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Home My WebLink AboutApplication and WC .•.� . � :�/ � Cumbe'rland F A R M S TOWN OF YARMOUTH BOARD OF HEALTH TWN OFFICE BLDG 1146 RT28 S YARMOUTH, MA 02664 OctQ�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. ��cFr��o oc� � 7 �,�,� HEALTH DEPT, Cumberland Farms, Inc. 100 Crossing Boulevard, Framingham, MA 01702 508-270-1400 sC�� www.cu mberlandfarms.com ` � '� TOWN OF YARMOUTH BOARD OF HEALTH �� ; APPLICATION FOR LICENSE/PERMIT-201'7 ��'� *Please complete form and attach all necessary documents by D c n be�l6 20I . Failure to do so will result in the retum of yow applicat�on pac et. ESTABLISHMENT NAIv1E: LOCAITON ADDRESS: � TEL•#: �3 MAILINGADDRESS: "` E-MAIL ADDRESS: ' + OWNER NAME: �� CORPORATION N APPLICABLE): " s � t ��ti MANAGER'S NAME: ^ ` ' ' T'EL.#: �� n Q�S� �MAILING ADDRESS: ��,�- POOL CERTIFICATIONS: �� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desig�ated (b! J�1 Pool Operator(s}and attach a copy of the certification to this form. �,`v-� 1. 2. � �a W � Pool operators must list a minimum of two empioyees currendy certified in standard First Aid and Community ;> .. ��'R Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at aii times. Please list the r' �� ` employces below and attach cop�es of their certtficatioas to this form.l'he Heatth Department will uat use past � ` �a:� years'records. Yoa must provide new copies and maintain a file at your place of bnsiness. 0 � � p` �; �; �� i. z. -� :�; � 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 Satritary Code for Food Service Establishments, 105 CMR 590.000. ��- -+ Please attach copies of certification to this application. The Healt6 Department will not use past years'records. �� You must provide new copies and maintain a file at your establishment. 1. ��.tfP� �� 4(�� 1 �1 2. �txin _ �E1� 1Qi1.t-t �'� �- PERSON IN CHARGE: � � � ' Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �J`� �.�,��.�,. �� r• �� I 1, 2. �.� ALLERGEN CER'I'IFICATIONS: ��-` 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 Establisl�ments,105 CMR 590.009(G}(3}(a). Please attach copies of certification to tlris application. TLe Health Department will not use past years'records. Yon muat provide new copies and maintain a 51e at your establishment. 1.� � �C'v i 2. HEIMLICH CERTIFICATTONS: All food service establis�iments with 25 seats or more must have at least one employee lrained in the Heimlich Maneuver on the premises af all times. Please list your employees trained in anti-cholang procedures below and attach copies of employee certifications to this form. The Health Department will not nse past years'records. Yoa must provide new copies and maintain a file at your ptace of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY ��F'15�9 L l-02 LODGING: LICENSE REQUIRED PEE PERNIIT# LICENSE REQUIRED FEE PERMTf# LiCENSE REQUIRED FEE PERM[T# (301�I TQ�I.SfiI63-0Z ae�a sss cnan� sss Mo�, a�io IA1N S55 �CAMP S55 _SWQdMING POOL S110ee. �.ODGE SSS �T'RAILERPARK 5105 _WHIItLP�L S110ea FOOD SERVICE: LICENSEREQ UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE�p UIRED FEE PERMIT# 0-100 SEA'I'S j!25 _CON'fINENfAL S35 NON-PROFIT S30 >100 SEATS 5200 ,COMMON VIC. S60 — iOLESALE S80 =RESID.KTl'CHEN S80 RETAIL SERVICE: LICENSE REQLIIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT!f =Q5,000 sq.ft 5150 � �RO�ZEIJ DESSERT�S40 �I'OBACCO F� S 10 �� NAME CHANGE: S15 AMOUNT DUE _ $ Z�o�•OC� •*•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM+'•"• ADMINISTRATION Under Chapter 152,Secdon 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of eny 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 MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED �✓ OR / WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED z�� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES ✓ NO MO'FELS 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 tean 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 sha11 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 coll�tion of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be coasidered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department pnor ta opemng. Contact the Health Department to achedule the inspectian three(3) days prior to opening.PLEASE IJOTE:People are NOT altowed to sit in the pool area until t1�ie pool has been inspected and opened. POOL WATER TESTWG: The water must be tested far 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 CI,OSING:Every outdoor in ground swimming pool must be drained or covered within seven(�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 opemng. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarcnouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. These farms can be obtatned at the Health Deparbnent,or from the Town's website at www.yatmouth.ma.us under Health Department, - Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and moathly thereafter,with sample results submitted to the Health Departmen� Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have ban met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor 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 establishmetrt is prohIbited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCJRN � THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ; ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., P , NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF TH; RIOR TO COMI�� CE NT. RENOVATIONS MAY REQUIRE A SI LAN. , DATE: � SIGNATURE: PRINT NAME&TITLE: � � Rev.IO/17J16 �',��flA! � w,��rn i �'"`� The Commonwealth of Massachusetts �epartment of Industrial Accidents I Congress Street,Suue 100 Boston,�o2rr4-2017 www mass.gov/dia Workers'Compensation Insurance Aft3davit:Gen�ral Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Apnlicant Information Please Print Le�ibiv Business/Organization Name:Cumberland Farms, Inc. Address: 100 Crossing Boulevard City/State/Zip:Framingham, MA 01702 Phone#:508 27�1400 Are you an employer?Check the appropriate box: Business Type(required): 1.�✓ I am a employer with 3+208 employees(fuli and/ 5. �Retail or part-time).* 6. �Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance requiredj 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.❑Manufacturing no employees.[No workers'comp.insurance required)* 11.❑Health Care 4.❑ We are a non-profit organization,staffed by valunteers, with no employees.[No workers'comp.insurance req.] 12.�Other 'Any applicant that ch�ks box#1 must ttl�fili out the section below showing their workers'compensation policy infonnation. **If tlre corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ACE Prr�perty&Casuaity Insurance Company Tnsurer's Address:33 ArCh Street,Suite 2900 City/StatelZip: goston, MA 02110 Policy#or Self-ins.Lic.#SCF48603257 Expiration Date:4/1/17 Attach a copy ot 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 crimina]penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORI}ER 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 cert�;fy, er the 'ns andpenalties ofperjury that the informationprovided above is true and correct. Si ature• Date• ' • Phone#:508 270 1480 Official use only. Do not write in this area,to be completed by city ar town officiaL City or Town• Permit/License# Issuing Authoriity(circle one): i.Board of Health 2.Building Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#: www.mass.gov/dia �`�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/30/2016 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 POLICIES ' BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE H�LDER. 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). � CONTACT . PRODUCER � � NAME: AOII RISk SEI'V1C25 NOPth2dSt, InC. p p E FAX � � Provi dence RI Offi ce (ac.nio.exc�: �866) 283-7122 �� . 800-363-0105 � 100 westminster street, lOth Floor e�a� Providence RI 02903-2393 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA Indemnity tnsurance Co of North America 43575 CUMBERLAND FARMS, INC. INSURERB: ACE At11Ef�Cdtl Insurance Company 22667 100 Crossing Boulevard INsuRERC: Framingham MA 01702 USA INSURER D: INSURER E: INSURER F: - COVERAGES CER7IFICATE 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. Limita shown are as requested LTR TYPE OF INSURANCE INS NND P��Y NUMBER MMIDD/YYYY MMIDDM'YY LIMITS � COMMERCIAL GENERAL LWBILITY EACH OCCURRENCE . � CLAIMS-NWDE ❑OCCUR PREMISES Eaoccurtence � MED EXP(My one person) � PERSONAL 8 ADV INJURY � m GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL ACaGREGATE � � POLICY ❑�E a �LOC PRODUCTS-COMPIOP AGG � OTHER: o n AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT `�� Ea accident ANY AUTO BODILY INJURY(Per person) Z OWNED SCHEDULED BODIIY INJURY(Per accident) d AUTOS ONLY AUTOS �" HIREDAUTOS NON-OWNED PROPERTYDAMAGE V ONLY AUTOS ONLY Per accident i� � m UMBRELLA LIAB OCCUR EACH OCCURRENCE V EXCE38 LIAB CLAIMS-MADE AGGREGATE � DED RETENTION A WORKERSCOMPENSATIONAND w�RC48603245 04 O1/201 4 O1 2017 X PER OTH- B EMPLOYERS'LL4BILITY y�ry SCFC48603257 04/O1/2016 04/O1/2017 STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $Z�OOO�OOO OFfICER/MEMBEREXCLUDED? �N�A (Mantlatory in NFQ E.L.DISEASE-EA EMPLOYEE $2,OOO�OOO I/yes,deswibe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT � $2,OOO,O00- � � DESCWVTION OF OPERATIONS/LOCATION31 VEWCLES(ACORD 101,Additional Remarks SeMduk,may be attachad if more space is nquind) The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. y�.. �y � � � �r__ �+ CERIIFICATE HOLDER CANCELLATION "��-. ti� SIiOULD ANY OF THE ABOVE DESCRIBED POLIqES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE NALL BE DEWERED IN ACCORDANCE WITH THE ' POLICY PROVISIONS. � TOW� of varmouth AUTHORIZEDREPRESENTATNE rown Clerk 1146 rtoute 28 ' South varmouth MA 02664 u5A r�/� `��f p�� I/',p ,�� e�Y4�aser 7.�e1k c/1' L�fa«A� 07988-2015 ACORD CORPORATION.Ail rights reserved. 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