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HomeMy WebLinkAboutApplications and WC G3��:;�0`�'�LD c�� �8 �u�5 � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMIT-2015 HEALTH GEPT `—' * D cember 1 S 2014. Please complete form and attach all necessary documents by e Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: sPeedway#24ss 'I'AX ID; � ��' ���'�� LOCATION ADDRESS:441 Main Street,W.Yarmouth, MA 02673 TEL.#: 508-775-1263 MAIL,ING ADDRESS:Speedway LLC Attn: Licensing Dept. P.O. Box 1580 Springfield, OH 45501 E-MAIL ADDRESS:0002438@Stores.Speedway.com; ssowry@speedway.com � & . ' ' OWNER NAME: S eedway , LLC � ' `'� � � � � � CORPORATION NAME (IF APPLICABLE): '"�y ` ° " ��/ MANAGER'S NAME: Antoniya Milanova TEL# �32-425-8965 � � � MAILING ADDRESS:441 Main Street, W.Yarmouth, MA 02673 k."� �L� �� 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.NA 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�le 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, 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. l,Antoniya Milanova 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1,Antoniya Milanova 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,Antoniya Milanova 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-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.NA 2. 3. 4. RESTAURANT SEATING: TOTAL# NA OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $110 —INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 —'TRAILERPARK $105 WffiRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �<25,000 sq.ft. $150 �5 —FROZEN DESSERT $40 �TOBACCO $110 �-6 $ NAME CHANGE: $15 AMOIJNT DUE _ $260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or rencwal. of any license or perznit to operate a business if a pexson or compa.ny does not have a Certificate of Worker's Compensation lnsurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURA.NCE AFFIpAVIT MUST BE COMPLETED AND SIGNEA,OR CERT. OF INSURANCE ATTACH.E.DX OR WORKER'S COM.P. AFF.IDAV.IT S1GNE.D AND ATTACHEDX Town of Yarmouth taxes and liens must be paid prior to rcnewal or issuance of your permits. PLEASE CHECK A:P.�'ROPRIATELY IF PA1.D: YES x NO MOTELS AND OTHER LO.DGI.NG ESTABLISHMENTS TRA1�iSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transicnt 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 mai.ntain 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 ofa 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 C.M:R 64G, as amended, shall generally be considered Transient. POOLS POOL OPEN.ING:Al.l swimming,wading and whirlpools which have been closed for the season must be inspected by thc 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 sit in thc pool area until the pool has been inspected and opcncd. POOL WATER TESTING: The watex must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to fhe .H.ealth Department three {3) days prior to open.ing, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONA:L FOOD SERVICE OPEN:iNC: All food service establishments must be inspected by the Health Department prior to opening. .Please contact the Health Deparhncnt to schedulc the inspection three(3)days prior to opening. CATE.RING PO.LICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Dcpartment by �ling 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.varmouth.ma.us under.Health Department, Downloadable Fonns. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results subn�itted to the Health Depamnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSID.E CA.FES: Outside cafes(i.e.,outdoar seating with waiter/waitress 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 establishmcnt is prohibited. NOTIC.E:.Permits.run annually from J anuary l to Decem.ber 3 l. IT.IS YOUR RES.PONSIB.ILI.TY TO R.ETURN THE COM.f'LETE.D RENEWAL A.PPLICATION(S} AND REQUIRED FEE(S)BY.DECEMB.ER I5, 2014. 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 COMMENCEM.E.NT. RENOVATIONS MAY R. UIRE A S[TE P AN. DATE: ( O ���IS SIGNATURE: T PRINT NAM..E&TIT.L.E:Jaso Cetei by Power of Attorney Re��. 1 1-03114 � The Commonweallh ofMassachusetts Department oflndustrial Accidents O�ce oflnvestfgations 600 Washington S7reet Boston,MA 011ll www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name;speedway, ��C�:� Addi'e55:Soeedwav LLC Atln: Licensinq Dept P O Box 1580 Springfield OH 45501 City/St3t0/Zip:Sprinpfieid OH 45501 PhOriC #:937-863�870 Are yon an eroployer?Check t6e appropriate box: Busiuess Type(required): 1•Q 1 am a employer with 5-10 employees(full and/ 5• ❑ Retait or part-time).* 6. ❑ Restaurant/BadEating Establishment 2.❑ i am a sole proprietor or partnership and have no employees working for me in any capacity. �• ❑Office and/or Sales(incl.real estate,auto,etc.) [No workers' comp. insurance required) g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have �0.0 Manufacturing no employees. [No workers' comp, insurance requiredJ• 4.❑ We are a non-profit organiza[ion,staffed by volun[eers, >>•❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other Conveniece Store/Gas Station •Any applicant that checks box#I must also fill out the section 6elow showing their workcrs'compensation poticy infortnation. . "If the corporete officers have exempted lhemselves,but the co�poration has olher employees,a workers'compensation puGcy is required and yv¢ry en organization should chock box NI. 7 om an employer that is prnviding workers'compensatlon insurance jor my emp(oyees, Betow ts Ihe policy Information. Insurance Company Name: Old Republic Insurance Company Insurer's Address: 445 S Moorland Rd, Suite 300 City/State/Zip: Brookfield, WI 53005 Policy#or Self-ins. Lic.# MWC30512700 Expiration Date: ����16 Attach a copy of t6e workers' compensation policy declaration page(showing the policy namber and eapiration date). Failure to secure coverage as required under Section 2SA of MGL c. 152 can lead to the imposition of criminal penelties of a fine up to$1,50D.00 and/or one-year imprisonmettt, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to�250.00 a day against[he violator. Be advised that a copy of Ihis statement may be forwarded to the Office of Inves[igations of the D1A for insurance coverage verification. I do hereby cenify,u t ins and penallles ojperjury that the injormatlon provided above is due and correct Si n re: Date: �' Pho e#: 937-863- V�l`l� l�. ��n= YuI�E's ��t� O�ciaf use on[y, Do not write in this area,to be compteted by city or town ojjlciaG City or Town: PermiUf.iceese q Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Towa Clerk 4.Licensirtg Board 5. Selectmen's OfYice 6. Other Contacf Person: Phone#: www.mass.gov/die , ,ac izo v� CERTIFICATE OF LIABILITY INSURANCE °"'�,"�°°""�", � 6/22/2015 ��� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TNE CERTIFICATE HOLDER. TMIS i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ' BELOW. TMIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�, AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER �� IMPORTANT: If the certiFlcate holtler is an ADDITIONAL INSURED,the poliry(fes)must be entlorsed. If SUBROGATION IS WAIVED,subjeet to the terma and contlitions of the policy,certain policies may require an endo�sement A statement on this certificate Uoea not confer rights to the ��, certtficate holder in lieu of such andorsement s. � PRODUCER NTA NFME: Hylant Group-Cleveland . rHowe Fqx ���. 6000 Freedom Sq Dr, Ste 400 - � x�: ' Independence OH 44131 ADDRES : �. INSURER S AfFORqNG COVERAGE NAIC p �' INSURER F. � INSURED MARAT3 INSURERB: �. Speedway LLC INSURERC: ' S00 Speedway Drive INSURER D: ��. Enon, OH 45323 � INSORER E: � INSURER F: �', COVERAGES CERTIFICATE NUMBER:376100608 REVISION NUMBER: '�. THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED. NOiYVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS �,: CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ,. EXCLUSIONS AND CONDITIONS OF SUCH POLIGES.LIMITS SHOWII MAV HAVE BEEN REDUCED 8Y PAID CLAIMS. �, �NT�p TVPEOFINSURANCE � �L UBR pOLICYNUMBER MMIupDIWYY MM�� LIMITS GENERAL LIPBILITY � EACHOCCURRFNCE $ i COMMERCIALGENERALLIABILRY D R � ' REMI Eaocarta S '�i CLAIMSFIADE �OCCUR MEDEXP(Anyanepe�n) g PERSONALBFDVINJURV S � GENERALAGGREGATE y � �', GEN'LAGGREGATELIMITAPPLIESPER: PRODUClS-COMP/OPAGG E ,, POUCV PRO �� E FUTOMOBILE LIABILITV Ea awtletn � ANY AUTO � BODILY INJURY(Per person) E ' ALLONNED SCHEDUIED �. AUT0.5 AUTOS BODILYINJURV�Peractl0eriq S �� HIREDAlfr05 q�p�E� PROPERTVDAMAGE E �. PeracoGem E .,� UMBREL1AUAB ppCUR EACHOCCURRENCE 8 j EXCESSIJnB ClAIMS-0tADE AGGREGAIE y . DED RETENTIONS S q WORKEftSCOMPEnSqnoN MVJC30512700 7/1f2015 7/tl2018 X �STATU- OTH- � ANpEMPLOYERS'WBILITY ��N � ANVPROPRIEfOR/PqRTNEWEXECtl11VE I OFFICER/MEMBEREXCLUDED9 ❑ N/p E.LEACHACCDEM y5,0pp,00p '� (Ma�MtlaryinNN) E.LDISEASE-EAEMPLOYE 55,000,000 Hyea,Gesaibe un0er , DESCRIPrIONOFOPERATIONSbebw E.LDISFASE-POLICVIIMR E5,OOO,ppO �.,' DESCRIPTION OF OVERATONS/LOCpT10N51 VFHICLES (Atlach AfAR�101,AdCpional Remarks Schetlule,if more space is required) '�, CERTIFICATE HOLDER CANCELLATION ', SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE '�� Evidence of Insurance-Speedway qCCORDANCE W TH�THE POL CY PROVISION'SE W��� BE DELIVERED IN " Al11HOR�D REPRESENTATNE , r,��,� " � �198&2070 ACORD CORPORATION. All rights reserved. ��. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD � � ��� ��z��c &XP� �,�y � ___.. _._. ---� r TOWN OF YARMOUTH BOARD OF IIEALTH `(��1 r ' ' - � � APPLICATIONFORLICEN5FJPERMIT-2015 ��-+ n � ��p � � F,`.;� � ,� :,315 a •Please complete form and attach all necessary docutnents by December IS 2014. E Failure to do so will result in the retum of your applica '� . �� ESTABLISHMENTNAME:SpeeawaY#2438 --.—._ _ .. __'�� LOCATfON ADDRESS:441 Main Street W Yafmoum,MA 02673 TEL.N: (����54263 MAII,ING ADDRESS:ATTN�Licensing-P O Box 1580 Sprin9field Ohio 45501 E-MAII,ADDRESS: � OWNER NAME: Hess Retail O rations,LLC CORPORATION NAME(IF APPLICABLE): psz�azs-esus MANAGER'S NAME:Kyle Rowe TEL.#: MAILING ADDRESS:ATTN Licensing P O Box'1580 Sorinafi Id Ohio 4550� POOL CERTIFICA'IIONS: The pool supervisor must be certi6ed as a Pool Operator,as required by Sffite law. Please lis[the designated Pool Operntor(s)and attach a copy of the certification to this form. 1. 2. Poot operators must list a minunum of two employees cuirently certified in basic water safety,sfandaid First Aid and Community Carviinpnlmonary Resuscitation(CPR),having one certified employce on premises at all times. Please Gst the employces below and a[tach copies ofthe�r certifications ro this form.The Health Departmnut will not use past years'records. You must provide new copies and maintain a file at your plsce of business. t. 2' 3. 4. FOOD PROTECTION MANA('iERS-CLRTIF'ICA'1'IONS: All food service estxblishments are re4wTed to have aY least one full-time employee who is certified as a Food Protection?�Sanager,as defined in the State Sanitary Code for Food Service Es�ablishmenu, 105 CMR 590.000. Please attach copies of cenification to this application. The Aealth Department will not use pastyears'recorda. You must provide new copies and maintain a file at your establishment. 1. Z' pERSON IN CHARGE: Each food establishment must have at least one Person in Charge(PIC)on sice dudng hours of operation 1. 2' ALLERGEN CERTIPICATIONS: � All food service establishments are required[o tiave at least one full-time employee who has Allergen certificatioo, as defined in the Smte Sanitary Code for Food Service EstablisLments,105 CMR 590.009(G)(3xa). Pleau auacL copies of certification to this application T6e Aealth Department will not use past years'records. You must provide new copies sud maintein a file at your establishment. 1. z" HEIMLICH CERTIFICATtONS: All food service establishments with 25 seats or more must have at least one employec trained in tk�e Heimlich attsch copies of employ�certifi ations to this fosan�Th Hpealth Deap artment 1wiI1 not ugse p t years'�rleco ds. You must provide new copies and maintain a file at your piace of 6asiness. t. z' 3. 4. RESTAiJRANT SEATING: TOTAL k OFFICE USE ONLY WDGNG: L10EhSERGQU!IiED FLE PERMIT# LICENSERCQUIRED FEG PEAMITk LICMOTELEQUTAED SEQ P CADIN 555 —SWIMMINGPOOLSIIOea —16Nt�J 555 CAMP f55 —WH7RLPOOL 5�10ce.__ —LOD(iE S55 =�RAILERPAItK 5705 _ FOOD SERV[CE: WC6':dSCREQUIREU PEE PF.RbfITN UCETISF REQUTAED FEL PERMITd LIC ON-P OFT�D 530 PGRMITS 0-IOOSGTS 5123 _CON77NEYTAL S35 __ —�OLESALF. S80 —>l�p�,p� y700 __ —COMMUN VIC. f60 =�ID.KITCIIE.\' S60 REiAd SER�9CE: LICEOSE�QI+'�AFD f50 PERUiTk LICENSEREQUIRFD FEG PF.RMIT# UC�ENDWGUPoOD S25 vE��TM sq >25,OOOsq.R S2R5 OBACCO 5710 ���� �<15,WOsq.ft 5150 -��ol —fROZENDESSERTT40 �T ---�"'—'—��� AMOUNT DUE = S I 5.OG �y NAMECHINCE: ` SIS ![� �•+••PLEASE 7URN OVER AND COMPLETE OTNER SIDE OP FORM•"•' ADMIIVISTRATION Under Chapter 152,Secfion 25C,Subsec[ion 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or peauit to opecate a business if a person or company does not have a Certificate of Worker's Compensaflon ]nsurance. T'HE ATTACAED STAT'E WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MiJST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED_ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED_ Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of youc permits. PLEASE CHECK . APPROPRiATELY IF PAID: YES N� �� MOTELS AND OTHER LODGING ESTABLISHhIENTS � TRANSIElYT OCCUPANCY: For purposes ofthe iitnitalions ofMotel or Hotel use,Ttansient occupancy shatl be � lunited to the temporary and short tecm occupancy,ordinarily and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonstrate t6at they mainiaiu a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more thw d�irfy(30)days,and an aggregate of not more tLan ninety(90)days within any six(6)month period. Use of a guest unit as aresidence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Escise,as defined in M.G.L.a 64G or 830 CMR 64G,as amended,st�all generally be considered Transient. POOLS POOL OPEMNG:All swimming,wading and whirlpools whichhave been closed forthe season must be inspected by the Health Department prior to ope�1�9. Contact the Health Department to schedu►e the inspecfion three(3) days prior to opening.PLEASE N01B:People are NOT allowed to sit in the pool area until the pool has been inspected and opened POOL WAT'ER 1'ESTING: The water mus[be tested for pseudomonas,total coliform and standard plate coutrt by a State certified lab, and submitted to the Health Department three(3)days prior to opening,snd 9uarterlY thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven("n days of closing. FOODSERVICE SEASONAL FOOD SERVICE OPENIIVG: All food service establishments must be inspected by the Health Department prior to opening. Please contact ihe Health Department to schedule the inspecrion tluee(3)days prior to opemng. - CATERING POLICY: Anyone who ca[ers within the Town of Yazmouth mus[notify the Yazmouth Health Department by filing the . requued Temporazy Food Service Application foan 72 houcs prior to the catered event. These fotms can be obtained at the Health Department,or from the Town's website at www.varmouth.maus under Health Depaztrnent, Downloadabie Focros. . FROZEN DESSERTS: � Frozen desserts must be tested by a State cer[ified lab prior to opening and montlily thereafter,with sarnple results submitted to the Health DepaRmen[. Failure to do so will result m the suspension or revocation of your Frozen Dessert Pernut untii the above terms kiave been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus[have prior approval&nm the Board of Health. OUTDOOR COOIQNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. N01TCE:Permits run annually from January 1 to December 31. IT IS YOURRESPONSIBII,ITY TO REl"URN TI-IE COMPLETED RF.NEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISFIIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS M1 Y REQ SITE PLAN. ��DATE: �-Z�I' �a SIGN : _ PRINT N &TITLE: hn Harti r of AHome a�..��ro3na� .