HomeMy WebLinkAboutLicense-App-CertsDocusign Envelope lD: D89FA390-0C1A-4EF1 -8280-93941 4392E21
I,I]IIUST BE POSTED OI{ PREMISES*t
This License affirms thatthe specified premises, structure, or portion thereof has met the necessary
conditions including any insp€ctions reguired at the tame of issuance.It must be framed or laminated and prominently displayed in a clearly visible location within the approved
premises.
Interim Health Director James Ga rdiner
Slgnature of Interim Health Director ItZiu*
A The Commonwealth of lrlassachusetts
Town of Yarmouth
Health Department
FOOD ESTABLISHM ENT LICENSE
Dollar Tree Slore #O4227
35 Long Pond Drive
ISSUED TO:Certificate No.
BOHF-26-7
The purpose of 105 CMR 500.000 is to establish minimum standards for those persons engaged in the
business of preparing, processing, or distributing food for sale in Massachusetts.
105 CMR 50O.000 shall be liberally construed and applied to promote the underlying purpose of protecting the
pubtic health.
License Expiration:
December 3t,2l,26
3o.rd ot HG.lth:
Hillard Boskey, Nl.D., Chairman
Mary Craig, Vlce Chairman
Charles T. Holway, Clerk
Laurance Venezra, DVM
Eric Weston Fee: +15O.0O
Restrictions / Condltions: Ret.ll Food <25,OOO Sq, Ft,
remoH-lt iLl itef
Details
lnternal Only
License Restrictions/Conditions
Retail Food <25,000 Sq. Ft.
Expiration Date*
12t31t2026
Business lnformation
Business Name'
Dollar Tree Slore #04227
Business Mailing Address (if different)
500 Volvo Parkway, Chesapeake, VA23320
Business E-Mail*
MA-l icensing@dollartree.com
Business Legal Entity
Corporation
Business Address in Yarmouth *
35 Long Pond Drive
Business Phone #'
774-325-6038
Business Type*
Retail Service
Corporation Name (if applicable)
Dollar Tree Stores, lnc
Tax lD (FEIN or SSN)-
FEIN
ls this a NAME CHANGE?
No
Owner / Manager lnformation
Owner's Name*
Dollar Tree Stores, lnc
Manager/Contact Person Namet
Michelle Russell, District Manager
FEIN
*-..-7365
Owner's Phone Number
757-321-5000
Manager / Contact Person Phone Numbef
305401-2402
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFIGATIONS
Name of Certified Food Protection Manage(S)
All food service establishments are required to have at least one (1) PERSON lN CHARGE on site
during hours of operation
Emergency Telephone Number
305-401-2402
Please attach copies of certifications for all listed below:
List all Certified Food Protection Managers*
Thomas List
List all employees with Allergen Certification'
Holly Lachance
Establishment Operations
Length of Permit
Annual
Address
35 Long Pond Drive, South Yarmouth, MA
Email
MA-licensing@dollartree.com
Location is Permanent Structure?
Yes
Name and Title
Holly Lachance, Store Manager
Telephone Number
508-470-0081
Establishment Type
I
I
I
I
I
I
I
I
Continental Breakfast
Non.Profit
Residential Kitchen for Retail Sale
Frozen Oessert
Retail Square Footage'
Less than 25,000 sq. ft.
Common Victualler
Wholesale
Food Service
Retail Service
Vending Food
I
I
Other Name Change Onlyr
Affidavit
New construction, remodel or conversion requires an Occupancy Permit from the Building
Department in order to receive a valid Food Permit.
l, the undersigned, attest to the accuracy of the information
provided in this application and I affirm that the food
establishment operation will comply with ,l05 CMR 590.000 and
all other applicable lalv. I have been instructed by the Board of
Health on how to obtain copies of ,l05 CMR 590.000 and the
Federal Food Code. Pursuant to MGL Ch. 62C, Sec. 49A, I certify
under the penalties of perjury that I, to the best of my
knowledge and belief, have filed all state tax returns and paid
taxes required under law.'
Stephanie R
Ankney
Jan 9, 2026
Worker's Compensation lnsurance Affidavit
Type of Business.
We are a corporation and its officers have
exercised their right of exemption per c. 152, S
1(4), and we have no employees. [No workers'
comp. insurance requiredl**
Submitted by Staff
I
Business
Retail
I do hereby certify, under the pains and penalties of periury, that
the information provided above is true and correct.*
Stephanie R
Ankney
Jan 9, 2026
Food / Retail 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 seventy-two (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 lhe suspension or revocation of your Frozen Dessert Permit until the above terms have been met.
