HomeMy WebLinkAboutApplication and WC Fo2 Zo �� �CC�C�ez 5 �12te,�f .
��� TOWN OF YARMOUTH BOARD OF HE T '.��
1APPLIC{A-TION'SFOyRC�LICENSE/PERMIT- Ol�tl: 1 � 2�14
` * Please Com�leteRfo�an�"att'�chrail�i�e"��s`' o e s b 2
Failure to do so will resultt`n Y1ie 4f yot�a lic
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ESTABLISHMENT NAIVIE:_�eSS `t t�p�s S 2�12,51 TAX m•
LOCATION ADDRESS: \353 YYb��+r� .S`�' TEL#• '7 L�-I la�b
MAILING ADDRESS: -- .��,-�'
E-MAIL ADDRESS: Haea Reta��operat�ons, ��c
OWNER NAME: i Hess alaza/� Flaberty —
Woodbr(dge, N] 07095 —
CORPORATION NAME (IF APPLICABLE): �sza5aesso
MANAGER'S NAME: -�� � gp�' 1� - Z-6623(fax)
MAILING ADDRESS:
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 tlus form.
L 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, 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. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: N�A' Q(e-�=o ���
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 Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your establishment. .
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certificafion,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.
L 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 a11 times. Please list your employees trained in anti-chokmg 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. 2.
3. 4.
RESTAiJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT#
B&B $55 � CABIN $55 MOTEL $55
INN $55 CAMP $55 SWIMMINGPOOL $80ea.
_LODGE $55 TRAII,ERPARK $105 WIIIRLPOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL � $35 NON-PROFIT $30 �
>100 SEATS $l60 COMMON VIC. $60 � WHOLESALE $80 -
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25
�<25,OOOsq.ft. $80 —FROZENDESSERT $40 TTOBACCO .
NAMECHANGE: $15 AMOLTNTDUE — $ I
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'*** ��-`N �����11�
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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 Compensafion
Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSUliANCE 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 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�naintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than tliirty(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 Deparhnent prior to opening. Contact the Health Department to schedule the inspection three (3) days
prior to opening.PLEASE NOTE: People aze 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 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 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 Yazmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Appiication 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.vannouth.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 ar revocation ofyour 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 Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation, or display of any food product by a retai] ar 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
COMMENCEME TT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: /� SIGNA'I'[JRE: ����
� v�.��;d�� �—
PRiNT NAME&TITLE: �����a�� ,r. ��� ,r��
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Rev. 10/08/13
°'" �. Form cr-sr Uo977
Massachusetts Department of Revenue 2014 - 7016 '
Cigarette Excise Unit
Retailer License for Sale ot Cigarettes and Cigars and Smoking Tobacco
is License must 6e posted and visibk at all tines 8ales to persons under 1Y years of age are prohi6itad by law.
ppication Number: Ad731 License Number Date of Issue:
ederal IdentifcatWn or SoGal Security Number: YYY-4B-YZ'1S 00977 . 08/08/2014
'ling address�ar license: . Reteil sale location(if ditferent then meiling address)
HESS RETAIL OPERATIONS LLC HESS EXPRESS 21251
1 HESS PLAZA TAX 6TH FLR 1353 MAIN ST
OODBRIDGE, NJ 07095 S YARMOUTH, MA 02864
is certifias that the t�payer nemetl above has pald the required Iicense fee aM Is Iice�ed to aell at retail at the eddress shovm ebove uMil
Septetr+ber 30,2018. This licenee is not trensfereble,and is subject to euspenslon lor failure ta wmply wifh the lew.
" Fortn CT-3T 0'f 0�2
Massachusetts Department of Revenue 2014 - 2016
Cigarette Excise Unit
Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco
0
his License must 6e posted and visible at all times. Sales to persons umler 78 years of age are prohibited by law. .
pplicatbn Number: AJ7S7 �icense Number: Dete of Issue: .
