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HomeMy WebLinkAbout2022 App-License-Certifications ..""►""►, TOWN OF YARMOUTH BOARD OF HEALTH t h\ APPLICATION FOR LICENSE/PERMIT - 2022 (' A '� ?. * Please complete form and attach all necessary documents by De ember 1 T. Failure to do so will result in the return of your application p ESTABLISHMENT NAME: S ' EFci kApp g 0 N H 5" TAX ID: LOCATION ADDRESS: 13S3tC. 2 , SoLtt (trD141 ,N)A Ceti+-Li5° TEL.#: 3q$- IS MAILING ADDRESS: 00 Eox ISgD- lncs-nSe so\ fd .04 E-MAIL ADDRESS: b A S-Ii IPS S OWNER NAME: )CPG Wool W.-- CORPORATION LLCORPORATION NAME (IF APPLICABLE): P('d Way L L L_ MANAGER'S NAME: Ini C.h cF 1 .S'►m mads TEL.#: (S-D6 30,e- 21 s C) MAILING ADDRESS:VaGc,1 ISC• �s� L"14 • S Qn nq ;dd 014 -I 5-SL k 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. Of 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. N/ _ 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 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. qhs 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. N/' 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. iv"/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. !V I A 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$110ea. 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285ENDING-FOOD $25 • 7<25,000 sq.ft. $150 _FROZEN DESSERT $40OBACCO $110 NAME CHANGE: $15 �Jet:r)Jl.1 AMOUNT DUE = $ a CO.�J *****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 t„,-- OR 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 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 18, 2020. 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: II i j I /2 I SIGNATURE: .6G�l..&)G QJ3 PRINT NAME &TITLE:`-0)a`13C\'w,.7,: ti1�,� ��°pE'��" lit Ucense Coordinator Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-4960-07 Issue Date: 1/1/2022 Mailing Address: Location Address: SPEEDWAY, LLC 1353 ROUTE 28 SPEEDWAY #2445 SOUTH YARMOUTH. MA 02664 ATTN: LICENSING DEPT. P.O. BOX 1580 SPRINGFIELD, OH 45501 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 Weston 411 4•1r ruce G. Murphy, MPH,R.S., 1.H0 ames G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-4962-07 Issue Date: 1/1/2022 Mailing Address: Location Address: SPEEDWAY, LLC 1353 ROUTE 28 SPEEDWAY #2445 SOUTH YARMOUTH. MA 02664 ATTN: LICENSING DEPT. P.O. BOX 1580 SPRINGFIELD, OH 45501 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 . Bruce G. Murphy,MPH, R.S., C O/Jame, .Gardiner Health Director/Assista t Health II irector / I GLS: 1 3 2021 • �,lC �:_f jjG v�1.7•�,�r / `V I'r`��. ►.li. ?��1� . c s _9 - '£� 9v, ` :'.apt .n i�- •.n CERTIFICATE OF • �::::>,;.: ALLERGEN '1 AWARENESS • Afr, Name of Recipient:ANTONir,k ih'LANCIA 19 j Y Certifieate.Number:2x742" 11 ;, Date of Completion, W2 2o1s c l.: `lt4+k'� Date ofExpiration 9/29/2r12° • i. 41 �.Ct-,, I Issued I��,.�-f' - c,,a ?he above-namedperson is betel y issued this'urtifitah - mm��jj �� , •{��,6 1 for completing an allergen awareness trainin m �• ` 1111!4 � � 'dr ,c.:,. . rqT(0 AL I. I recognized by this Massachusetts Dgartment ofPuhl Health r RE q Rq >ll� in accordance with 105 GMR 390.009 G 3 a M u ad..e�, ASSOCIATION* • { >�' f )(J(� ' sachmetta Restaurant Ailociatioa 333'Ilaropike Road,Suite 202 w meetaunat .1 This certificate will be valid forfive(3)years from date ecnmpletlam bO '8�MA o177a O1g 'c<s"'. r1 rY. d I 508-303-9904 www.manamutanbuaoc, f � .,�,?.c ,- '�3 cam_ �a cr-, �;'lea. T+h� } "� f +.:"{U� (s; ✓:� it ',:a1;V.4 ' .. , Lis...-. `C/�f � ` '.•.r! fJ, �.k*. T t t.: r„%."‘" t .': Z The Commonwealth of Massachusetts Department of Industrial Accidents i . ` Via, l,_ ; Office of Investigations DEC 1 3 2021 i 1 Congress Street, Suite 100 _ t ' , Boston, MA 02114-2017 '�±'= ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ii(cc)<(,00,, (IC dbc. 0(e 6 u-6,/ d `H6 Address: LI LI I I(\Q'I l Si- City/State/Zip:\\J 'yl- \'a f mnou-1h ,MA_ Phone #: rj - 7 7S- 12-(p 3 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. etail 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. [11 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] l2.❑ 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#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: . i 1 lC t 1(' v. ,i; Insurer's Address: SOC Lod t1 6 .aChc\ctl hie,,.v,,, S . iF I ti� City/State/Zip: 1C1. 1A S --, 2'19.----y 1j" ...4 uge, 1"'Z•vc A Policy #or Self-ins. Lic. # NA;,.. al h `, I' 'j 6 A-2. ,.'--n4 Expiration Date: (C I I )2 / 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,c�tiyunder the pains and penalties of perjury that the information provided above is true and correct. Signature:�_J���I Y.:Nr,, 34--dfi Date: I I /18/N /; �1 8 License Coordl'nntor /� Phone#: C g.3 0 CO3` 4. (,cense Coordinator 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 --- -- 1 1 DEC 1 3 2021 .-----.1 (co A�oRv CERTIFICATE OF LIABILITY INSURANCE L__ DATE(MM/DDIVYYY)12/0612021 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 a certificate does not confer rights to the certificate holder in lieu of such endorsement(s). m PRODUCER CONTACT Aon Risk Services Southwest, Inc. NAME: m Dallas TX Office ((A/CC.No. at): (866) 283-7122 FAX No.): (800) 363-0105 T) 0 5005 Lyndon B Johnson Freeway E-MAIL x Sui to 1500 ADDRESS: Dallas TX 75244 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: ACE American Insurance Company 22667 SEI Speedway Holdings, LLC INSURER,: Indemnity Insurance Co of North America 43575 3200 Hackberry Road Irving TX 75063 USA INSURER C: ACE Fire Underwriters Insurance Co. 20702 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570090523823 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 INSR TYPE OF INSURANCE ADDL SUER POUCY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD . IMM/OD/YYYY1 /MM/DD/YYYY1 COMMERCIAL.GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE E PREMISES S( a RENTED (Ea occurrence) MED EXP(My one person) PERSONAL 8 ADV INJURY i,.1 Cu GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE co PRO- U) Li POLICY n JECT LOC PRODUCTS-COMP/OP AGG o OTHER: 1 n In AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT (Ea acddent) ANY AUTO BODILY INJURY(Per person) •• O —SCHEDULED BODILY INJURY(Per sodden!) Z OWNED AUTOS — AUTOS ONLY PROPERTY DAMAGE .0 HIRED AUTOS NON-OWNED (Per accident) V —ONLY —AUTOS ONLY • !_ t w UMBRELLA LIAB OCCUR EACH OCCURRENCE V EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND WLRC68919265 10/01/2021 10/01/2022 X PER STATUTE OTH EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N AOS E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBEREXCLUDED? N NIA WLRC68919228 10/01/2021 10/01/2022 (Mandatory In NH) AZ, MA E.L.DISEASE-EA EMPLOYEE $1,000,000 If yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,006 ME DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mom space I.required) RE: Speedway Store #2438 at 441 Main Street, West Yarmouth, MA, Speedway Store #2440 at 14 East Main Street, West Yarmouth, MA and Speedway Store #2445 at 1353 Route 28, South Yarmouth, MA. rial MI 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. PrA Town of Yarmouth AUTHORIZED REPRESENTATIVE 1146 Rt. 28 south Yarmouth MA 02664-4451 USA uSAelr, eSeiloa A „ � c9fe `ea4-rfa MI ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGIENCY CUSTOMER ID: 10039991 }}{j �j LOC#: J�^'c' 1 3 2 0 21 .et Rr4' ADDITIONAL REMARKS SCHEDULE Page 710 _ AGENCY NAMED INSURED Aon Risk services southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER See Certificate Number: 570090523823 CARRIER NAIC CODE See Certificate Number: 570090523823 EFFECTIVE DATE: ADDITIONAL REMARKS _ THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER � INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY IN SR ADDL SUER POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR TYPE OF INSURANCE INSD WVD DATE DATE (l1M/DD/YYYY) (MM/DD/YYYY) WORKERS COMPENSATION C N/A sCFc68919307 10/01/2021 10/01/2022 WI ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10039991 LOC#: .AC`f3Rlf) '---- ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER -_ See Certificate Number: 570090523823 CARRIER NAIC CODE See Certificate Number: 570090523823 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liabilily Insurance Named Insured Schedule Speedway LLC; speedway Prepaid Card LLC WIP LLC speedway.com LLC SWTO LLC; _ PF] Southeast LLC speedway of Massachusetts LLC Tesoro Northstore Company; Speedway Western Holdings LLC DEC 13 2021 TRMC Retail LLC Tesoro West Coast Company LLC; Tesoro south Coast Company, LLC; fi' ,^,! T' Ir,. Tesoro Sierra Properties, LLC; 2Go Tesoro Company; Western Refining Retail TRS II, LLC Western Refining Retail TRS I, LLC Western Refining Texas Retail Services, LLC western Refining Retail, LLC Giant Stop-N-Go of New Mexico LLC; Giant Four Corners, LLC; Northern Tier Bakery LLC ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of AC.ORD