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Home My WebLink AboutApplication and WC ` ,'. _. Fo6L �p!s - s�zlz�� °' � TOWN OF YARMOUTH BOARRll OF HE LT�[�(y'[; �VJ[�o APP ICATION FO ICENSE/PERMIT 2014 � (� �yc� R� a� �� w�-. y UE(� 17 ?�014 � * Please comp ete form an attach � �� ts by ecem er I3 OI ' Failure to do so will result'ii�th �our pli�i �.�� ti � E�, ESTABLISHMENT NAME: �p��cD�,�cS a�au� ' T.�iD� �-� LOCATION ADDRESS: E �v�q� TEL.#: q O- MAILING ADDRESS: " E-MAIL ADDRESS: � OWNER NAME: Hess ReteO Oper one, i Hess PI CORPORATION NAME(IF APPLICABLE): Woodbndge, Nl 07095 MANAGER'S NAME: ,1 1732-750-6350 — MAILING ADDRESS: � ]FLAHERTY@SPEEDWAY,COM 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. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary 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. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. i. Q�,.l Q sda�' a. PERSON IN CIIARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �. Q�,,��ga� �- 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 establis�ment. 1. P�� dD�' � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich 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 t►le at your place of business. L 2. 3. 4. P.ESTAiIRP.NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 _INN $55 CAMP $55 � SWIMMINGPOOL $80ea _LODGE $55 � —7RAILERPAItK $105 WHIRLPOOL $SOea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-IOOSEATS $85 _CONTINENTAL $35 NON-PROFIT $30 � >700 SEATS $160 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 �<25,000 sq.ft. $80 _FROZEN DESSERT $40� �TOBACCO 9 NAME CHANGE: $15 � AMOUNT DUE — *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��--u""�'"` � ��'�� .fiz��-( 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 MIJST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WOR.KER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '/ Town of Yannouth 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 limitafions of Motel or Hotel use, Transient occupancy sha11 be limited to the temporary and short term occupancy, ordinarily and customazily 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 generatly 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 Departrnent to schedule the inspection three (3) days prior to opening.PLEASE NOTE: People are NOT allowed to srt 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 standazd 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 pooi must be drained or covered within seven (7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: All food service establishxnents must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days priar to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify tl�e 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, Dowriloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar 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 COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. 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 13,2013. 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: / � SIGNATURE: ,� PR1NT NAME &TITLE: `�� x'=��1( Rev. 10/08/13 � �y � """' , Form CT-3T pQy�7 Massachusetts Department of Revenue 2014 - 2016 ' Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco hls Lieense must be posMa and viside at all fvnes. Salea to peraons undar�8 years of age ara prohiWtad by law. � pplicetion Number: AJ741 License Num6er. Date of Issue: ederel�denti6cation w SoGal Security Number: 222-46-2225 00987 09/OB/2014 iling atltlress Tor license: RMail sale bcation(H AHferefd tlan mailing address) HESS RETAIL OPERATIONS LLC HESS 21243 1 HESS PLAZA TAX 8TH FLR 50 OCEAN ST WOODBRIDGE, NJ 07095 HYANNIS, MA 02601 This certilas }hat the taxpayer nametl above has paid the required license fee and is Iicensetl to