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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 rs.-L*. ._.,' *Please complete form and attach all necessary documents by December 15.2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15`i. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: Ocean State Job Lot#206 TAX ID: LOCATION ADDRESS: 1080 Massachusetts 28 TEL.#: 508-394-1386 MAILING ADDRESS:375 Commerce Park Road, North Kingstown, RI 02852 E-MAIL ADDRESS: permits@osjl.com OWNER NAME: Ocean State Jobbers, Inc. CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: Diane Whit, Store Manager TEL.#: 508-394-1313b MAILING ADDRESS: 375 Commerce Nark Road, Nortn Kingstown, i-o 02852 POOL CERTIFICATIONS: 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. n/a Pool operators must list a minimum of two employees currently 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 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/a 2 n/a 3. n/a 4. n/a FOOD PROTECTION MANAGERS-CERTIFICATIONS: 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. 1. n/a 2 n/a PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Diane White, Store manager 2. Kenneth Cowap,Assistant Manager 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 -l-c!1 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. -0 1 n/a 2 n/a r6 w. 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 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'r 1 i You must provide new copies and maintain a file at your place of business. RECEIVED 1.3. n/a 2. 4. Mil1 i ` 15 2018 RESTAURANT SEATING: TOTAL# 1 EALTH DEPT. 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$110ea. 'n_LODGE $55 TRAILER PARK $105 _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 >l00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.& $50 >25,000 sq ft. $285 VENDING-FOOD $25 ] <25,000 sq.ft. $150 i-f'G_. _FROZEN DESSERT $40 _TOBACCO $110 —.0 NAME CHANGE: $15 AMOUNT DUE = $ 150.00 O *****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.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 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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. 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 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO I I APPR•VED BY THE�:OARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' QUIRE TE PLAN. ,1 DATE: it\ h � SIGNA ' A /.;AM. PRINT NAME&TITLE: •. � ' :i ill i>itof Rev.1023/18 .30 Lt E Ktro The Commonwealth of Massachusetts . =4-7-% Department of Industrial Accidents s' `liti . Office of Investigations Y '_, ,� 600 Washington Street '-=r; Boston,l A 02111 ',,- r` www.rass.gov/iiia Workers' Compensation Insurance Affidavit: General Businesses • A, ,licantInformation —- --- - Plea'ePrittLel,l_ Business/Organization Name:Ocean State Job Lot Address:375 Commerce Park Road City/State/Zip:North Kingstown, RI 02852 phone#:401-295-2672 Are you an employer?Check the appropriate box: Business ® ss eT pe( required): 1.® I am a employer with 4000+ . employees(full and! 5. or part-time).* 6. 0 RestaurantlfarlEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. Non-profit [No workers'comp.insurance required] . 0 Non-profit L 0 We are a corporation and its officers have exercised Entertahurient their right of exemption per c.152,§1(4),and we have 10,®Manufacturing no employees.[No workers'comp.insurance required] i 1 Health Care 4.0 We are a non-profit organization,staffed by volunteers, _ with no employees.[No workers'comp.insurance req.] 12,0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **lithe corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy iaaformalien. Insurance Company Name:,Safety National • Insurer's Address: 1832 Schultz Road City/State/Zip: St. Louis, MO 63146 Policy#or Self-ins.Lie.# LOC-4047223 Expiration Date: 10/1/20-it 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 MOL 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. Ido hereby certify,under the pains and pe .,ides of perjury that the information provided above--s true and correct. (� Date: 16 " 1/- l Sia,:ture ..h. f v �.ti_ l i Ph'I- .• 401-295-2672 Official use only. Do not write In this area,to be completed by city or town official City or Town• permft/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person[ Phone#; www.mass.govldia Client#:77587 OCEANSTA33 ' ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)10/01/2018 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Mary Karn Starkweather&Shepley PHONE 401435-3600 FAX 401 431-9387 (A/C,No,Ext): (A/C,No): PO Box 549 E-MAIL ADDRESS: mkarn@starshep.com Providence,RI 02901-0549 INSURER(S)AFFORDING COVERAGE NAIC# 401 435-3600INSURER A:Indian Harbor Insurance Company 36940 INSURED INSURER B:RSUI Indemnity CO Ocean State Jobbers,Inc. INSURER C SafetY National Casualt Corp. 375 Commerce Park Road Employers Mutual Ins 21415 INSURER D: North Kingstown,RI 02852 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER (MM/DDY/YYYY) (MM/DO//YYY YY) LIMITS A X COMMERCIAL GENERAL LIABILITY ESG004940701 04/01/2018 04/01/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $1,000,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 X 7 OTHER: $ D AUTOMOBILE LIABILITY 5Z8512819 04/01/2018 04/01/2019 (E aBccldenntSINGLE LIMIT 1,000,000 D X ANY AUTO 568512819 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ PROPERTY X AUTOS ONLY X AUUTO ONLY (Per accident)DAMAGE $ $ B UMBRELLA LIAB OCCUR NHA082326 03/01/2018 04/01/2019 EACH OCCURRENCE $15,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000,000 DED RETENTION$ $ C WORKERS COMPENSATION LDC4047223 10/01/2018 10/01/2019 X STATUTE EORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) **Auto Liability Information** D 5B8512819 Eff Date: 04/01/2018 Exp Date:04/01/2019 Auto Liability:Any Auto,Hired Auto, Non-owned Combined Single Limit: 1,000,000 CERTIFICATE HOLDER CANCELLATION Proof of coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1197869/M1197020 TLF