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Home My WebLink AboutApplication and WC �� aoi� � ^" � �� TOWN OF YARMOUT BOARD OF HE LTH�� Z�� `' `` �,� � .� APPLICA�TION FOR I.ICENSE/PE�RM�I�T 20�tC 1 7 LU}4 ` t�� * Please compleYeyYorm��attac,tl a necessary d"ocum ts 3 Ol _ � ' Failure to do so resu�t,i�;th�return of your ESTABLISHMENT NAME:_��S F1�D�PS a,a�y TAX ID• �.�� LOCATION ADDRESS: 4 I TEL.#:�� MAILING ADDRESS: E-MAIL ADDRESS: Hess Retall ope�anans,«c OWNER NAME: 1 ►iesa alaza/� Fiaherty Woodbridge, NJ 07pg5--- CORPORATION NAME (IF APPLICABLE): �szaso-esso MANAGER'S NAME: �� 3z" Z' S23(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 this form. 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),hauing 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 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, lO5 CMR 590.000. Please attach copies of certification to this application. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �1PAv��f wa\ r 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. [�� eAv�r �o� � 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. L�1�irlor v�o� � 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 IIJ1V $55 CAMP $55 SWIMMING POOL $80ea. _LODGE $55 _TRAILERPARK $]OS _WHIRLPOOL $80ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE � PERMIT# 0-100SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.R. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 +�25,000 sq.ft. $80 � _FROZEN DESSERT $40 =TOBACCO 7 NAMECHANGE: $15 AMOUNTDUE $3�",.C�� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** tl_ � Q�f bS�7 Z K- � ��1�� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 WORK�R'S COMPENSATION INSURANCE 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 ar 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. POOL5 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 srt in the pool azea 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 Deparhnent 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 CAFES: Outside cafes (i.e., outdoor seating with waiter/waitress seroice), must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 3 L TT 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., PAINTTNG, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:_ /a � � SIGNATURE:_ � T�� -- ��,a(�� p��;��j�'�`lf PRINT NAME & TITLE: �� C�`'�� Rev. 10/OS/l3 "' Fortn CT�T ooys7 Massachusetts Department of Revenue 2014 - 2016 Cigarette Excise Unit . Retailer License for Sale of Cigarettes and Cigars antl Smoking Tobacco hfs Lkense must be poste/1 and visibk at ell tWxs. Sales to persons under 18 yeara of aga are prohibitM by law. � pqicatian Number: AJ741 License Number. Date Of Issue: ederel�derdification w Social Securiry Number: 222d6-2225 00987 09/08/2014 ifinp atltlress for licenae: Refail sale localion(N Cffterent than malling atldress) HESS RETAIL OPERATIONS LLC HESS 21243 1 HESS PLAZA TAX BTH FLR 50 OCEAN ST WOODBRIDGE, NJ 07095 HYANNIS, MA 02801 This certifies thet the taxpayer nametl above has paid the required license fae antl Is licensed to sell at retail at the address ahovm above uMil September 30,2(116. This Ikense is nol Vansferable,and is aubject to suspenslon lor failure to comply wilh the law. Fortn CT-3T o�oos Massachusetts Deparbnent of Revenue 2014 - 2016 Cigarette Excise Unk Retailer License for Sa�e of Cigarettes antl Cigars and Smoking Tobacco is l.icense must be posted antl visible al all limes. Sales to perwns untler 18 years of age are prohibited 6y law. pplkation Number AJ761 � License Number Date