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Home My WebLink AboutApplication and WC Town of Yarmouth TOWN OF YARMOUTH BOARD OF HEALTH Board of Health APPLICATION FOR LICENSE/PERMIT-2019 1146 Route 28 S.Yarmouth,MA 02664 *Please complete form and attach all necessary documents by December 15,2018. NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 156 Failure toq do so will result in the return of your application packet. 511-00ast3E 1531 s ESTABLISHMENT NAME: Dollar Tree#07724 TAX ID: -133171ASi;III LOCATION ADDRESS:... Main Street West Yarmouth,MA 02673-4948 TEL.#: 508-827-3177(store', (',;1 MAILING ADDRESS: 500 Volvo Parkway Chesapeake,VA 23320-1604 _ C� cJ1 E-MAIL ADDRESS: OWNER NAME: Dollar Tree Stores,inc. o Inn' CORPORATION NAME(IF APPLICABLE): Dollar Tree Stores,inc. H MANAGER'S NAME: TBD TEL.#: MAILING ADDRESS: 500 Volvo Parkway Chesapeake,VA 23320-1604 POOL CERTIFICATIONS: `'r' : Fs Thepool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated '114- Pool Operator(s)and attach a copy of the certification to this form. 1. n/a 2. rII Pool operators must list a minimum of two employees currently certified in standard First Aid and Community A 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 �' yearsrecords. You must provide 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 are required to have at least one full-time employee who is certified as a Food fi 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. 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 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. 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'records. You must provide new copies and maintain a file at your place of business. 1 n/a 2. 3. 4. RESTAURANT SEATING: TOTAL# n/a 130 t+FIC("332- 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 I0ea. —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 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# >25,000 sq ft. $285 VENDING-FOOD $25 lk • x <25,010 sq.ft. $150 15n f0- _FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 150.00 *****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 OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES 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 m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 6/5/19 SIGNATURE: PRINT NAME&TITLE: Nicole Taft -Store Set-up Coordinator Rev.10/23/18 The Commonwealth of Massachusetts t,u Department of Industrial Accidents All, Office of Investigations 1 Congress Street,Suite 100 1�IIt mr:timarBoston,MA 02114-2017 www.mass.govfdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:DOLLAR TREE STORES,INC. Address:525 Main Street, City/State/Zip:West Yarmouth,MA 02673-4948 Phone#:store# Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating 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. [No workers'comp.insurance required] 8. Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers' comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 110 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: . Insurer's Address: 1 ' if° ,, City/State/Zip: Policy#or Self-ins.Lie.#_ 1 Expiration Date: l' i Attach a copy of the workerb'compensation policy declaration page(showing the policy number an 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 c ;�',under the ,,', and penalties of that the information provided above is true and correct. Signature ( J Date:6/4/19 Phone#:757-321-5939 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.govfdia • -A CERTIFICATE OF LIABILITY INSURANCE DA 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 r. BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED O REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. p IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy{les)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 s certificate does not confer rights to the certificate holder in lieu of such endorsement{s). ee PRODUCER CO DTII ID Aon Risk Services Central, Inc. PHONE (855) 283-7122 FAX 800-363-0105 9 Grand Rapids MI Office (Arc'No.EN): (AIC.Na): 50 Louis Street NW EMAIL suite 200 ADDRESS: Y Grand Rapids MI 49503 USA INSURERS)AFFORDING COVERAGE NAIL C NSURED NSURERA: Safety National Casualty Corp 15105 Dollar Tree, Inc.; NSURERB: Liberty Insurance Corporation 42404 Dollar Tree Stores, Inc. 500 Volvo Parkway PSURERC: Chesapeake VA 23320 USA INSURER b: INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER:570072924429 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. Limits shown are as requested 'NSR ADM SUBII POLICYIPF POLICY tXP TYPE OF NE)RANCE RED yyyp POLICY NUMBER ((�L�rL��loD �M�pp UNITS LTtt X COMMERCIALGENERILLLIABILIY GL4U594U9 09/0 /201 d9/d172019 {OCCURRENCE 31,000,000 A CLAIMS-MADE x0 OCCUR SIR applies per policy teres & conditions DAMALUETO RENTED $1,000,000 PREMISES IEs ooansnoel MED Ears(Any ons pawn) Excluded PERSONAL&ADV INJURY 31,000,000 ,®,I GEEMLAGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE $15,000,000 4 POLICY ECT LOC PRODUCTS•COMR'OPAGG 52,000,000 S yl OTHER: r A AUTOMOBILEUADLITY CA54059210 09/01/2018 09/01/2019 CO � EDSINGLELMY $2,000,000 m X ANYAUTO BODILY INJURY(Per person) 0 z —SCHEDULED BODILY INJURY(Per mondani. 2 i OWNED AUTOS -ANIRE�DAU L8 —NON-OWNED PROPERTY DAMAGE —ONLY —AUTOS ONLY (Per sodded a B x UMBReLL ua9�X OCCUR TH7651292030018 09/01/2018 09/01/2019 EACH OCC URRENDE $5,000,000 V EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DEDI 'RETENTION A WORXERS COMPENSATION AND , . LDS4059207 09/01/2018 09/01/2019 X PERSTATUTE I EN. EMPLOYERS'LIABILITY ff.,, !N AOS Excl TX A ANY PROPRIETOR/PARTNERIEXECUTIVE (N,NIA PS4059208 09/01/2018 09/01/2019 El-EACH ACCIOENT $1,000,000 ((Ileen:E�InNE E%CIJAEDI WI EL OLSEASE•EA EMPLOYEE $1,000,000 r dElO iN OF OPERATIONS below EL DISEASE-POLICY Lear S1,000,000-- DESCRIPTIO A EXcesS wC 5P4059214 09/01/201809/01/2019-EL Each Accident $1,000,000_ Excess WC - OH EL Disease - Policy $1,000,000 ME SIR applies per policy terns & conditions EL Disease - Ea Emp- S1,000,000'Z.�-, DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101.AddInaW Remarks Schedule,may be attached Emcee space Is required) T Evidence of Coverage. aa.. 41,1 CERTIFICATE HOLDER CANCELLATION +: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE NAIL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Dollar Tree, Inc. AUTHORIZED REPRESENTATIVE lie 500 volvo Parkway Chesapeake vA 23320 USA e �ksaela! e�sest ars a III 61988.2015 ACORD CORPORATION.AU rights reserved. ACORD 25(2015103) The ACORD name and logo are registered marks of ACORD