The URL can be used to link to this page

Home My WebLink About15-013 Rein's Real Baking 1 � � i . � . s � , �� " 15�-613 ;� 2QlS V+encior Application .�`� �Pr��c�s�ec! & Patentially Hazardous Foc�ds� � °�� Ba�s �tiv�r �ar�m Nlarket MAY�14 2�j�� 31101d Main Street, 8ass River, MA t1Z654 HEALTH DEPT. � _ 2015 Market Dates. Thursdays,3un�13.-Sept. 17 9 AM-1:3a PM Saturdays,.lune 13-Sept. 19 9 AN#- 1c3� PM j �� ` �� . ! Rain/+�r Shine � ' '� �.�a.� � . _ i �, , � . �:t �� `. � Nam�: � - � �'��,�i�-� �..�� ; Farm/VendQr Name 1�-�� --��- ��-��.� ��-� Farm/Susiness Address � c�� /`�C-t��`� �`}�.,��c�►`�� f��J� t}� �`.��. Farm Website: _ w� , �� `Y��..� �� ,�i� � ��-��- ��.aS�C2�.��tr��.1 Telephane �Work} o e � (Cell} ```•,c�$��"-�ilb� Emaif: �'"'t.. � � "�.�� .�� - ��i�-� �� ,��`c�v� Best way to cc�ntact you ___.__��t �t �- ` N�mes of Qesigr�ated Person{s} in charg� sell#ng at the BI��M* *P�rson in�harg�e is responsibie for all operations and must be on site frt�m 8.3fl AM -1:3fl PM and be a liaison for ali eorrespondence b�tw�en town afficials {health, paliee,firej and the Market Manager. ��',�-�� a(�`�� Phc�ne �`�°`�'`� '� --�lt��'� �-� +� � � �CZ..� �"�.L� Phone X��` `"`� �`�`-� 1 ��{ i��..�'�*�� v�� (�-"�'"C` "`7'�`! �f "� ��..` � �t �"1 P�roducef Product you w�ll be sell�n�: (List all. Us� separate page if needed. P�ck�ged food items must have p�t�ntial allergens listed as well as ingredi�nts�, Labels shfluld ha�e uendars name and address. � �' � � � � ��` �� ? Sampl�s PrQvid�d? �Explain methods..of ser�rin�s�rnpl�s: siaes, covered, iced?� �' '� ,�`� 1.�� "�� ``.� �t�� C��►� �--� "��,�t�r'�"� ��''�~�- �, b t�1� ��..�� .� `�,�;� Wh�r+e w�il food be prepared� . c,.,�� ► � °�`�r�� ; �� . ��-��.� Check& attach cc�pies�vvith ap�i��cati�►r�. Capy of m�st recent insp�ciion report of facility where food is prepared :�- �ciduct Liabilifiy lnsurance �� ✓°'F Saf� Certificatic�n Food A1lergy Awareness Training Certification _._._ t�i �� Complete and attach Wc�rkers Campensation Affid�vit. � � . �,�.. ��.�.L-- �.l�3iL-t`�'i ��"�- �C�� , Any additional ifiems must b� app�rove+d by the Neatth Directvr prior to being sold at the BR�M. Please nc�tify Market l�lana�er at [ea�t one w�ek in advance or by 10 AM on Monday preceding the Thursd�y Market and she will get clearance for you. � �� Tr��y� — $zo�.c�o�`` ��tn c��ys - S�7s s��ur��y� — zoo.a� � A St396 non-refundable depasit is due by Apri!3t7.2015. Fina) payment i�due by May 2C?, 2015. Ali fu!!-seasvn uendors are expect�d t� attend w�ekly. If a seasonal vendar dnes not show up at� Market and has not given nc�tice ta the Market Manag�r,that venclor will receive nfltice from the Market Manager that his/her space is forfeited far the remaining season.There are no r�funds. � EduCators, tVl�ster Gardeners, IVo charg� Mt'3N PRQ�IT and Authors and Sustainable Living EDU�ITit)NAL Gi�OUPS advocates ta shar� and display tt�eir knowEedge and work. � M�st be�pprov��i by the Mark�t Manag�r � � ' - �.. Ple�s+� make your check �ayable ta t�e Bass River Farnners Marke# 2. Y�ur 5a°� depc�sit+ Bc�arrd of N�alth Fee c�f$St�.Q�} * must be recei�red k�y April 30`h to reserve yQur s�ace. * Se�aarate check made out to�h�e Yarr»c�utfi Bcaard c�f Health 3. All ful! seasan vendc�rs must be pai�! in full b�r May 2�Dth. ,�r By si�ning#h�s fc�rm the ver�dor �cknov�rledges that he f sh�e has read and v�rill cor�ply with the guidel�n�s f�r�th� 20i5 B�t�M wh�cf� are a�ra�lable �n +aur web�ite. wvvww.bassriverfarmersmarket.arg �hard ccapies on requ��t� �..� Applicants Signature � ��-��c �� .��;�c; Date _� �� l �`� Please return complet�� applicati�r� t�: Bass River Facm+�rs Nlark�t P� Box 137►� South Yarm�e�th, M�4 02fa�4 Mark�t Manag�r: �arlene Veara {774} Zi7-1��7 � i ,r i�..,','a� � .. . .. f � j'� . . . � ' t� � � � � � .. �'�. � . . . ' � �.� . ' �� . *�� . �.. � . . . � „�� :: � ' � :. � � � �� +'�„ wu�; � �° #� � � �, � � �,: � �• � �.`:� � #� �� ' � � � � � �,� � ' �� '� ,� . ,� � , � : � � �� ` � '� ,� �" �� , � ,� � �� : �;' � �� '� '� � � � � � �.� � . � � � � I � � ' � � �- �� `� � � �..�J �' �� _ � � � ' `� �� " � �� ,, � �� b' � � �' � � � �� ; � r , � � � �� ° � � �' � �� : �� ; � s. -. . . �_ ��;. .� ; �. . � � � , .� � � � � � �� : F � �� § � , � � � � �� — ,� � �. : � .� —�-��._e �.��.�.�._�._ __ _ ..,�..__ _. .�.,�,:; �..�.�,�,,�.��_z�.,�� ....�k�� I ! I ' . � �, ., . ,..��r�,. �� .� � � i � � S� � �; F w� 5 : f .. ': .� �' 3 3i„ '. . ;,•'�:. � . � ..: � : � . . � . . ;.: �. z � � � 8 � � � � � ,�- ,�wr,r;X', � � . � , �� . .. „ � � � y i � � � § �° 7 v= � �r � r �.. t� � L F �� 9w� � � � . . . � ��. ' ' -., ¢ r � �� ^ �� I�`�` �, ��i �fpf�' ;. � , . ,j ,..:, ;�'. �. ,. ; i ; i ' . a , ; , + , , i i � «i N � W � � � � LTr yg N N � � '� v� �r" �, o � b10 � � �' � � � ° o .s"�'' �, � �o � � Ey � ~ � x � z A ~ ° � ° rn W " [••i a. � t � � ' � � � O � w � .� �D� � � b � � a � � � � � d -d .:O v . U � � 0 0 > � � x � � o �o � A w � �-�' [-� W v� ,� o � � �' A � � .� O � � �O °` GQ � x �' w w � � � � w � � � � � O � EW �� p � �o � � pq .� '^' � O O a � � � � � � p � a � � o � � � � N U Ey -� °' � � � � •'� o ., �s � �, ,� M Ey ~ � 'b � r��_y �j � '� V� " ' V./ � o O �� . � � � .� � � '� `v .� �; � '= �°� � � � . �"� U � � ,� �e y �, ��, .� A a � �: r. a� -� e� ;a .� � � .� � �s a v� o � "" � `� � � � � � o �� ' O � � � "s y W A.i '~ � E-� W r; z '� `� v � � a�i �i' c� � `� ,, .S4 �t, s` � O •�'i rc.t � � ,-'� � O ~ a ►�' a � E�' � E° a i � ' . a , , � � ?'he C,a�mrr�rv�ealth a�'I�lassachus�tt's 1�e�artment nf Irulu��riaC Acczr�ents : Q,f�GG'lJ�I�tYL+S�I�lXl�LCJI1'S , l�� iJ,,'S}tE1°L�„�'1t1tE+�tl"�@� Btl5�t7lt, .�`i!�' {��,��j WWW.llttX.TS.�XIV��[f�l Wt�rk€rs' Compensation� insurance��fid�vit: �cneral8usiness�3 A licant lufvrm�tio�n Piease Print.t,e 'b1v BusinesslC3r�ani�atit�n:�+1�me: �` � ��, _ �. �--�.:L.-_�.��,...,�,f,� � . �d��:_.� �� __��--,...-•..�.._r..... .� p �_.............�_.. �_-_ .�.�....�.�,_______�...�.� �1C�r'��B�E',i�I�JJ; �i��Vlj�1 �t"� �e�� 7OY1�#�:_��"'^� .� �" '�i �� ; u -- _� Are y�u a�ezt�ployer?Ch±�ck the apprupriate box; Business T`ype(rxyuired): � 1.� I am a emplc�yer with . �mplayees{full ancll �, []Retail � �r part-tim�}.* —._._._._._. �,, (� Rest�zuranilf3arlEatin��stablishmer�t , 2,(� T am a sUle propriett�r or p�rtnership and h�vz nc� '� e�nplov��s workin�fnr me in any c��acitv. 