Federel Identification or Social Security Number: 222-46-2226 01002 09/08/2014
Mailiig address for Iicense: � Refail sale location('rf differem than mailing address)
HESS RETAII OPERATIONS LLC HESS EXPRESS 21252
1 HESS PLAZA TAX BTH FLR 792 MAIN ST
WOODBRIDGE, NJ 07095 � OSTERVILLE, MA 02655
This certifies Ihat the taxpayer named above has paid the required license fee end is licensetl M sell at retaii at the atlAress shown ebove until
S ember 30,2016. 7his Ilcense is not tranafereMe,aM is subJect to suspension tor failure to compy�Nth the law.
/ ,� Form CT-3T 01035
Massachusetts Department of Revenue 2014 - 2��6
Cigarette Excise Unit
� Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco
his License must be posted antl visible at all times. Sales to persons under 18 years of age are prohibited by law.
pplicafion Num6ar: AJ817 � License Number. DBtC Of ISSUe:
ederel IdenUficatlon a Soclal Securiry Num6er: 222-46-2225 01035 09/08/2014
(Iing address for license: Retail sele bcatlon(1!dif(ereM than meiling atldress)
HESS RETAIL OPERATIONS LLC HESS MART 2125¢j
1 HESS PLAZA TAX 6TH FLR 343'SCENIC HIGWAY
WOODBRIDGE, NJ 07095 BUZZARDS BAY, MA 02532
TMia nPrtlln< ihat Nw�axnawr named a6ove has oeid the reauired license fee and is licensed to sell ai relail at the address shovm aCove untll
� The Commonwealth of Massachusetts
Deparhnent oflndustrialACcidents
Offue oflnvestigalions
= 1 Congress Street,Suite 100
Boston, MA 02174-20I7
www mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Aaplicant Information Please Print Leeibly
Business/Organization Name:Hess Retail Operations, LLC dba Hess Express �
Address: �353 mo��r� ��' -
City/State/Zip:� QC J MA O `�_ Phone#: ��"-3��"a�S�
Are you an employer?Check the appropriate box: Business Type(required):
1-0 I am a employer with `r�� employees (full and/ 5• �❑ Retail
or paet-time).• 6. ❑RestauranUBar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estatq auto,etc.)
employees woridng for me in any capacity.
[No workers' comp. insurance required] � $� ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment
thev right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workezs' comp. insurance required]** t l.�Health Care
4.❑ We aze a non-pro6t organizallon,stafted by volunteers,
with no employees. [No workers' comp. insurance req.] �2.�Other
"My appiicant that chxks box Bl must also Fdl out lhc section below showing thcir workers'compcnsation policy informetion.
"If the w�pore[e o�cers have exempted themselves,6ut lhe corpora[ion has other employecs,a workers'compensation policy is requi2d and such an
organization should check box 1!1.
I am an emp[oyer that is provulirsg warkers'compensatton insurance fa�my employees. Below is the policy lnjormatron.
Insurance Company Name:Old Republic Insurance Company
Insurer's Address:445 S. Moorland Rd.Ste 300
City/State/Zip: Brookfield,WI 53005
Policy#or Self ins. Lic.# MWC30246500 Expiration Date:��1/2015
Attach a copy o[the workers' compensation policy deelara[ion page(showing the poiicy number and.expiration date).
Failure to secure coverage as required under Sectiw 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 f'orm 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.
!do hereby cerl�,under the pains and�/tles o perjury lhat!he tnjormation provrded abave 7s true and ca�rect.
aimature —Z Date• �O�/O/I�_
�
Phone#:732-750-6350
Offictal use nnly. Do not write ln fhis area,ta be rompleted try crty or town o�ciaL �
City or Town: Permit/License N
Issuing AuthoriTy(circle one):
1. Board of Health 2.Building Department 3.Cityffown Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
wwW.mass.gm/dia .
� R� �� CERTIFICATE OF LIABILITY INSURANCE °"�'"""°°"""'
sis no+a
THIS CERTIFICATE IS f33UED A3 A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY qR NEGATIVELY AMEND, EXTEND�OR ALTER TFiE COVERAGE AFFORDED BY THE POLICIES
� BELOW. TH13 CERTIFICATE OF IN3l1RANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 138UING IN3URER�S�. AUTNORIZED
REPRESENTATIVE 6R PRODUCER,AND THE CERTIFICATE HOLOER.
IMPORTANT: If the certtlicate holder Is an ADDIiIONAL INSURE�,tha policy(ies)must ba enEoned. If SUBROOATYON IS WAIVED,suCJ9ct to
the terms and conditlons of the policy,certain polleles may requlre an andormemeM. A statement on this�certiflcats does not�onler Aphts to the
certlfieate holdar In Ileu ot such entloraemen s.
r�mouc�e
u
HyIantGroup-Cleveland PH��N.Q�6-QQ]-�OSO ' � No:
6000 Freedom Sq�r, Ste 400 - .� ��
Independence OH 4413f � 0 4•
INSURER 6 AFFOROING COVEItAGE _ N�IC Y
WS�RERA: ic Insurance Co
ir+sue�o MARAT-3 WSURER B: _
H855 Retail Operatiorts, LLC IN811RERC:
1 Hess Plaza iNsuneao:
Woodbridge, NJ 07095 .
�Haurtert s:
INSURERF:
COVERAGES CERTIFICATE NUMBER:g39865088 REVISION NUMBER:
THIS IS TO CERTIFY THAT hiE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME�ABOVE FOR THE POCICY PERIOD
INDICATED. NOT4NTHSTANDING ANV REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO N411CH iHIS
CERTIFICATE MAY 9E ISSUED OR MAY PERTAW�, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEHMS,
EXCLUSIONSANDCONDITIONS OF SUCH POLICIES.LIMITS SHONM MAY HAVE BEEN REDUCEO BV PAI�CWMS.
�NTp iYPlOFINSIIRANCE pOucvNUNBER MMIOOY FF PMI��y uN�
GENERALIIA&LITY EACHOCGt1RRENCE 3
COMMERCIALOENERALLIABIIITY P NISE Eeoc S
�CWMS-M0.DE OOCCUR MEDE%P aro rson S
. PER30NALbAOVINJl1RY S
GENERALAGGRECATE 5
OENLAGGREf3ATEUMITAPPLIESPER: PRODUCTS-COMPIOPAGG S
AOLICY P LOC 5
RII'NMOBILE LNBIUTY Ea BMldyn
ANYAVTO BOOILYINJURY(Parpsson) 5
ALLOVMED SCMEOUIE� BOOILYINJURY(Pe�eati�enp 5
NI1T03 AlJT05
HIREDAUT0.5 ��p��E� PPOPEtlTY0A1AAGE _
f
UMBREWILIRB OCCUR EACXOCCURRENGE 3
ESCElE WB CUIMS�MAOE AGOREGATE 3
�ED RETENTONi S
q WORKERSCOMPEN80.TION UV�30248500 0/1/2014 /1Y2015 HCSTATU� OTH.
ANU ENPLOYERS'LIA611JTV
ANYPROPRIEfORIPPRTNERIEJtECUTIVE� N�A E.L.EACHACCIDEM 55,000,000
OFFICERrtAEMeERIXCLUDE09
(NaneemrylnNN) E.L.OISEASE-EAEMPLOYE SS,OOO,UOD
Ifyes tlesaiCe wber
�ES�RIPl1pN OF OPERATIONS bobw E.4 OISEASE�POLICY IIMIT f5 000 000
DESCRIPTDN OF OPERA710N$I LOCA�ION$/VENICLES(Atteeh ACORD 10t,AtlEkbnal R�mnks Sc�eEule,l/mom pwa b nqWntl)
CERTIFICATE HOLDER CANCELLATION
8HOULD ANV OF THE ABOVE DESCRIBEU PoLICIES BE CANLEILED BEFORE
THE E%PIRATtON UATE THEftEOF, NOTICE WILL BE DEUVERE6 IN
ACCORDANCE WITH iHE POUCV PROVI810N3.
� A�UT�HpOR�IZED`R/E�PR1ESENTAPVE
/(Kn•.0 hM1"'� I
, �1988-2010 ACORD CORPORATION. All rights reserved.
ACOttD 25{2010/05) The ACORD name and logo are registered marka of ACORD