HomeMy WebLinkAboutApp-License-CertsDocusign Envelope lD: D89FA39O-0C 1A-4E F 1-8280-93947 4392E21
rT}iUST BE POSTED ON PREI{TSES**
This License affirms that the specified premises, structure, or portlon thereof has met the necessary
conditions including any inspections required at the time of issuance.
It must be framed or laminated and prominently displayed in a clearly visible location within the approved
premises.
Intenm Health Dire:tor James Gard iner
Signature of Interim Health Director I y e*1.,"u
A
'
The Commonwealth of Massachusetts
Town of Yarmouth
Health DGpaftment
FOOD ESTABLISHMENT LICENSE
Dollar Tree Store #07724
525 Main Street, West Yarmouth, MA
ISSUED TO:Certificate No.
BOHF-26-8
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.OOO shall be liberally construed and applied to promote the underlying purpose of p.otecting the
ublic health.
License Expiration:
December 31, 2A26
Board ot l{.alth:
H illard Boskey, M.D., Chairman
Mary Craig, Vace Chairman
Charles T. Holway, Clerk
Laurance Venezia, OVPI
Erlc Weston Feer $15O.OO
Restrlctions ,/ Condltlons: Retail Food <25,OOO Sq. ft.
p
Details
lnternal Only
License Reslrictions/Conditions
Retail Food <25,000 Sq. Ft.
Expiration Date*
12t3',U2026
Business lnformation
Business Name'
Dollar Tree Storc#07724
Business Mailing Address (if different)
500 Volvo Parkway, Chesapeake, VA 23320
Business E-Mail*
MAJicensing@dollartree.com
Business Legal Entity
Corporation
Business Address in Yarmouth *
525 Main Street, West Yarmouth, MA
Business Phone #*
508-827-3177
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
0wner's Name*
Dollar Tree Stores, lnc
Manager/Contact Person Name*
Maureen Brown, Store Manager
FEIN
..-*-7365
Owner's Phone Number
757-321-5000
Manager / Contact Person Phone Numbef
508-375-7223
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS
Name of Certified Food Protection ilanager(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
305401-2402
Please attach copies of certifications for all listed below:
List all Certified Food Protection Managers'
Thomas List
List all employees with Allergen Certification-
Maureen Brown
Establishment Operations
Length of Permit
Annual
Address
525 Main St, West Yarmouth, MA
Email
MA-licensi ng@dollartree.com
Location is Permanent Structure?
Yes
Name and Title
Maureen Brown, Store Manager
Telephone Number
5081375-7223
Establishment Type
I
I
I
I
I
I
I
I
Continental Breakfast
Non.Profit
Residential Kitchen for Retail Sale
Frozen Dessert
Retail Square Footage.
Less than 25,000 sq. ft.
Common Victualler
Wholesale
Food Service
Retail Service
Vending Food
I
I
Other Name Change Only
I
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 atfirm that the food
establishment operation will comply with ,l05 CMR 590.000 and
all other applicable law. I have been instructed by the Board of
Health on how to obtain copies of 105 CMR 590.000 and the
Federal Food Code. Pursuant to [tlGL Ch.62C, Sec.49A, lcenify
under the penalties of periury that l, to the best of my
knowledge and belief, have filed all state lax returns and paid
taxes required under law.*
Stephanie R
Ankney
Jan I, 2026
Worker's Compensation lnsurance Affidavit
Type of Business*
We are a corporation and its ofiicers 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
!
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-tvvo (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 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 intormation
above.'
I
Notice
PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILIry
TO COMPLETE THIS APPLICATION EACH YEAR.
ALL RENOVATIONS 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 understand the Notice
information above'
Workers' Compensation Insurance Affidavit:
General Business
Applicant Information:
Narne : ( Bu si n ess/Organ ization/ I nd ivid ual )
Dollar Tree Stores, lnc.
23320Full Addressi 500 VOLVO PARKWAY CHESAPEAKT , VA Phone: (757) 321-500(
1. O I u, a employer with * 10-15 employees (full and/or pad-
time)*
, a I am a sole propnetor or partnership and have no employees working_ v for me in any capacity. [No workers' comp. rnsurance requrred.] '
^ We are a corporation and rts officers have exercised their right of
3. L) exemptron per MGL c. 152, &1(4), and we have no employees. [No
workers' comp. insurance required,l *
I am a general 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 Project (r€quired)
s. !l netait *
6. O Restaurdnt/BarlEating Establishment *
7. O office andlor Sales a
8. O Non-Profit *
9. ! Entertainment *
10. O Manufacturing *
11. O Health care *
tz. O othe. *
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation polacy information.**If the corporate officers have exempted themselves, but the coaporation has other employees, a workers' compensation policy is required
and such an organization should check box #1.
Are you an employer? Check trre appropriate box.
I am an employer that is providiog workers' compensation insurancG for my employees. B€low is the policy and job site
information,
Attach a copy of the workels' compensation poli€y declaration page (showing the policy number and expiration date),
Failure to secure coverage as required under MGL c. 152. 925A 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 SIOP WORK ORDER and a fine of up to $250.00 a day agaanst the violator. A copy of
this statement may be forwarded to the Office of Investigataons of the DIA for insurance coveraqe verification.
National Union Fire lns. Co c/o Marsh USA, LLC
91112026Polacy # or Self-ins Lic.#
Job Site Address
Expiration
Date:01 41 1 1 760(wk) 3509372(liability)
108 MILK ST WESTBOROUGH 01581
Insurance Company
Name:
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Stephanie R Ankney, Manager Licensing & Permits
Signature
(7s7) 321-5000
Phone Number
Lt9/2026
Date
official use only. Do not wrlte ln this area, to bo completed by citY ot town official'
City or Town: Permivlicense #
Issuing Authority:
Phone #Contact Person
tnformation and Instructions
Massachusetts General Laws chapter 152 requires all employerc to provide workers' compensation for their employees. Pursuant to this statute,
an employee is defined as ".,every person in the service of another unde. 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 enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,
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 or
repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment to be deemed to
be an employer"
NlGL chapter 152.S25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license
or permit to operate a business or to construct buildings in the Commonwealth for any.pplicant who has not produced
acceptable evidence of compliance with the insurance coverage required." Additionally, IYGL chapter 152525C(7) states. "Neither the
Commonwealth nor any of its political subdivision shall enter into any contract for the performance of public work until acceptable evidence of
compliance with the insuTance requirements 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 Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' 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
lndustrial Accidents for conformation of insurance coverage. Also be sure to sign and date the affidavit. The affldavit 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 workers' compensation policy, please call the Department at the number
listed below. Self-lnsured companies should enter their self-insurance license number on the appropriate line.
Clty 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 Olfice of Investigations has to contact you regarding the applicant, Please be sure to fill in the permit/license number
which vrill be used as a reference number, In addition, an applicant that must submit multiple permit/license applications ln any given year,
need only submit one affidavit lndicating current policy information (af necessary) and under "lob Site Address'the applicant shou!d 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 valid affidavit is on file for future permits or licenses. A new affidavit must be filled 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 Ieaves etc.) said person is
NOT required to complete this affidavit.
The Office of Investigations 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.
The Department address, telephone and fax number are as follows
Commonwealth of Massachusetts
Department of Industrial Accidents
Offi ce of Investigations
1 Congress Street
Boston, MA 02114-2017
lel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
FAXI #617-727-7749
www.mass.gov/dia