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Home My WebLink AboutApplication and WC a TOWN iOF YARMOUTH BOARD OF HEALTH �� APPLICATIqN FOR LICENSE/PERMIT-2018 ~' *Please complete form and attach alI necessary documents by December I5.2017. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: pee way 2438 ' TAX ID: LOCATION ADDRESS: 441 Main St.,West Yarmouth,MA 02673-4844 T'EL.#: (508)775-1263 MAILING ADDRESS: P O Box 1580-License Dept.,Springfield,OH 45501 E-MAIL ADDRESS: slstevens@speedway.com OWNER NAME: S eedwa LLC CORPORATION NAME(IF APPLICABLE): S eedwa LLC MANAGER'S NAME: Antoni a lYlilanova ' TEL.#: (508)775-1263 2 p � MAILING ADDRESS: P O Box I580-License De t.:,S rin field,OH 45501 � � � : � � � POOL CERTIFICATIONS: = W � ' The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designate p N � ', Pool Operator(s)and attach a copy of t�e certification to this form. � o �� -� -+ � ' 1. N/A 2. ' i Pool operators must list a minimuxn of two employees currently certified in standard First Aid and Communi � Cardiopulmonary Resuscitation{CPR),having one certified employee on premises at ali times. Please list the employees below and attach copies of lheir certifications to this form.The Health Department will not use past years'records. You must provtde new copies and maintain a file at your place of business. 1. N/A 2. . 3. 4• FOOD PROTECTION MANAGERS-CERTIFICATIONS: - All food service establishments aze reguired to have at least one fizll-time employee who is certified as a Food � 1 Protection Manager,as defined in the 5tate 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 msintain a file at your establishment. � " �' _ I, Antoniya Milanova 2. '� �� ; �:�� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � I 1, Antoniya Milanova 2. � i ALLERGBN CERTIFICATIONS: � All food service establishments are reqti�ired 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 applicatid�. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. � I 1, Antoniya Milanova 2, j 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 a11 times.: Please list your employees trained in anti-chokmg procedures below and attach copies of employee Gertifications to this form. TLe 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 2. 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 ' S55 MOTEL �110 —INN $55 CAMP $55 _SWIMMiNG POOL$110ea. L�DGE $55 _ RAILERPARK $105 WHIRLPOOL S110ea. FOOD SERVICE: M 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 ; RETAII,SERVICE: ' LICE OSE REQUIRED $50 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �+�a,��<25,OOOsq.ft. $I50 � �'�ROZEN�ESSERT$$40 �TOBA CO FOODa$��5 �� 1� V� NAME CHANGE: $15 , AMOUNT DUE _ $ �.�00.00 � **'�*'PLEASE TURN OVER AND COMPLETE OTHER SYDE OF FORM*'�*'* ; 8 0�kF—�5—��5p.-c�3 � o�'C�P—t5�s3-43 r i � � 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 CER"X'.OF INSURANCE ATTACHED X OR WORKBR'S COPvIP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal oz issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: 'YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pU�rposes of the limitations of Motel or Hotel use,Transient occup�x�cy sha11 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 thiriy(30)days,and an aggregate of not more than ninety(9�)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered t�ansient. 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,sha11 generally be considered Transient. POOLS POOL OPENING:All swimming,wajding and whirlpools which have been closed for the season must be inspected by the Health Department prior to ope�ing. Contact the Health Department to schedule the inspection three(3) days prior to opening.PLEASE NO'�'E:People aze 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 CLOSYNG:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ,� closing. FOOD SERVICE SEASONAL FOOD SERVICE OPE�TING: All food service establishments must be inspected by the Health Departxnent prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to openmg. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth 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 fr,om the Town's website at www.varmouth.ma.us under Health Deparkment, 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 revocarion of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAF�`S: Outside cafes(i.e.,outdoor seating witli waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepararion,or displ�y of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from J�nuary 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETIJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. � � ALL RENOVATIONS TO ANY FQOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REFORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. DATE: Ih"I b'�I � SIGNATURE: �(?1�,. PRINT NAME&TITLE: Sharon Terry,License Coordin or for Speedway LLC , Rev.10/12/17 i � � A'c�� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YVYY) i �.-�-'"� 10/18/2017 ! THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS � CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATIVELY AMEND, EXTEND OR A�TER 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 have ADDITIONAL INSURED provisions or be endorsed. I 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 ri hts 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 AFFORDING COVERAGE NAIC# INSURERA:OI(� R2 ublic Insurance Co 24147 . iNsuREo MARAT-3 INSURER B: Speedway LLC iNsuReR c: 500 Speedway Drive INSURER D: ' Enon,OH 45323 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1571767167 REVISIQN 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. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD NND POLICY NUMBER MM/DDlYYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE � OCCUR DAMAGE 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/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-ONMED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ � DED RETENTION$ $ � q WORKERS COMPENSATION MWC31083800 7/1/2017 7/1/2018 X PER OTH- j STATUTE ER AND EMPLOYERS'LIABILITY Y/N � OFFICER/MEMBER/EXCLU ED?ECUTIVE � N�A E.L.EACH ACCIDENT $5,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional 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 POLICY PROVISIONS. South Yarmouth MA 02664-4451 AUTHORIZED REPRESENTATIVE �� ., O 1988-2015 ACORD CORPORATION. All rights reserved. ; ACORD 25(2016l03) The ACORD name and logo are registered marks of ACORD � 1