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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 Zr.?) "Please complete form and attach all necessary documents by December 13,2019. Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15°. ESTABLISHMENT NAME: RITE AID #10194 TA.XID: LOCATION ADDRESS: 918 ROUTE 6A TEL.#: (508) 362-2114 MAILING ADDRESS: License Administration MS 3215 /PO Box 901 Deerlield,IL 60015 E-MAIL ADDRESS: taxlicenserenewals@walareens.com OWNER NAME: Waimea Eastern CO.. Inc. CORPORATION NAME(IF APPLICABLE): Walgreen Eastern CO., Inc. MANAGER'S NAME: TEL.#: (508) 362-2114 MAILING ADDRESS: MS 3215 /PO Box 901 Deerfield,IL 60015 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. - 2. Z z Pool operators must list a minimum of two employees currently certified in standard First Aid and Community rn © ill Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the-0- employees e-- employees below and attach copies of their certifications to this form.The Health Department will not use past r\) yearsrecords. You must provide new copies and maintain a file at your place of business. 1 rr < ia, c 3. 4. I rs 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. ,T 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: d 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)(3Xa). 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. 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. 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$1 IOea. LODGE $55 TRAILER PARK $105WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>I00SEATS $200 COMMONVIC- $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,000sq.ft. 5150 _FROZEN DESSERT $40 _TOBACCO $1y10 NAME CHANGE: $15 AMOUNT DUE = $J w•040_ *****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.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 Ito December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2019. 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 ITE PLAN. \ ' DATE: 11/05/19 SIGNATURE: ` J\ PRINT NAME&TITLE: Kaylpnn De Los Santos LicensB Specialis,License Administration Rev 10/15/19 Walgreen Eastern CO.,Inc. The Commonwealth of Massachusetts Department of Industrial Accidents '# — 1 Office of Investigations =Fall= 1 Congress Street, Suite 100 }' 4.41Boston,MA 02114-2017 '' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: RITE AID#10194 Address: 918 ROUTE 6A City/State/Zip: YARMOUTH PORT,MA 02675 -5102 Phone #: (508) 362-2114 Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with 7 employees(full and/ 5. ❑ 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.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.10 Other Retail Drng &Sundries *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the 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: Please see attached Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 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 certify,under the pains and enalties of perjury that the information provided above is true and correct Sig ature. 1111111piiikt '. Ha I n De Los Santos Date: 11/05/19 License Specialist,License Administration Phone#: (847)-3154376 Walgreen Eastern CO.,Inc. 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): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia PRODUCER ,.. •.., _w� „a �a W" a w uK � t a soe MARSH USA INC IS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO 540 W.MADISON RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM.THIS MEMORANDUM DOES N. CHICAGO,ILLINOIS 60661 AMEND,EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW.ANY USE,DUPLICATION UNITED STATES OF AMERICA OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS PROHIBITED. INSURED 7,... '.'i"�€ �" ..n.. .• w_.. .au..::�4aY.tw,..z.;.a`trifsirs COMPANY ZURICH AMERICAN INSURANCE COMPANY 16535 WALGREEN CO.AND SUBSIDIARIES A 300 WILMOT RD.,MS#3228 COMPANY INDIAN HARBOR INSURANCE COMPANY 36940 DEERFIELD,ILLINOIS 60015-5223 B UNITED STATES OF AMERICA COMPANY AMERICAN ZURICH INSURANCE COMPANY 40142 COMPANY DSELF INSURANCE `?..R.+.,.= u.zr.n.+o: Ln'!.+#Wa.abeam'aw.}G r.1ve.iwk:n`m rdo'4'r!<u•r'.«a.SYx^ev.Lke.J E 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 MEMORANDUM 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. A GENERAL LIABILITY GLO 9310091 15 7/1/2018 7/1/2019 © COMMERCIAL GENS LLLITY GLO 931018415(Puerto Rico) 7/1/2018 7/1/2019 Elag223MEZiii 5 000 000 CLAIMS MADE El OCCUR PERSONAL&ADV INJURY 4 000 000 ©Blanket Additional Insured EACH OCCURRENCE 4 000 000 ©Per Policy ly 1._111� 1(:.ur"l =1 500 000 X Blanket Contractual Liability Liquor LiabilityI�di1la:Il:�, •^l.�:Ll' 0 Ell A AUTOMOBILE LIABILITY BAP 9310096 15 7/1/2018 7/1/2019 ©ANY AUTO COMBINED SINGLE LIMIT $ 5,000,000 •ALL OWNED AUTOS BAP 9310183 15 (Puerto Rico) 7/1/2018 7/1/2019 -SCHEDULED AUTOS MI HIRED AUTOS BODILY INJURY(Per Person) $ =NON-OWNED AUTOS BODILY INJURY(Per Accident) $ 11. PROPERTY DAMAGE $ B EXCESS LIABILITY US00079295LI18A 7/1/2018 7/1/2019 PER CLAIM 5 000 000 UM©arHReFORM EMMR5171MINIMMI 5 000 000 �oniER THAN UMBRELLA FORM C WORKERS COMPENSATION/ WC 9310092-15(AOS) 7/1/2018 7/1/2019 WORKERS COMPENSATION A EMPLOYERS LIABILITY WC 9310094-15(WI) LIMITS STATUTORY A EWS 9310448-15(MA) A PARTNBRS/EXECURVE j( INCL EL EACH ACCIDENT 2 000 000 A OFFICERS ARE: EXCL EL DISEASE-POLICY LIMIT 2 000 I I EL DISEASE-EACH EMPLOYEE 2 000 000 D PRODUCT LIABILITY Self-Insured 7/1/2018 7/1/2019 EACH OCCURRENCE 2 000 000 AGGREGATE 2 000 000 ,' ,.a,� .�,. �„.�,,.�..�x , ,r_,.. .,u„;,oa. .�..a«... szL&Sidova.w.�,^,s, :a..aa::•. ,a : '� �;,, OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS,LENDERS,MORTGAGEES,GROUND LESSORS, VENDORS,CUSTOMERS,CLIENTS,AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. ' is WALGREEN EASTERN CO.,INC. OFFICERS AND DIRECTORS WKI'UHAIE I I1UNE TITLE NAME ADDRESS NUMBER Ownership 108 Wilmot Road President&Director Richard Ashworth Deerfield, IL 60015 (847)914-2500 0% 108 Wilmot Road Vice President John Saylor Deerfield, IL 60015 (847)914-2500 0% 108 Wilmot Road Vice President Alan Nielsen Deerfield,IL 60015 (847)914-2500 0% 108 Wilmot Road Treasurer&Director Todd Heckman Deerfield,IL 60015 (847)914-2500 0% Vice President& 108 Wilmot Road Secretary Joseph Amsbary,Jr. Deerfield,IL 60015 (847)914-2500 0% 108 Wilmot Road Director Alexander W.Gourlay Deerfield,IL 60015 (847)914-2500 0% 108 Wilmot Road Assistant Treasurer Susan Halliday Deerfield,IL 60015 (847)914-2500 0% License Automation Page 1 of 1 License Automation License Search Results Location Location City ST License G Lic Mult License Renewal License License Address Type Ind Lic. Exp Due Renew Amt 10460- 1041 SOUTH S* ROUTE YARMOUTH MA FOOD/MILK L 0 12/31/19 12/15/19 11/12/18 $150.00 28 RITE ID #10194 918 YARMOUTH • 19695-S ROUTE PORT MA FOOD/MILK L 0 12/31/1912/15/19 12/26/18 $150.00 • 6A Total $300 21700835 Hay 11.5.19 Please mail Licenses To: License Administration Haylynn De Los Santos Walgreen CO. License Specialist, NS 3215 / PO Box 901 PHONE # (847)-315-3376 Deerfield, IL 60015 FAX # (847)-368-6525 *I will be ont of the office on Fridays* taxlicenserenewab@walgreens.com walgreens.com (Group email) LL ii NOV 12 2019 HEALTH DEPT http://licenseautomation.walgreens.com/LicenseAutomation/servlet/walgreens.lic... 11/5/2019