of Issue: ederal IdeMillratbn or Social Security Number 222-46-22'25 01005 09/08/2014 'ling address tor licenae: Retail sale location('rf df%rera man mailing address) HESS RETAIL OPERATIONS LLC HESS EXPRESS 21244 1 HESS PLAZA TAX 6TH FLR 441 MAIN ST WOODBRIDGE, NJ 07095 W YARMOUTH, MA 02673 This certifes that the taxpayer mmed above has paid the required license fee snd is licensed to sell at retail�at the address shown above until September 30,2016, 7his license is rat transferable,and Is subject to suspe�ion for failure to comply with the law. `" Form CT-3T Q�OQ7 Massachusetts Department of Revenue 2��4 - 20�6 Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco 0 his License must ba postfld and visible at all times. Sales to perwns under 18 years of age are prohibited by law. pplicatfon Number: AJ786 Licerue Number. D9tB Of ISSUB: ederel Identification or Social Security Number: 222�6-2225 01027 09/08/2014 ailing address iw licrose; Reteil sale location pf diflereM Nan mailing adtlress) HESS RETAIL OPERATIONS LLC HESS EXPRESS 21245 1 HESS PLAZA TAX 8TH FLR 317 FALMOUTH RD WOODBR�DGE, NJ 07095 HYANNIS, MA 02601 This certifies that the taxpayer rremed above has paid ihe required Iicense fee and 16�iCensetl to sell at retail at Me address shown above until Septemher 30,2016. This license is not hansfereble,antl is subjec[ta suspensbn.fa laflure to comph/wilh tlie law__�_____ ___ Form CT-3T 0��8 Massachusetts Department of Revenue 2014 - 2016 Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco is License muat be postad and visFble at aU times. Sales to persons under 18 years of age are prohibi[ed by law. � pGcaewn Numter: AJ765 . uce�e Number: Date of Issue: Federal ItlenBficatbn or Social Securiry Number: 222-46-2225 01008 . 09/OB/2014 Mailing address fw Ilcense: � Relall sale locetim(N diRereM than maili�eddress) . HESS RETAIL OPERATIONS LLC HESS EXPRE$5 21246 1 HESS PLAZA TAX 6TH FLR 14 EAST MAIN ST. WOODBRIDGE, NJ 07095 W YARMOUTH, MA 02673 r� The Commonwealth of Massachusetts Department oJlndustrialAccidents O�ce of InvesKgations 1 Congress Street,Suite 100 Boston,MA 02174-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Plesse Print LeaiblV Business/Oiganization Name:Hess Retail Operations, LLC dba Hess Express ��,� l� Address: �-I y I C�^O��r� �' City/State/Zip: � Qc' u MA (c�1 Phone#: � '��S��2.1a3 Are you an employer?Check the appropriate box: Business Type(required): L❑� I am a employer with 5'�� employees (futl and/ 5� ❑� Retail or pac[-[ime).' 6. ❑Restaurant/Bar/Ea[ing Establishment 2.❑ I am a sole proprietor or partnership and have no 9. � Office and/or Sales(incl.real estatq auto,etc J employees worldng for me in any capaciry. [No workers' comp. insurance required] 8� ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainmen[ thev right of exemp[ion per c. 152, §1(4),and we have �0.0 Manufacturing no employees. [No workers' comp. insurance required]** i l.�Health Caze 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.j 12•❑Other `My applicantthat chccks boz HI mus[also fdl out lhe sectlon below showing thcir workers'compensation policy information. "If[he comorate o�cers have exempted themsclves,but Ihe enmoration has o[her employecs,a workers'compensazion policy is requircd and such an organizazion should check box k 1. I am an employer thatls providing workers'compensatlon insu�ance fa�my empfoyees. Below is tke policy 1njo�mallon. Insurance Company Name:Old Republic insurance Company InsurePs Address:445 S.Mooriand Rd. Ste 300 City/State/Zip: Brookfield,WI 53005 Policy#or Self-ins. Lic.# MWC30246500 ExpiraHon Date:��1i2015 Attach a copy ot the workers' compensation policy declareHon 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 penal[ies of a fine up to 51,500.00 and/or 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 this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. !do hereby cert�,under the palns and ena/ttes ajperjury that the lnformatlon provided abave Ls true and carrect. Sipnature� ��T_ Date� I�/O/�� Phone#:732-750-6350 Offiela!nse nn[y. Do not write Itt thts area,to be compfeted by efty or town ojfle[at. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia � f''� R�� CERTIFICATE OF LIABILITY INSURANCE °"re,"""°°""�" si n �n THIS CERTIFICATE IS f33UED AS A MATTER Of INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE XOLDER. TNIS CERTiFICATE D6ES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTENU OR ALTER TNE COVERAGE AFFORDED BY TNE POIICIES BELOW. THI3 CERT7FICATE OF INSURANCE DOES NOT CONSTI7UTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORI2ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER. IMPORTANT: If the certiflcate holder Is art ADDI710NAL INSUHED,thg poliey(lee)must be entlo'sed. If SUBROGATION 19 WAIVED,suDJeot to Ne tertna and condlUons of the policy,certaln policlee may requlra an endorsement. A statameM on[his-certifipte tloes not eonfer Aghts W Ne cartMlute holder In Ileu ol sueh endoraemen s. � rrsoouc�e uare : Hylant Group-Cleveland rxor��.2�s-aa7- a� no� 6000 Fraedom Sq Dr, Ste 400 � � i� Independence OH 44131 o g: INSUREft 5 AFFORDING COVEftAOE NAIC Y WSURERA: ic Insurance Go INSURED MARAT-3 IN9URER B: H055 RetBil Ope�ations, LLC ixsursEac: 1 Hess Plaza ir�suneao: Woodbridge, NJ 07095 . INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER:g39865088 REVISION NUMBER: TMIS IS TO CERTIFY THAT iHE POLICIES OF INSURANCE LISiED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED A80VE FOR 7HE POLICY PERIO� INDICATED, NOTMTHSTANDING ANY REOUIREMENT,7ERM OR CONDITION OF ANV CONTR4CT OR OTHER DOCUMENT IMTH RESPECT TO WMICH iHIS CER7IFICATE MP.Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIeED MEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOWN MNY HAVE BEEN REDUCEO BV PAID CWMS. �� 1VPlOFINSURqNCE n04CYNVMeER PM�M�EFF MOMLM��wy U�� OENERALWBILIIY . EACHOCCIIRRENCE 5 COMME0.Cl4L GENERAL LIABILIiV S CWMS-MAOE Op�CUR MEDEXP aro S . PERSONRLBAOVINJI/RY S . GENERAIAGGREGATE S OENLAGGRE6A7ELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG i POLICY �4 LOC $ FUTOMOBILE WIBILJTY EeactlOaM ANY AUiO BOOIIY INJURY(Per porson) S Al1TO�ED AUTOS�EO �D�LYINJURY(P&aC60enp i HIREDAUTQS NON-0NMED PROPERTYpAMAGE s AUTOS P xdtlaM S UMBRELLALIAB p�CUR EACMOCCURRENCE 5 E%CE9SLIA9 CUIMS�MADE AGCREGATE 5 DED RETENTIIXJS b q WORKENSCOMiENBATON WC90248500 0/1/2016 HY2015 KLSTATU- OTH� I1NU EYPLOYERS'LIABILIlY ��N ANYPROPRIETOPIPRRTNERiFIlECUTNE E.LEACHACGDEM 55,00O,OOD OFFILER?AEN9EREXGW�ED9 � N/A �wne.mry m xx) E.L OISEASE•EA EMPLOYE 55 000,000 Ifyes tloaciba vtlar OESCRIPf10NOFOPERATI0N5balow � E.L.�ISEASE�POLICYLIMIT 55000000 UESCftIP110N OF pPEM1qN51 LOCqTpNS/VEHICLES(Apaeh ACORD t Ct,AdUMlaul Ram�Ms SaMtluN,Hmon�W c�b nqWntl) CERTIF{CATE HOLDER CANCELLATION SHOULD ANV OF THE A90VE DESCRIBED POLICIES BE GANCELLE�BEFORE THE E%PIRATION UATE THEREOF, NOTICE N7LL BE DEWERED IN � ACCOROANCE WITH THE POLICY PROVI810NS. A�IIT�XpOW�ZED�R(E�PR.�EjS—ENT111IVE /lKtit�"1�•^'�+ I U �1988•2010 ACORO CORPORATION. All righta reserved. ACORD 25(2010/052 The ACORD name and logo are rogistered marks of ACORD