HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee
Town of Yarmouth $150.00
Food Establishment License
Number: BOHF-19-3531-02 Issue Date: 1/1/2021
Mailing Address: Location Address:
STATION AVENUE SHELL 446 STATION AVE
COLBEA ENTERPRISES, LLC SOUTH YARMOUTH, MA 02664
2050 PLAINFIELD PIKE
CRANSTON, RI 02921
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
RESTRICTIONS: Soda, chips, candy,juice.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
t 41114111
Bruc`"G. Murphy, MPH, R.S. CHO/rallory R. Langler, R.S.
Health Director/A sistant Health Director
The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Tobacco Product Sales License
Number: BOHTP-19-3534-02 Issue Date: 1/1/2021
Mailing Address: Location Address:
STATION AVENUE SHELL 446 STATION AVE
COLBEA ENTERPRISES, LLC SOUTH YARMOUTH, MA 02664
2050 PLAINFIELD PIKE
CRANSTON, RI 02921
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
1
Bruce G. Mur•hy, MPH, R.S., HO/ allory R. Langler, R.S.
Health Director/Assistant Health Director
F. 1°I- 3t
,• " ��^ l Com( -34.37-5
14Th
TOWN OF YARMOUTH BOARD OF HEALTH
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.
.. s - ,.. �
ESTABLISHMENT NAME: ML Se! TD "
—Ott t-
f LOCATION ADDRESS
MAILING ADDRESS O vie/m.6-6a mite .lT 1JvroRp
_ 0:-e��ki'y
ADDRESS: aVi9C0 nubQ eQfll►de kke pr > tom
OWNER NAME: Col„bea�'tters m� LI xm�_,
CORPORATION NAME(IF APPLICABI,E)_ CV( Lip Jz f LL( ,
MANAGER'SNAME
6 ,1+10
MAILING ADDRESS:Is! Ql!1►!'�� 1711 ....
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. Nifit 2'
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Jar 2 8 `Z.021
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.
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. l h1 2 _... _
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
ALLERGEN CERTIFICATIONS:
AV food service establishments are required to have at least one full-time employee who has Allergen
ti 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.
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.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE
REQUIRE
D F
EE PE
RMIT
_B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP$55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE
REQUIRE
D F
EE PE
RMIT#
0-100 SEATS $125 CONTINENTAL $35 NON-
PROFIT $30
>100 SEATS $200 COMMON
VIC. $60 _W
HOLESALE $80
RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE
REQUIRE
D F
EE PE
RMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING - FOOD
$25
<25,000 sq.ft. $150 FROZEN DESSERT $40 !TOBACCO
$110
NAME CHANGE: $15 $ � Get) AMOUNT DUE =
*****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 V,,/ 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
18,2020.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMEN OTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND 'Re VED BY T ' BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE• RE A 'ITE PLAN
DATE: 141 la1/40
SIGNATURE: / //d6/)(
PRINT NAME&TITLE: A (o (lac I V P ° 0)C1 kJ
Rev.10/15/19
- '1
r
The Commonwealth of Massachusetts,',.1,;,,,, Print Form
...�..a = Department of Industrial Accidents
.��r''p
�^ 1 ; Office of Investigations
" 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C (betk lt lef)1.CL . Aiail ale niek,a- Ti)
Address: . oco Pfau n{ d P)k-
City/State/Zip: (i',Kci of 11)viiie,4OD‘l a I Phone#: W 0 f t/'t%?—C
Are ou an employer?Check the ppropriate box: Business Type(required):
1. I am a employer with t 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. ❑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.❑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. Other yirrethoo ' e s
ive
*Any applicant that checks box 41 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: recompJf(j+ Y3'l(,r 4 j pure-thee (-f oil i p{'
Insurer's Address: 'P` C . -g �J41
City/State/Zip: C) i) arnlV1CL- j 01 lt 61-0(670
((?
Policy#or Self-ins.Lic.# 62074 L pExpiration Date: I JI �J(c 0( I
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofpc-MA for insurance cover.:,e erifi ion.
I do hereby ce i,un er th-: >#.' s and p: alti'. o erjury that/the information provided above is true and correct.
/ 1)) (-if a0°ao
Signature: i d- ) Date: /?