OUTSIDE CAFES: Outside cafes (i.e., outdoor seating with server 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.
I acknowledge that I have read and understand the information
above.*
I
Notice
PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY
TO COMPLETE THIS APPLICATION EACH YEAR.
ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT (PAINTING, NEW EQUIPMENT, ETC.) MUST
BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.
RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
I acknowledge that I have read and und€rstand the Notice
information above*
Workers' Compensation Insurance Affidavit:
General Business
Applicant Information:
Namet (Business/Organizationfindividual)
Dol,ar Tree Stores, lnc.
23320Furl Addressi 500 VOLVO PARKWAY CHESAPEAKT , VA Phone: (757) 321-500(
i r\ I am a sole proprietor or partnership and have no employees working'' v for me rn any capacity. INo worke.s' comp. insurance requrred.]
^ We are a corporation and its officers have exercised their right of
3. L) exemption per MGL c. 152, &1(4), and we have no employees. [No
workers' comp. insurance required.] *
I am a qeneral contractor and I have hired the sub-contractors listed
4. O on the attached sheet. These sub-contractors have employees and
have workers' comp. insurance. **'
Type of Proiect (required)
5.9 Retail "
6. ! RestauranvBar/Eatinq Establishment *
7. C Office andlor Sales *
8. O Non-Profit *
9. O Entertainment *
10. ! Manufacturing '
11. E Health Care *
12.0 other *
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informataon.**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,
Are you an employer? Check the appropiiate box.
1. O , u. a employer with ^ 10-15 employees (full andlor part-
time)*
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Aftach a copy of the work€rs' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, 525A is a criminal violation punishable by 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. A copy of
thiS statement may be forwarded to the Office of lnvestigations of the DIA for insurance coverage veriflcation.
National Union Fire lns. Co c/o i/arsh USA, LLC
9t1t2026Policy # or Self-ins Lic.#
lob Site Address
Expiration
Date:01 41 1 I 760(wk) 3609372(liability)
1OB MILK ST WESTBOROUGH 01581
Insurance Company
Name I
I do h€reby certify under the pains and penalties of perjsry that the information provided above is true and correct.
(7s7) 321-s000
Phone Number
7/9t2026
Date
offlclal us€ ooly. Do not write in thls area, to b€ completed by city or town official.
City or Towni PermivLicense #
Issuing Authority:
Contad Person: Phone #:
Information and Instructions
Stephanie R Ankney, Manager Licensing & Permits
Signature
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,
an employee is defined as "..every person in the service of another under any contract of hire, express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing
engaged in a joint ente.prise, and including the legal representatives of a deceased employet or the receiver or trustee of an indavidual,
partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three
apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction oT
repair work on such dwelling house oT on the grounds or building appurtenant thereto shall not because of such employment to be deemed to
be an employer"
MGL chapter 152.S25C(6) also states that "every state or local licensing age.cy shall withhold the issuance or renewal of a license
or permit to opGrate a business or to construct buildings in the Commonwealth for any applicant who has not produced
acceptable evidenae of compliance with the insurance coverage required." Additionall, MGL chapter 152S25C(7) states. "Neither the
Commonwealth nor any of its political subdivision shall ente. into any contract for the performance of public work until acceptable evidence of
compliance with the insurance requiTements of thiS chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-
contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or
Limited Liability PartneEhips (LLP) with no employees other than the members or partners, are not required to carry \i/orkers' compensation
insurance. If an LLC or LLP does have employees, a policy is required. Be advised that his affidavit may be submitted to the Department of
Industrial Accidents for conformation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to
the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have
any questions regarding the law or if you are requested to obtain a \4orkers' compensation policy, please call the Department at the number
listed below. Self-Insured companies should enter their self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to
fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to flll in the permit/license number
which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,
need only submit one affidavit indicating current policy information (if necessary) and under "lob Site Address'the applicant should write "all
locations in." s copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof
that a vatid altldavit is on file for future permits or licenses. A new amdavit must be fllled out each year, Where a homeowner or citizen is
obtaining a license or permit not related to any business or commercial venture (i.e. A dog license or permit to burn leaves etc.) said person is
NOT required to complete this affidavit.
The Office of lnvestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate
to give use a call.
Ihe Department address, telephone and fax number are as follows
Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street
Boston, MA 02114-2017
Tel, *617-727-4900 ext. 7406 or 1-877-I4ASSAFE
FAX| #617-727-7749
www.mass.gov/dia