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Home My WebLink AboutApplication and WC I a TOWN IOF YARMOUTH BOARD OF HEALTH � �� APPLICATION FOR LICENSElPERMIT-2018 ` *Please complete form and attach all necessary documents by December I S 2017. Failure to do so will result in the return of your applicat�on pac et. ESTABLISHMENT NAME: pee way 2440 TAX ID: LOCATION ADDRESS: 14 East Main St.>West Yarmouth>MA 02673-8107 T'EL.#: (508)775-0964 MAILING ADDRESS: P O Box 1 S80-License Dept.,Springfield,OH 45501 E-MAIL ADDRESS: slstevens@speedway.com OWNER NAME: Speedway LLC CORPORATION NAME(IF APPLICABLE): Speedway LLC MANAGER'S NAME: Bryan Vantilburg TEL.#: (508)775-0964 MAILING ADDRESS: P O Box I580-License Dept:>Springfield,OH 45501 POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. _ 1. N/A 2, � � (°�,'"`I Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � N � Cazdiopulmonary ResuscitaUon(CPR),having one certi�ied employee on premises at all times. Please list the = w � employees below and attach copies of�heir certifications to this form.The Health Department wil!not use past � rv � years'records. You must provide�new copies and maintain a file at your place of business. -p � $'�y I : � � � 1. N/A 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food F - 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 m�intain a file at yaur establishment. r.4,� 1. N/A 2, PERSON IN CHARGE: ' �� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. -0 1. N/A �� r' 2. ,._,, .� �; ALLERGEN CERTIFIGATIONS: ' All food service establishments are reqi�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 applicatian. The Health Deparhnent will not use past years'records. You must provide new copies and maintain a file at your estabtishment. ' i. N/A 2. HELMLICH 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 c,ertifications to this form. The I�Iealth Deparhnent 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 $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 SEA�'S $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. ' $60 �VHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ,LICENSE REQUIRED FEE PERMIT�! L[CENSE REQUIRED FEE PERMIT# <50sq ft. $50 >25,000sq R $285 VENDING-FOOD SZS ��a�<25,000 sq.ft. $I50 � _FR07_EN DESSERT $40 =TOBACCO 5110 �.��`$..�� NAME CHANGE: $IS AMOUNT DUE = S 2,�oO,OO *'***PLEASE TURN OVER AND COMPLETE OTHER SI'DE OF FORM•**** Q�,},�Q��C�p'� 1 �� r� �r—�v e � �o�k�F-�S-�g55-0 3 � ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut 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 i AFFIDAVIT MUST BE COMl'LETED AND SIGNED,OR i CER'X'.OF INSURANCE ATTACHED X ' OR WORKER'S COPvIP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK � APPROPRIATELY IF PAID: �;YES X NO MOTELS Al'�D OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pU�rposes 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 ihey maintain a principal place of residence elsewhere.Transient occupancy shail generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(9p)days within any six(6)month period. Use of a guest unit as a residence or j 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,shall generally be considered Transient. �i i � � � POOLS � � �� POOL OPENING:All swimming,waiding 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 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 colifor►n 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 OPF�TING: All food service establishments must be inspected by the Health Depariment prior to opening. Please contact the Health Department to schedule the ins�Section three(3)days prior to opening. 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 obtaxned at the Health Department,or f�om the Town's website at www.varmouth.ma.us under Health Department, . Downioadable 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. Eailure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating witli waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,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 RESPONSIBII.ITY TO RETtJRN THE COMPLETED RENEWAL APP�ICAT`ION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVAT'IONS TO ANY F�OD ESTABLISHi�NT, 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: I�")�.}�� SIGIITATURE: PRINT NAME&TITLE: Sharon Terry,License Coordin or for Speedway LLC Rev.10/12/17 � , '`�c a� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YYYY) �...�''' 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 AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER 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. 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 NAME:CT Melissa Love Hylant Group, inc.-Cleveland PHONE ,216-447-1050 F^'� .216-447-4088 6000 Freedom Sq Dr, Ste 400 E-MAIL � Independence OH 44131 INSURER S AFFORDING COVERAGE NAIC q , INSURERA:OIC� R@ ubiic 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: 1571767167 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. INSR TypE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD NND POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAI LIABILITY EACH OCCURRENCE $ CLAIMS-MADE � OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAI&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) $ I OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERSCOMPENSATION MWC31083800 7/1/2017 7/1/2018 X PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5,000,000 OFFICER/MEMBER EXCLUDED? � N�A (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 OPERA710NS/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(2016I03) The ACORD name and logo are registered marks of ACORD