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HomeMy WebLinkAboutApplication and WC1 - a TOWN iOF YARMOUTH BOARD OF I3EALTH ��� APPLICATION FOR LICENSE/PERMIT-2018 *Please complete form and attach all necessary documents by December 1 S,2017. Failure to do so will result in the return of your application packet. ' ESTABLISHMENT NAME: pee Way 2445 TpX ID; � LOCATION ADDRESS: 1353 Route 28,South Yarmouth,MA 02664-4509 TEL.#: (508)398-2159 ! MAILING ADDRESS: P O Box 1580-License Dept.,Springfield,OH 45501 E-MAIL ADDRESS: slstevens@speedway.com i OWNER NAME: Speedway LLC i CORPORATION NAME(IF APPLICABLE): Speedway LLC =m n °� ; MANAGER'S NAME: Paul Jr McHugh ' TEL.#: (508)398-2159 D � � � MAILING ADDRESS: P O Box I580-License Dept.,S�ringfield,OH 45501 = w � � POOL CERTIFICATIONS: �m �'" � The pool supervisor must be certified 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, Pool operators must list a minimum of two employees cuirently 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�heir 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 2. � , .: �� : 3. 4. �. FOOD PROTECTION MANAGERS-CERTIFICATIONS: r � All food service establishments aze required to have at least one full-time employee who is certified as a Food p 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. F �;� 1. N/A '� � 2. ��';��:� � PERSON IN CHARGE: � Bach food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. N/A 2. ALLERGEN CERTIFICATIONS: All food service establishments are req�iired 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 pravide new copies and maintain a file at your establishment. 1. N/A � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ox more must ha�e at least one employee trained in the Heimlich Maneuver on the premises at a11 times.: Please list your employees trained in anti-cholang procedures below and attach copies of employee qertifications 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 2. 3. 4. RESTAURANT SEATING: TOTAL i# 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 SWIMMINGPOOL$110ea =L�DGE $SS TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CpNTINENTAL ' $35 NON-PROFIT $30 —>100 SEATS $200 COMMON VIC. ' $60 —WHOLESALE $80 �RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT k ,LICENSE REQUIRED FEE PERMIT� LICEN$SE REQUIRED FEE PERMIT# Q ' �laiv�['1 �<25,OOOsq.ft. $1�50 �Q !�FROZENDESSERT$$40 �TbBA CO FOODaS10 �.00 �� v�� l. "wl Nr1ME CHANGE: $15 AMOUNT DUE _ $ 2,G�.00 •***"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'�**** �lQ�T�"�S'��`P� I dolkF�t�-���0-� -0"5 , I � ADMIIVISTRATION i ; Under Chapter 152,Section 25C,Subsection b,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 AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CER'C.OF INSURANCE ATTACHED X I ' OR , WORKER'S COh�1P.AFFIDAVIT SIGNED AND ATTACHED � ' Town of Yarmouth tvices and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK A.PPROPRIATELY IF PAID: I YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pUu'poses of the limitatians of Motel or Hotel use,Transient occup�ncy 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(9Q)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered tiansient. 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 OPETTING:All swimming,wajding and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Deparnnent to schedule�the inspection three(3) days prior to opening.PLEASE NO'1�'E:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TE5TING: 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 OPF�TING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the ins�ection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must norify the Yarmouth Health Department by filing the requtred Temporary Food Service Application form 72 houxs prior to the catered event. These fortns can be obtained at the Health Department,or fxom the Town's website at www.�armouth.ma.us under Health Department, Downloadable Fornis. ' FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Healfh 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 CAF�S: Outside cafes(i.e.,outdoor seating witli waiter/waitress service),must have prior approval from the Boazd 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&om Jsnuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FaOD 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 QUIRE A SITE PLAN. ; DATE: �O—' ��.(���SIGNATURE: PRINT NAME&TITLE: Sharon Terry,License Coordina r for Speedway LLC Rev.IO/12/17 i I 1 A��� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/OD/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 CONTACT NAME: Me�ISS2 LOVE Hylant Group, Inc.-Cleveland P"o"E ,216-447-1050 F^X .216-447-4088 6000 Freedom Sq Dr, Ste 400 E-MAII j Independence OH 44131 INSURER S AFFORDING COVERAGE NAIC# INSURERA:OICI R@ ublic Insurance Co 24147 INSURED MARAT-3 INSURER B: Speedway LLC INSURER C: 500 Speedway Drive Enon, OH 45323 INSURER D: 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 j INDICATED. NOTIMTHSTANDING 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 I LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD�Y MM DY� LIMITS { COMMERCIAI.GENERAL LIABILITY � EACH OCCURRENCE $ { CLAIMS-MADE � OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ i MED EXP(Any one person) $ i j PERSONAL&ADV INJURY $ I GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT � LOC PRODUCTS-COMPlOP AGG $ OTHER: g AUTOMOBILE LIABILITV Ea accident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURV f AUTOS ONLY AUTOS (Per accident) $ � HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB � OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ' A AND EMPLO ERS'L ABIL�ITY Y�N MWC31083800 7/1/2017 7/1/2018 X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5,000,000 OFFICER/MEMBER EXCLUDED? ❑N N f 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 OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additfonal 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 POUCY PROVISIONS. South Yarmouth MA 02664-4451 AUTHORRED REPRESENTATIVE ��� , �O 1988-2015 ACORD CORPORATION. All rights reserved. ' ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD '