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Home My WebLink AboutApplication and WC . .•.� �� i Cumbe'rland F A R M S TOWN OF YARMOUTH BOARD OF HEALTH TWN OFFICE BLDG 1146 RT28 S YARMOUTH,MA 02664 _ Oc��er�4;2016 _ _ __ . . _ _._ . _ -- _ -------— __ ___ _ Dear Valued Supplier: We are moving! Please note th t, effective as of December 1, 2016,the co orate headquarters of Cumberland Farms, Inc. will be: 165 Flanders Road Westborough,MA 01581 Our fax and telephone numbers will remain unchanged. Kindly update your records accordingly. _ F�LCE'E O�T � � �,�p� HEALTH DEpT Cumberland Farms, Inc. 100 Crossing Boulevard, Framingham, MA 01702 508-270-1400 sC�� www.cumberlandfarms.com • � �� TOWN OF YARMOUTH BOARD OF HEALTH , APPLICATTON FOR LICENSE/PERMIT-2017 : *Please complete form and attach all necessary documents by �rr l6 OI . �:�� Failure to do so wiU result in the rctum of your application pac,cet. �� ESTABLISHIViF,1JT NAME: . �� LOCAITON ADDRESS: TEL.#: �x — �3'� , MAILIIVG ADDRESS: ` E-MAII,ADDRESS: ' OWNER NAME: -�'- CORPORATION NAME(�' Pp;,i�qg�): , MANAGER'S NAME: TEL.#: — �' �� MAII,ING ADDRESS: POOL CERTIFTCATIONS: T6e pool supervisor muat be certified as a Pool Operator,aa required by State law. Please list the dcsignated Pool Operator(s)and attach a copy of the certification to this form. 1• 2. . Cardio ult�no must list a minimum of two employees curnntly certified in standard First Aid and Community ` �- � � p nary Resuscitation(CPR),having one certified employce onpremis�s at all times. Please list the �� °'"'" employees below and attach copies of their certifications to this form.The Health Department wiii not nse past � �«� �°' years r�orda. You mnst provide new copies xnd maintain a file at your place of bnsinesa i� ,;, Ce Tj ��'t: i. 2. � � 3. 4. ;-°�q7 � �r'i �—I' a.:;`:a �`s FOOD PROTECTION MANAGER$-CERTIFICATIONS: �J �' All food service establishments are required to have at least one ful-time employee who is certified as a Food - --. - - Protection Manager,as defined in the State Saaitary Code for Food Service Establishments, 105 CMR 590.000. ��.,_ ---.� Please attach copies of certification to this applicadon. The Health Deparhnent will not use past yea�s'records. �;; -�;_' ; You must provide new copies and maintnin a file at your estxbliahmen� � 1. 2. �...' �.� , PERSON IN CHARGE: ; �. % Each food e.ctablishment must have at least one Person In Charge(PIC)on site during hours of operation. .. � 1 2 � .i ALLERGEN CER'I�ICATIONS: �/�,� ; All food service astablishments are requi�+ed to have least one full-time em lo ee who has All � � P Y ergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(Gx3Xa). Ptease attach copies of certification to tl�is application The HealtL Department will not ase past years'recurda, yon must provide new copies and maintain a file at your establishment. 1. 2 HEINII,ICH CERT�TCATTONS: All food service establishmeats with 25�ats or more must have at least one employa trainod in the Heimlich Maneuver on the premises at all titnes. Please list your emnploya s trained in anti-choking procedur��low and attach copies of employee certifications to this form. The Aealth Deparhnent will not ase paat years'recorde�. You must provide new copies and mainhin a file at your place of business. �. 2. 3. 4 RESTAURANT SEATING: TOTAL# r.oncnvc: oFFrcE vsE oxl,Y 6ot}�-15�bs-oz LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMTT!J LICENSE —�B �s cnernr sss _Mo.�.�u�so r� r�rra Boti�CP-t5-5tb"1-aZ �TADC'*E SSS 1RAILER PAltiC S105 —SW��L Sl IOee. ._WHIRLPOOL S110ea. ROOD SERVICE• LICENSE REQUIItED FE6 PERMIT 8 LICENSE REQUIRED FEE PERMIT# LICENSER�p UIRED FEE PERMif N a�oo sEn3�•s s125 „_CONTINEtVTAL S33 NON-PROF77' S3p >l00 SEATS 5200 COMMON VIC. S60 _�WI��LESALE S80 RETAIL SE1tVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FF.E PgRM1T N <SOsq R� SSO >25 000sq•ft. 5285 VENDING-FOOD S2S �I.[ =Q5,000 sq.R 5150 �S '�'�RbZEN DESSERT S40 ZfOHACCO 5110 ..� NAME CHANGE: SIS AMOITNT DUE = S_26�.00 *••"*PLEASE TURN OVER AND COMPLETB OTHER 3IDE OF FORM+*"�� t ADMINISTRATION Under Chapter 152,S�tion 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or peimit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED �/ � OR • / WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED V Town of Yarmouth texes and liens must be paid prior to renewal or issuance of your permits, pLEqSE CHECK APPROPRIATELY IF PAID: ' / YES V NO MOTELS AND OTHER LODGING ESTABLISIiMENTS TRAr1SIENT OCCUPANCY: For purposes of the limitations of Mote1 or Hotel use,Transitnt occupancy s�ll be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotei use. Transiem occupants must have and be able to demonsh�ate that ttiey maintain a principal piace of msidence elsewhere.Transient occupancy sl�all generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not moce than ninety(90)days within any six(6)month period. Use of a guest unit ay 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 OPE1vI1�iG:All swimming,wading and whirlpools wlrich have bcen closed for thc season must be inspected by the Health Departmentpnor to openmg. Contact the Health Department to schedule tLe inspechon three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in thc pool area un61 the pool has been inspected and opened. POOL WATER TESTWG: The water must be tested for pseudomonas,total coliform and standard 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 poo]must be drained or covered wiWin seven('n 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 tlu+ee(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yatmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event These forms can be obtained at the Health Depar�nettt,or from the Town's website at www yarmouth ma us under Health Department, • Downloadabie Forms. FROZEN DESSERTSc Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with satnple results submitted to the Health Department, Failure W do so will result in the suspension or revoc�ion of your Froun Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval firom the goard of Health. OUTDOOR COOKINC: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. NOTTCE:Pern►its run annually from January 1 to December 31. IT IS YOUR RESPONSIBII,iTy TO RETURN � 1'HE COMPLETED RENEWAL AppLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � , Ai•i, RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., p C,, �W EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF PRIOR TO CO E . RENOVATIONS MAY REQUIRE A SITE DATE• �� _SIGNATURE: PRIlVT NAME&TI'lT.E: � • Rev.(0/17116 ��,�17L1�1dt r.��y� , � The Commonwealth ofMassachusetts Department of Industrial Accidents I Congress Street,Suite l00 Boston,MA 02114-20I7 www.mass.gov/dia Workers'Compensation Insurance Aftidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Anplicant Information Please Print Le�iblv Business/Organization Name:Cumberland Farms, inc. Address: 100 Crossing Boulevard City/State/Zip:Framingham, MA 01702 Phone#:508 270 1400 Are you an employer?Check the appropriate box: Business Type(reqaired): 1.[�✓ I am a employer with 3�208 employees(full and/ 5• []✓ Retail or part-time).* 6. �RestaurantlBar/Eatir.g Establishment 2.❑ I am a so(e proprietor or partnership and have no employees working for me in any capacity. �• ❑Office andJor 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 10.0 Manufacturing no employees.[No workers'comp.insurance required]* 4.