aell et retall at the atltlress ahovm ahove unfii September 30,2016. This licenu is not transferable,and ia subject to suaper�slon lor lallure ro compty with the law. ti Fortn CT-3T 07005 Massachusetts Department of Revenue 2014 - 2016 Cigarette Excise Unit + ReWiler License for Sale of Cigarettes antl Cigars and Smaking Tobacco is Lieense must 6e posted and vlsiWe M all times. Sales to persons under 78 years of age are prohibked 6y law. � pplicatbn Number AJ761 License Number. Date of ISSUO: ederal IdeMifrc�ation or Social Securiry Number: 222-46-22'15 0�005 09/08/2014 ' 'ling addreas for license: Reqil sale Iocation(if dif(ererd than maping address) HESS RETAIL OPERATIONS LLC HESS EXPRESS 21244 1 HESS PLAZA TAX BTH FL.R 441 MAIN ST WOODBRIDGE, NJ 07095 W YARMOUTH, MA 02873 This certifies that the ta�ayer named above has paid the required license fee and is licensed to aNl at retail�at the address shown aDove urrtil Septem6er 30,2018. 7hls Ikense Is rwt trans�erable,and is subject to suspe�ion for failure to compty with the law. " Fortn CT-3T ��27 Massachusetts Department of Revenue 2014 - 2016 Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco is License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited hy law. pplication Numher: AJ786 License Number: DatB Of ISSuB: ederel IdeMification ar Social5ecurity Number; 222�6-2225 01027 09l08/2074 s9ing address far license: Retail sale locatlon(it dHlereM Man mailirn�address) HESS RETAIL OPERATIONS LLC HESS EXPRESS 21245 1 HESS PLAZA TAX 8TH FLR 317 FALMOUTH RD WOODBRIDGE, NJ 07095 HYANNIS, MA 02601 This certifies that the taxpeyer named alwve has paid the required Iicense fee and is licensed to sell at retail at the addrese shown above until tem6er 30,2016. Thia license is�wt hansfereble,and is subject M suspensbn(a(ailure to comply with the law. Form cT-sT 01008 Massachusetts Department of Revenue 20�4 - 20�6 Cigarette Excise Unit Retailer License for Safe of Cigarettes and Cigars and Smoking Tobacco is License murt be postad and visibk at all times. SalPs to persons under 18 years of age are prohibited by law. �C ^� liratbn Number: AJ765 License Numter: Date of Issue: i�v Federel ItlanBfication or Social Security Number: 222�46-2225 01008 . 09/OB/2014 Mallhg address for license: � Retail sale locatim(H diNereM then maflirg eddress) , HESS RETAIL OPERATIONS LLC HESS EXPRE55 21246 1 HESS PLAZA TAX 6TH FLR 14 EAST MAIN ST. WOpDBRIDGE,NJ 07095 W YARMOUTH, MA 02673 � The Commonwealth of Massackusetts Department ofindustria[ACcidenu O�ce ojlnvestigations l Congress Street,Suite 100 Boston, MA 01114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Plesse Print Leeiblv Business/Organization Name:Hess Re[ail Operations, LLC dba Hess Express a�ay� Address: 1 y £ �lA�ri �71 City/State/Zip:� G�t'ttrx� MA 13 Phone#: �S" �,S'D��I Are you an employer?Check the appropriate box: Business Type(required): 1.0 1 am a employer with �� employees(full and/ 5. ❑� Retail or part-time).'" 6. ❑Restaurant/Bar/Ea[ing Es[ablishment 2.❑ 1 am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl.real estate,auto,etc.) employees worldng for me in aay capacity. [No workers' comp. insurance requ'ved] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment thev right of exemption per c. 152, §1(4),and we have �0.0 Manufacturing no employees. [No workers' comp. insurance required]** ll.Q Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. (No workers' comp. insurance req.] �z,❑Other "My applican[that chccks hoz Nl must also fill out thc secdon below showing ihcir workels'compensation policy infirmation. `•If[he comora[e o�cers have exempted thcroselvrs,bu[1he cnqaration has other employccs,a urorkets'compensazion policy is required and such an organizazion should check box N I. /am an emp[oyer thru is providing workers'compensatlon insurance fa�my employees. Below is the policy lnjoimation. Insurance Company Name:Old Republic Insurance Company Insurer's Address:445 S. Moodand Rd.Ste 300 . City/State/Zip: Brookfield,WI 53005 Policy#or Self-ins. Lic.