Phone#: Lit/— 9 ' 0 ooJ
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
r
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS
CERTIFICATE OF INSURANCE DOES HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR
PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poltcy(les)must have ADDITIONAL INSURED provisions or be endorsed, If
SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement en this
certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER NAME OT CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE:P.O.BOX 328 PHONE
Este 888-339.4949 FAX
Nob 507-048.4664
OWATONNA,MN 55080 ADDRESS:CLIENTCONTACTCENTERCaIFEDINS.COM
INSUReRIS)AFFORD(/JO COVERAGE NAIL 7f
INVITER AI FEDERATED MUTUAL INSURANCE COMPANY 1393$
IHGURED 176-6005 INSURER B:
COLBEA ENTERPRISES LLC,EAST SIDE SERVICE CENTER INC, INsunER 01
MVC ENTERPRISES INC,EAST SIDE MANAGEMENT INC
2050 PtAINFIELD PIKE INSURER D:
CRANSTON,RI 029212062 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:I REVISION NUMBER:2
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 MAYBE ISSUED OA 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. y£X
!�R TYPE OF INSURANCE AD
IN R sYAM POLICY NUMBER UdealiYyYYI (l J D!Y'/YYI UST
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE1
DppMMppGe T nt EO
GWMS•MADE OCCUR _DEMISES IEaaswrrenwl
MED EXP(Any Orla atrial)
PERSONAL ADV DLIURYAEA AOOA OATS LIMIT APPUES PER: GENERA/.AGGREGATE
POUOY IPRO- aLO4 PRODUCTS-COMP/0P A00
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO BDDILY INJURY(Par yam]
UT
OWNED AUTOS ONLY AEOUCED
U709 tummy INJURY(PIT MIMI/
MEC Auras ONLY HON•OWNEY
AUTOS MT
UMBRELLA MAD OCCUR EACH occURRERCE
EXCESS LIAB ^CIA:ME'MADE AOORECATE
DED I I RETENTION
WORKERS COMPENSATION X !PER STATUTE! 10T
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNEREEXECUTIVE EL.EACH ACCIDENT $1,000,000
A OFEICER/MEMBEREXCWOFD? NIA N 6074191 07/01/2020 07101/2021
(Mandatory in NN) E.DISEASE-EAEMPLOYEE $1,000,000
II yea. I under OF CrEAATIONS Herm [
DLECRIPTION EL D16EASE•PDUOY MDT $1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS'VEHICLES(AC ORD TOLD Addiranat Ramedu Ediedato,may Aa stS had Il mora;pica la rev:Iran
{
CERTIFICATE};OLDER CANCELLATION , �7
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTNOAIZEO AEPAESENTAnVE gtAJ,,,
41/144A1,64 6
Cil 19E8.2016 ACORD CORPORATION.Ail rights reserved.
ACORD 25(2010103) The ACORD name and logo are registered marks of ACORD
j1
I �
ssnc.r164 Commonwealth of Massachusetts Letter ID:LI582442048 FV-
Department of Revenue Notice Date:September 4,2020 O }
W Geoffrey E.Snyder,Commissioner Account ID:CGL-I 1710146-060
1r• w'
4z, rol, mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
111111'111111l1in1IIIII111111i,iuuuiln1.1.1.iI''Iilni,siliiie
COLBEA ENTERPRISES LLC
EAST SIDE ENTERPRISE
2050 PLAINFIELD PIKE
CRANSTON RI 02921-2062
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
tiS` sFT� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
kz; ASI, A ;, Retailer License for Sale of Cigarettes
Y� L
;yF ro04 This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
COLBEA ENTERPRISES LLC Account ID: CGL-11710146-060
COLBEA ENTERPRISES,LLC Location ID: 11710146-0103
446 STATION AVE License Number: 1508513792
SOUTH YARMOUTH MA 02664-1208
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
019
y s hn-sF>, Commonwealth of Massachusetts Letter ID:LI504667200 'EVA
Department of Revenue Notice Date:September 2,2020
Geoffrey E.Snyder,Commissioner Account ID:CRL-11710146-066
fewoF* mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
IIn1i11i1titlll11t,1,tltIt...nittllt11ti1tlllltinttlttnt
COLBEA ENTERPRISES LLC
COLBEA ENTERPRISES,LLC
2050 PLAINFIELD PIKE
CRANSTON RI 02921-2062
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
ocFros, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
, Retailer License for Sale of Cigars and Smoking Tobacco
0-e- This license must be posted and visible at all times.The-sale of tobacco
products to anyone under 18 years of age is prohibited.
COLBEA ENTERPRISES LLC Account ID: CRL-11710146-066
COLBEA ENTERPRISES,LLC Location ID: 11710146-0104
446 STATION AVE License Number: 1964738560
SOUTH YARMOUTH MA 02664-1208
•
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
...4-0CX1-iCtx Commonwealth of Massachusetts .�
Lcttcr ID:L1776503360 0
Department of Revenue Notic
020
Geoffrey E.Snyder,Commissioner Accountu Date:May 13, 101
ID:EDL-11710146-090
trrmass.gov/dor
LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS
11111111111111k riilunIIItln111111IInnlli111111 uuii
COLBEA ENTERPRISES LLC
COLBEA ENTERPRISES,LLC
2050 PLAINFIELD PIKE
CRANSTON RI 02921-2062
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
MASSACHUSETTS DEPARTMENT OF REVENUE
pA ' Retailer License for Sale of Electronic Nicotine Delivery Systems
stems
3 VIA
'1/4 z` This license must be posted and visible at all times. The sale of
�r0F
tobacco products to anyone under 21 years of age is prohibited.
COLBEA ENTERPRISES LLC Account ID: EDL-11710146-090
COLBEA ENTERPRISES, LLC Location ID: 11710146-0137
446 STATION AVE License Number: 1301239808
SOUTH YARMOUTH MA 02664-1208
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 13, 2020 Expiration Date: September 30, 2022