❑ We are a non-profit organization,stat�'ed by volunteers, 11.0 Health Care with no employees.[No workers'comp.insurance req.) 12.�Other *My applicant that checks box#1 must al�fill out the sectiun below showing their workers'compensation policy information. **if the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization shoutd check box#1. I am an employer that is providing workers'compensation insurance jor my employees Below is the policy information. Insurance Company Narne:ACE Froperty&Casuaity insurance Company Insurer's Address:33 Arch Street, Suite 2900 City/State/Zip: goston, MA 02110 Policy#or Self-ins.Lic.#SCF48603257 Expiration Date:4��17 Attach a copy of the workers'compensation policy declaration 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 penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day again the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f surance coverage verification. I do hereby certify, er the 'ns and penalties of perjury that the inforniation provided obove is true and correct. Si ature: Date: ' • Phone#:508 270 1480 O�cial use only. Do not write in this area,to be comp[eted by city or town officia� City or Town• Perrait/License# Issuing Authorlty(circle one): l.Board of Health 2.Building Department 3.Citylfown Clerk 4.Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia r �`�� CERTIFICATE OF LIABILITY INSURANCE °AT03�M�,°'�""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATiVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. � If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on � this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). � PRODUCER �EACT � � � AOn RiSk 58rviCES NOrthEdSt, I11C. Provi dence RI Offi ce ac.No.ext�: �866) 283-7122 aC� : 800-363-0105 m 100 westminster Street, lOth Floor E.Mqa '� Providence RI 02903-2393 USA /�ortess: _ INSURER(S)AFfORDING COVERAGE NAIC# INSURED INSURERA: indemnity Insurance co of North nmerica 43575 CUMBERLAND FARMS, INC. INSURERB: ACE AmEf1C311 insurance Company 22667 100 Crossing Boulevard Framingham MA 01702 USA INsur�RC: IN3URER D: - INSURER E: � � � INSURER F: COVERAGES CERTIFICATE NUMBER:570061581929 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested � TR TYPE OF INSURANCE g POLICY NUMBER M M UMITS �. COMMERCIAL GENERAL LUIBILITY EACH OCCURRENCE . CLAIMS-MADE ❑OCCUR � PREMISES�Ea ou�urrenoe � MED EXP(My one person) � PERSONAL 8 ADV INJURY N PR0. GENERALAGGREGATE � GEN'L AGGREGATE LIMR APPLIES PER: POLICY ❑�ECT �� .PRODUCTS-COMP/OP AGG � OTMER: � 0 A��B�� COMBINED SINGLE LIMIT � � a accident ANV AUTO BODILY INJURY(Per person) Z OWNED SCHEDULED BODILY INJURY(Per aeeideM) AUTOS ONLY AUTOS � HIREDnU705 NON-OWNED � PROPERTYDAMAGE v ONLY AUTOSONLY � Peraeeident � Y UMBRELLA LWB OCCUR � EACH OCCURRENCE V EXCE33 LIAB CLAIMS-MADE AGGREGATE DED RETENTION � A WORKERSCOMPENSATIONAND WLRC48603245 0 1 2 1 4 Ol Ol � EMPLOYERS'LIABILITY X STATUTE OTH- B Y/N SCFC48603257 04/O1/2016 04/O1/2017 ANY PROPRIETOR I PARTNER I EXECUTIVE N E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED4 �N/A SZ�OOO,OOO i (ManGrory N NFI) E.L.DISEASE-EA EN�LOYEE S2,000,000 Hyes,tleseribe under E.L.DISEASE-POLICY IIMtT� S2,000,000� DESCRIPTION OF OPERATIONS bebw � DESCWPTION OF OPERATIONS/LOCATIONB/VEMCLES(ACORD 101,Additlonal Remarka Seh�dule,may be attacMd H moro apace is nquind) � � rhe insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. y� ��-% � � � �L� CERTIFICATE HOLDER CANCELLATION � ti� 81i0ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE Wl1 BE DEWERED M ACCORDANCE 1MfH THE ' POLICY PROVISIONS. TOWn of varmouth pUT1pWZEDREPRE3ENTATNE � � Town Clerk 1146 ►toute 28 _ 5outh varmouth MA 02664 u5A � "',f �� 7.�if1r(c� 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORO