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HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-1092-06 Issue Date: 1/1/2021 Mailing Address: Location Address: TTEEN CORPORATION 465 STATION AVE STATION AVENUE CONVENIENCE STORE SOUTH YARMOUTH. MA 02664 1 PATRICK'S WAY FORESTDALE, MA 02644 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Retail; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston41 Bruce G. Murphy, MP•, R.S., C ti //.11ory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-1094-06 Issue Date: 1/1/2021 Mailing Address: Location Address: TTEEN CORPORATION 465 STATION AVE STATION AVENUE CONVENIENCE STORE SOUTH YARMOUTH, MA 02664 1 PATRICK'S WAY FORESTDALE, MA 02644 IS HEREBY GRANTED A 2021 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston / I1 ruce '. Murp , MPH, R.S. C ! allory R. Langler, R.S. Health Director/Assistant Health Director SThfio tit Ave Corn. • oF.....`;q TOWN OF YARMOUTH BOARD OF HEALTH + AA: APPLICATION FOR LiCENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 5+tx4;oc5-1 '��te . Cry esmi -etre TAX ID: LOCATION ADDRESS: y 51- s-ka440,-r1 S 1taa $,.ta w o7(y "I'F — MAILING ADDRESS: ± Pct}*a-j& uDcttq Fo -essdo,./e : IrnA 026411 E-MAIL ADDRESS: v i sl cL f oo . Corn- OWNER NAME: \J i Sl.at S 11UP11 ce-- LULU CORPORATION NAME (iF APPLICABLE): " -pEtn C.,e -at2,hocnHEALTH DEPT MANAGER'S NAME: 'moi p--; Shu1S1ct. TE.L.7473estr-szerrsttry MAILING ADDRESS: j Qq---a-j dK5 Loc{cj } Qe-- rnp.02642, 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 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. 2. 3. 4. FOOD PROTECTION MANAGERS-- CERTIFICATIONS: All food service establishments are required to have at least one hill-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. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. l. \h'V1 i c5111,‘.1.vc\c - ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one lull-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. \11,5\fl0221-5V1ULK\4_ 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 i-Iealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 2. 3. 4. RESTAURANT SEATING: TOTAL It OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT If LICENSE RI QUIRED FEE PERMIT ft LICENSE. REQUIRED FEE PERMIT If n o.n u•cc 4:SS MU H 010 - The Commonwealth of Massachusetts _ Department oflndustrialAccidents ""' i Office of Investigations ==i111 = 1= _;. ,= y 1 Congress Street, Suite 100 A -,. Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: L-- • _Ar,1:1. ;*Es) .: 4' l_ Iit. 6 Address: L5 - c)- cci;occ\ Pco e,- City/State/Zip:6..9e pu-th r'iN 0266Q Phone #: 5c&-52L • 1f�f Are you an employer? Check the appropriate box: Business Type (required): 1.2e 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. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. n 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.E Health Care 4.7 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.n Other `Ay applicant that checks box g l 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 41. I am an employer that is providing workers' compensation insurance for my employees. Belownis the policy information. Insurance Company Name: 5QC,P,AtACj' e'+5 R {A,Q.L e'sd1c cit S Ui Insurer's Address: J— - Roue Li City/State/Zip: CDC)Lt\--k -De--sy i S, MVO- 0266-t Policy # or Self-ins. Lic. # O 124 0 OC? 50 2.21 61 20.17-1-e4?-1)..... Expiration Date: .J.- 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 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 pairs and penalties of perjury that the information provided above is true and correct. Signature: Date: - b - v" 0 Phone #: C C) . - �.. 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 #: TTEECOR-01 MROSS ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/9/2020 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTE:ACT NAM _ RogersGray,Inc. PHONE 434 Rte 134 (A/C,No,Ext):(800)553-1801 I FAX No(877)816-2156 South Dennis, MA 02660 n DRIESS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company,Inc. 41360 INSURED INSURER B:Massachusetts Retail Merchants WCSIG,Inc.00000 TTeen Corp dba Station Ave Convenience INSURER C: 457 Station Ave INSURER D: South Yarmouth, MA 02664 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY1 (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7520026301 4/21/2020 4/21/2021 DAMAGE TO RENTED 250,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTEO�S ONLY AUTOSBODILYBODILY INJURY(Per accident) $ _ AUTOS ONLY NON-OWNED ONLY (Peri accidentDAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ $ B WORKERS COMPENSATION STATUTEPER OETH AND EMPLOYERS'LIABILITY Tteen 1/1/2020 1/1/2021 500,000 ANYAPROPRIETOR/PARTNER/EXECUTIVE Y/N 014000502216120 E.L.EACH ACCIDENT $ OFFICatoryin NH)EXCLUDED? N/A 500,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Convenience store 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 ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • ri 11 S c = =�• - - : � i_' eQ--'"----3' _ c _ ea`c a ter ? 411IMMIIMEM1111141111111210ameorsa ad.aai.Yai♦Ga...sY..aa..YY ..•Mfi.s.a..fi.1..1i1......ii.....aa ,rte > I\,,, . fi 70 ! .:' .ri I4-fes 77i 1 . 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Commonwealth of Massachusetts Letter ID:L1314007616 . 4-7 Department of Revenue Notice Date:May 7,2020 4 Geoffrey E.Snyder,Commissioner Account ID:EDL-11607554-013 E:vr of mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS 'III'I"IIIIIIIII'I'IIIIIIII'I"IIII"'II"III'I"IIIIII'IIlIIII' TTEEN CORPORATION 8 STATION AVENUE CONVENIENCE STORE 457 STATION AVE MEM SOUTH YARMOUTH MA 02664-1849 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE "I's MASSACHUSETTS DEPARTMENT OF REVENUE x'' ° f= Retailer License for Sale of Electronic Nicotine Delivery Systems h y"v �- This license must be posted and visible at all times. The sale of f, I O� tobacco products to anyone under 21 years of age is prohibited. TTEEN CORPORATION Account ID: EDL-11607554-013 STATION AVENUE CONVENIENCE STORE License Number: 288256000 457 STATION AVE SOUTH YARMOUTH MA 02664-1849 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 7,2020 Expiration Date: September 30,2022 al; t 11-:%4y Commonwealth of Massachusetts Letter ID:L1514754368 s Department of Revenue Notice Date:November 30,2020 ` 'L Geoffrey E.Snyder,Commissioner Account ID:CRL-11607554-010 4 9;1rtATOFP`, mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO TTEEN CORPORATION S= STATION AVENUE CONVENIENCE STORE -_ 457 STATION AVE SOUTH YARMOUTH MA 02664-1849 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ii/`s�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T { n i:� '`. Retailer License for Sale of Cigars and Smoking Tobacco '14. 0\** This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. TTEEN CORPORATION Account ID: CRL-11607554-010 STATION AVENUE CONVENIENCE STORE License Number: 1780865024 457 STATION AVE SOUTH YARMOUTH MA 02664-1849 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1, 2020 Expiration Date:September 30, 2022 oa .cxr.'r• Commonwealth of Massachusetts Letter ID:L0847317312 Department of Revenue Notice Date:November 30,2020 Clod: 4 " Geoffrey E.Snyder,Commissioner Account ID:CGL-11607554-007 2 2s. mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES IlilllisillllillluiIIiiIuiuIilillluiuIIilililisilllliilllsiIiI TTEEN CORPORATION o= STATION AVENUE CONVENIENCE STORE A= 457 STATION AVE SOUTH YARMOUTH MA 02664-1849 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE v, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes >F_ v' This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. TTEEN CORPORATION Account ID: CGL-11607554-007 STATION AVENUE CONVENIENCE STORE License Number: 2061264896 457 STATION AVE SOUTH YARMOUTH MA 02664-1849 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30,2022