�i MWC30246500 Expirallon Date:��1I2015 Attach a copy of the workers' compensation policy deelaration page(showing the poliey 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 andlor one-year imprisonment,as well as civil penal[ies 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[his statement may 6e fonvazded to the Office of Investigations of the DIA for insurance coverage verificarion. !do hereby cer[ify, under the pafns and pena/Ues o�ry that 1he tnforma!!on provided above Is lrue and carrecr. �Q �a/8/i� , Si¢nature� Date• Phone#:732-750-6350 Offictal use only. Do nat wrrte in thls area,to be comple[ed by city or town ofJtcial. City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Liceosing Board 5.Selectmen's Office 6.Other Contact Person: Phone#• www.mass.govldia ' co o• CERTIFICATE OF LIABILITY INSURANCE 91"Ma';°°""'"' THI3 CERTIFICATE IS ISSUED A3 A AMTTER OF iNFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE XOLDER. THIS CERTiFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER 7HE COVERAGE AFFORDED BY THE POLICIES BELOW. TFi13 CERTIFICATE OF INSURANCE OOES NOT CONSTI7UTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORI2ED REPRESENTATIVE OR PFiODUCER,AND THE CERTIFICATE NOLDER. IMPORTANT: If the ceRifleate holder Is an ADDITONAL INSURE�,the poliry(ies)must be endorsad. If SUBROOATION 18 WAIVED,subJatt to the terms and condklona of the policy,cartein pollcles may requlre an enEoroement. A atatomont on[his�certHicste does not confer rlphW to the csrtlfiute holder In Ilau of suah enqoraemen s. rnaoucen u Hylant Group-Cleveland vxor+e � o BODO Freedom Sq Dr, Ste 400 � � �� - Indepandence OH 44131 0 INSURER 5 AFFOROiNp WVERApE NAIC tl WSURERA: rance Co iwsurseo MARAT-3 INSIIRER B: Hess Retai!Operations, LLC INSURERG: 1 Hess Plaza Woodbridge, NJ 07095 INSURERD: . � INSURERE: INSYRER F: COVERAGES CERTIFICATE NUMBER:g39865088 REVISION NUMBER: THIS IS TO CERTIFY THAT hIE POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POCICY PERIOD INDICATED, NOTMTHSTANDING ANY REQUIREMENT,TERM OR CON�1110N OF ANY CONTRACT OR OTHER DOCUMENT W1TF1 RESPECT TO NHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCR�BED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AN�CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CWMS. �Nm 1VPlOFINSUMNCE PdJLVNUMBER P��YEFF PW pW�y U� GENEWILWBILITY EACHOCCl1RRENCE S COMMERCl4L(3EMERALIInBIIITY Eaarr�inence S CLAIMS-MADE Q OCCVR ME�E%P one enan S . PERSONRLBAWINJURY t � GENERALAGGREGPTE 5 6ENLAGGREGu1TELIMITAPPLIESPER: PRODUCiS-COMPIOPAGC S POLICY 4 LOC s FUlOMOBILFIIABIUTY EeactltleM ANYAVTO BO�ILYINJURY(Perpeson) i ALIONMEO SCHEDULE� BOpILYINJURT(PxetbOe� S nIITOS AUTOS HIREDAUTQS A�O�ED PpOPE�Ra pAMAGE s s UMBRELLA WB p�CUR � EAGH OLCURRENCE S !%CESSlIAB CUIMS•MAOE AG6REGATE S OED RETENTIIXJS S q WORI�RSCOMPENSATON WC302C8500 0/1l201< /1/2015 �1CSTATU• OTH� ANGEMPLOVERS'LIRBlLITV y�N RNYPROPRIEfORIPARTNERIFJ(ELUTNE❑ E.L.EpCHACGDEM 55,000,000 OFFICERIMEMBERE%CWOE09 NIA �Mu�tlabrylnNN) E.L.dSEASE-EnENPLOYE 55000,000 ttyes OatRibe Wer OESGRIPlION OF OPERATIONS btlow E.L OISEASE�POLICY LIMR SS 000 000 �ESCRIPTtON OF OPERl1TqN41 LOCA7qN$I VEXI0.ES(AtpM pCORO tO1,AtlEldwul Ram�rk�SCMtlWa,11 mon�p�ca I�nquME� CERTIFICATE HOLDER CANCELLATION SHOULD ANV OP THE ABOVE DESCRIBEO PoLICIES BE GANCELLED BEFORE THE EXPIRATION OATE T{iEREOF, NOTICE WILL BE DE4VEREG IN ACCORDANCE N7TH THE POLICV PROVISIONS. AIITIbR1iED REPRESENTATVE �� , 91988•2010 ACORD CORPORATION. All Nghts reserved, ACORD 25(2010I05) The ACORO name and logo are registered marka of ACORD