ft. $285 VENDING-FOO =�25,000 sq.ft. $150 �� =FROZEN DESSERT $40 ,�f7$ACCO 110 ?JZ NAME CHANGE: $15 AMOUNT DUE _ $ �� O• C1"0 '; *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � 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 x ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED X Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X 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 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 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 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 Department,or from the Town's website at www.varmouth.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 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 COMMENCEMENT. RENOVATIONS MAY RE UIRE SIT AN. � j� DATE: 3/31/17 SIGNATURE: t��5��SS"`�'3� ' PRINT NAME & TITLE: M�-chael Burdette / Licensing Specialist Rev. 10/12/16 : ° � The Commonwealth of Massachusetts �� '� ��;�� Department of Iredustrial Acciclents Office 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 Legibly Business/Organization Name:DG Retail, LLC dba Dollar General Store#17767 Address:100 Mission Ridge City/State/Zip:Goodlettsville, TN 37072 Phone #:615-855-4000 Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with employees(full and/ 5. Q✓ Retail or part-time).* 6. ❑ Restaurant/Bar/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. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, ll.❑ Health Care 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 is the policy information. Insurance Company Name:'°`CE American insurance Company Insurer's Address:c/o 26 Century Blvd., PO Box 305191 City/State/Zip: Nashville, TN 37230-5191 �� Policy#or Self-ins. Lic. #WLRC49110649 Expiration Date:2�1/2018 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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, nder the�ains and p alties of rjur that the information provided above is true and correct. � Si nature: Date:5/8/2017 Phone#:615-855-4361 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 Of�ce 6. Other � Contact Person: Phone#: t � www.mass.gov/dia 7 i � � � :ACO� , DATE(MM/DDlYYYY) � �....--- ERTIFICATE OF LIABILITY INSURANCE page � of � 02�0��20�� THIS CERTIFICATE IS ISSUED AS A MATTER OF tNFORMATION ONLY AND GONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND O�t ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT GONSTITUTE 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 have ADDITIONAL INSURED provisions or 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). PROOUCER CONTACT Willis of Tennessee, Inc. NAME'...., PHONE c/o 26 century sivd. �nrc,t�o_�zcz>._877-94.5-7378 F`� 888-467-2378 P.o. sox 305191 E-MAIL �ertificates willis.com Nashville, TN 37230-5191 . INSURER(S)AFFORDING COVERAGE NAIC# __ __ INSURERA:ACE American Insurance Company 22667-001 INSURED "-- Dollar General Corporation INSURERB:Berkshire Hathaway Specialty Insurance Co 22276-001 & Zts Subsidiaries & Af£iliates INSURERC ACE Fire Underwriters Insurance Company 20702-001 100 Mission Ridge _ Goodlettsville, TN 37072 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE PIUMBER:25185107 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 COPIDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS. INSR TypE OF INSURANCE DDL SUB ppLICY NUMBER POLICYEPF PO�ICY EXP LIMITS i A X_T.COMMERCIALGENERALLIABILITY XSLG27862433 �. /1/2017 2f1f201H EACHOCCURRENCE $ 5O0 OOO ( CLAIMS-MAQE�OCCUR PREMISES(taEoNccurence) $ 500 OOO j X ' SZR $750,000 MEDEXP(Anyoneperson) $ - ---- -_.......___......_._. PERSONAL&ADVINJURY $ 500 OOO GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ 2O OOO 000 PRO- X POUCY � �ECT � LOC PRODUCTS-COMP/OPAGG $ 2 O00 OOO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Eaaccident) $ � ANYAUTO BODILYINJURY(Perperson) $ OWNED SCHEDULED AUTOSONLY AUTOS BODILYINJURY(Peraccident) $ HIRED NON-OWNED PROPERTYDAMAGE �_—_� AUTOSONLY AUTOSONLY (Peraccident) $ $ B X UMBRELLAUAB X OCCUR 47UM030330901 �1�2�17 2�Zf2018 EACHOCCURRENCE $ 5 �OQ 00� ' EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5 OOO OOO � DED RETENTION$ $ pj WORKERSCOMPENSATION WI,RC49110649 f 1�2�17 2�1�2018 X PER 0 H- AND ERRPLOYERS'LIABILITY C ANYPROPRIETOR/PARTNERlEXECUTNEY�N SCFC49110650 OFFICER/MEMBEREXCLUDED7 � N�'�` �S�ZO17 Z�1�ZO1H E.L.EACHACCIDENT $ 1,000,000 A (MandatoryinNH} WCUC49110662 11�2017 2�1�2018 E.L.DISEASE-EAEMPLOYEE $ 1 ��0 �DO rf yes,describe under � r A DESCRIPTIONOFOPERATIONSbelow WCUC49110674 �1�2OS7 Zf1�ZO18 E.L.DISEASE-POLICYLIMIT $ 1,000�000 DESCRIPTIQN QP OPERATIONS f LOCATIONS 1 VEHICLES(ACORD 101,Addifional Remarks Schedule,may be attached if more space is required) DOLGENCORP of TX, Inc. is a non-subscriber to the Workers' Compensation System in the State of Texas and as such is not afforded benefits by the Workers' Compensation policies referenced herein in Texas only. Covers all cities/counties within the following states: AZ, CO, IL, KS, MA, MN, NH, UT, VT, ME and OR CERTIFICATE HOLDER CANCELLATION � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DG Retail LLC 100 Mission Ridge Goodlettsville, TN 37072 Coll:5026416 Tpl:2124713 Cert:2 85 07 �O 1988-2015 ACORD CORPORATION.All rights reserved. ' ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD '