HomeMy WebLinkAboutApp, License, WC & Certification The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Tobacco Product Sales License
Number: BOHTP-15-4953-06 Issue Date: 1/1/2021
Mailing Address: Location Address:
SPEEDWAY, LLC 441 ROUTE 28
SPEEDWAY #2438 WEST YARMOUTH. MA 02673
ATTN: LICENSING DEPT.
P.O. BOX 1580
SPRINGFIELD, OH 45501
IS HEREBY GRANTED A 2021 LICENSE
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
V
ruce G. Murph MPH, R.S. C X Mallory R. Langler, R.S.
Health Director/Assistant Health Director
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o►. TOWN OF YARMOUTH BOARD OF HEALTH
' APPLICATION FOR LiCENSE/PERMIT - 2021
y;< * Please complete form and attach all necessary documents by December 18, 2020.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME:SXedNal 2 -i 3$ TAX ID:
LOCATION ADDRESS:44 M1q;n 54', 1(`5 brmpw}k i1ti1A 0210-13 TEL.#: 503%115' 12.103
MAILING ADDRESS:'�.0. P0)( 15 D1 Lie n-e Dept Sprt ng-►Pldl 0I+ 45501
E-MAIL ADDRESS: LI CznSi 11 .speed W04. Com
OWNER NAME: Spf-ectv\ial LLC
CORPORATION NAME (iF APPLICABLE): ie a
MANAGER'S NAME:A kOnNIQ \ IJ ok TEL.#: 5D$-x"15-(2103
MAILING ADDRESS: -(1 Mom Si-, 1\lfsilarrno.44,1 MA 02,11113
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. case _lsttlic ±aignated
Pool Operator(s) and attach a copy of the certification to this form.
DEC 2 2 2020
T. r�
Pool operators must list a minimum of two employees currently certified in standard F rst X. 71'li .Oni-rifTitinity
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. r\; A 2.
3. 4.
•
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one lull-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. 1\1 P\ 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i AldtnIrt lal fX 2.
ALLERGEN CERTIFICATIONS:
All food service establishments arc 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 •
HEIMLiCH CERTIFICATIONS:
All food service establishments with 2.5 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.
i. N\N 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED LEE I'I-.RMti ll LICENSE REQUIRED PEI: PERMIT/t LICENSE REQUIRED PEI: PERMIT
RX-I1 Oat . r
ADM INISTRA'TION
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. TI-IE 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 I lotel 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 (hey 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, shalt generally be considered Transient.
POOLS
POOL OPENING: All Swimming, wading and whirlpools which have been closed for the season must be inspected by the
Ilcalth Department prior to opening. Contact the I lealth Department to schedule the inspection three (3) days prior to
opening. PLEASE NOTE: People arc 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 Ilcalth 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 I lealth 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 Llealth 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 hcertsc;and the tobacco license cap is reduced. _
NOTICE: Permits run annually from January I to December 3 1. IT IS YOUR RESPONSIBILITY TO RETURN
-.-.nAI,[,\ A my. ncnt IIDCrI r.>~Cic\ RV IIFr''FnARFR I R 7070
The Commonwealth of Massachusetts Fee
Town of Yarmouth $150.00
Food Establishment License
Number: BOHF-15-4950-06 Issue Date: 1/1/2021
Mailing Address: Location Address:
SPEEDWAY, LLC 441 ROUTE 28
SPEEDWAY #2438 WEST YARMOUTH. MA 02673
ATTN: LICENSING DEPT.
P.O. BOX 1580
SPRINGFIELD, OH 45501
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 Weston1111
Br ce G. Murphy, MPH, R.S., C 4O Mallory R. Langley, R.S.
Health Director/Assistant Health Director
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D AT E C?F E h � � .` DATE OF EXPIRATION
Irl frnws apply_ Che` V t �7 ; U� � ,"`�r�r-®+ cy for recertification requirements.
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• The Commonwealth of Massachusetts
Department of Industrial Accidents
la�`�='tom ./.
= Office of Investigations
=- 1= p 1 Congress Street, Suite 100
�•4 Boston, MA 02114-2017
:.it, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: -ca k t 4 it 5, -4. k G ZL _
Address: /-4141 �al 1'1 siyee-
City/State/Zip: f5+ q(y pook 1Ah 'MA 024-15 Phone #:50 -115 - I71P3
Are you an employer? Check the appropriate box: Business Type (required):
1. I am a employer with 'I 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]* -
11.0 Health Care
4.r] We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*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 providingiIworkers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:O I Z�I71JOl l C. Ins. Co I N y l ani ,,ro p 1 C, 1 �.vc\s l anti
Insurer's Address: lig U)O c(ef dOlm Jet• Or, V. ie., (AN
City/State/Zip: dr.pr \ CI an (' ' ` N4 01-\ 13 I
Policy # or Self-ins. Lic. # MW c, 3I J 2-2.-D Expiration Date: 01 I 01 I 2.,1
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 penalties of perjury that the information provided above is true and correct.
` LICENSE COORDINATOR I �,
Sienature:c 'I`IlS],t,} Date: )2 I I
Phone #: 63v7'J3-13 _
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 #:
ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
tom" 6/23/2020
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 CONTACT
Hylant Group, Inc.-Cleveland PHONE FAX
6000 Freedom Sq Dr,Ste 400 (A/c.No.Ext):216-447-1050 (A/C,No):2164474088
Independence OH 44131 ADDARESS: cleveland_hmi@hylant.com
INSURER(S)AFFORDING COVERAGE NAIC C
INSURER A:Old Republic Insurance Co 24147
INSURED MARAT-3 INSURER B:
Speedway LLC
500 Speedway Drive INSURER C:
Enon,OH 45323 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:485405692 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 EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE RENTED
$
CLAIMS-MADE OCCUR PREM SESO(Ea occurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _
POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $
_
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A WORKERS COMPENSATION MWC31380220 7/1/2020 7/1/2021 X STATUTE OTH-
ER
AND EMPLOYERS'LIABILITY Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $5,000,000
OFFICER/MEMBEREXCLUDED? N N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
In regards to:
Speedway Store#2438 at 441 Main Street,West Yarmouth,MA
Speedway Store#2440 at 14 East Main Street,West Yarmouth,MA
Speedway Store#2445 at 1353 Route 28,South Yarmouth,MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Yarmouth
1146 Rt.28 AUTHORIZED REPRESENTATIVE
South Yarmouth MA 02664-4451
2 t's -±'
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
op
uts Commonwealth of Massachusetts Letter ID:L0898792000
Department of Revenue Notice Date:September 11,2020 F
Geoffrey E.Snyder,Commissioner Account ID:CGL-11945027-224
'44W-rot' mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
IHpIIII'IIIA"IIIIII11'll'I'llidi1I111I11I'II'IIIIIIiniuii
SPEEDWAY LLC
SPEEDWAY LLC 2468
539 S MAIN ST RM 3212
FINDLAY OH 45840-3229
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
soc sc MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
11 OAa Retailer License for Sale of Cigarettes
owls This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
SPEEDWAY LLC Account ID: CGL-11945027-224
SPEEDWAY 02438 Location ID: 11945027-0190
441 ROUTE 28 License Number: 817862656
WEST YARMOUTH MA 02673-4844
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
Commonwealth of Massachusetts1 94
Letter ID:L0241305152
iLle' Department of Revenue Notice Date:September 22,2020
( 0 Geoffrey E.Snyder,Commissioner
Account ID:CRL-11945027-227
oi` mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
111I1I"III'11111111'"1111111P111111111111iii11111iI1011111
SPEEDWAY LLC
SPEEDWAY LLC 2468
539 S MAIN ST RM 3212
FINDLAY OH 45840-3229
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
4.0Pczos4, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
YsVr V 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 A;T
products to anyone under 18 years of age is prohibited.
SPEEDWAY LLC Account ID: CRL-11945027-227
SPEEDWAY 02438 Location ID: 11945027-0302
441 ROUTE 28 License Number: 1074632704
WEST YARMOUTH MA 02673-4844
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
£c8 Commonwealth of Massachusetts A4 Letter ID:L1505373760
P •
Department of Revenue Notice Date:September 11,2020 '�
g �t , Geoffrey E.Snyder,Commissioner Account ID:EDL-11945027-239
1x(1
vroo�' mass.gov/dor
LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS
III"I'IIIII1111111IIIIII1'1111"1111I41111IuI1111"1I'I1II'
SPEEDWAY LLC
SPEEDWAY LLC
539 S MAIN ST RM 3212
FINDLAY OH 45840-3229
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
isp tus4,_lMASSACHUSETTS DEPARTMENT OF REVENUE
rog '� `' Retailer License for Sale of Electronic Nicotine Delivery Systems
` e
4,
'n� This license must beposted and visible at all times.The
vro4* sale of
tobacco products to anyone under 21 years of age is prohibited.
SPEEDWAY LLC Account ID: EDL-11945027-239
441 ROUTE 28 Location ID: 11945027-0440
WEST YARMOUTH MA 02673-4844 License Number: 1043900416
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: September 11,2020 Expiration Date: September 30,2022