7. �]t7�'ice ancltor Sales{inct.rra(est�te,auto,-et:c.) �I [iVo wai'kt�'cc�mp.insursntc�required] 8, []Non-prvfii a.❑ We�re a cr�rpc�ration�nci its t�f�cers havz ixercised 9. []�at�rtain�nent iheir:riglit�f exem}ttic�n�r c. 152,�:E{�) a►�d i�e h�ve �o employees. [No workers'com . tnsuranc. , * 1�.[�:trlataufacturin�; p c rc quired 4,[� ��e area non-profit axgan.iz.ation,sraf!'Ec�bu vczlunreers, 11,Q I•3ealth Car� with no employees. [Ncr warkers'ac�anp. ins�,r�nLe rc�.) t2.[�bther ��`C��:.J � �.1�`'�Z. *Any appiirant that checks bnx r#i qju�t.aisa ii31 out tl��si.cci<an bclaw showinp tl�eir wc�akc�'epn�p4r�saiton��slicy irrformaEian.-�'�—.-•••_�:..µ..__.... *'"IPthe r,�rFxrrats:a�cers ha+e exer:�ptc�ci thcros�tve�.btrz th:c<>r��7ration hzts attier crrtpkr�;.�cs,n u�t�rkcrs"compeays�teicm pulicy is r•cyaittxi anci�u<:h an organi�tion shautd cltock boz!�l. 1�ra fc�a cmpinyer that is providing w�rl�r.s'cr�nr�r�n.satxon�rrsarance f�r rrey etnpl'�3}ee�. Belvw i,r tlr�pafity infornratiorx Incurance C:nmpany Nams: �..�...__ ____.....� . ................_ .�_....._._...._..______.__�._._......... � •,.._. ........_...,............ insurer'�A�ciress:______�___.. _.�_._ _ _............._._____._�......................._.._� ................_......--______�_..�..V.�..��_._..� C'ityl5late/Zip:_______y.___. �... _..._.._...�...._ .._ f'olicy#crx Sett=ins.Lic.#" ...�_......_�.._._._--------_.______ .....__ �;xpiration I3ate:�.......__ Attaeh a�opy af the workers'eompensation poiict�dectaration page{5}�nwing th�pal�cy nut�tber and expir��ion date). ��ilure to se�ure cavera�e as r�quired und�r Secti�n?5��f i�9CTL c.. 152 can le�d to the im�nxit�on af criminal�eaalties af�n finc up tn�1„SqU.{7{)andror on�-ye�r imprisonmc�i4,s�s tivetl as civil pei��fties in the fnrcn c�fa STt�P'WC3.Rif.ffl.RT7EFt�nc��xine ��f'up to�250.t�a day a��inst fhe vit�lator. Be acivi�ed tha�a cc�py�nf this�;tateinent rnay l��orwaxded ro th�Uff�e o.f Investigations of the D1A ti►r insuran�:e covera e veri�icatirr�. /do herehy certi u�rder thc pusins and�enalti�s rrfperjury tlrat f1:e in f'r�rmrrtit�N prnvitft�d rthnu[�is tr►s�t�r�d correc� i ture: �" � '�., 1 �+� �. l �'i��R 'a . _....._........... I)ate � _......� cs�� Phane#: i��S`"'� � � ��j l (�'s C.� _ ��.� ..�_............_..______. a�cial use�nnly. f�v nat wri�e in tlris axreu,ta be ca�ple2e�Iry city or tn��n rrffre� Cit,y or Town: _.. Perrr�itlt.acense# . tssui�g Authority�(c�rcie one): � 1.Bo�rd of He�ith 2.Buildittg i?epartmeni 3.�itylTown�lerk �.Licensing Board 3.�ele�hn�n's t3ffice (r.C?ther Cantact Person: Ptanne#: tuww.mass.gov%dia t i � ' . � � � i�� '�� CERTIFICATE OF LIABILITY INSURANCE �03/25/�2015 THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RI(iHTS 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 HOLDER. IMPORTANT: If the certi8cate holder is an ADDITIONA�INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A sWtement on this cerUBcate does not confer rights to the certificate holder in lieu of such e►�dorsemerrt�s). PRooucER ,�E.Y � FLIP Program Support Veractty Insurance Solutlons,LLC. °NONE . (888)568-0548 F^X No:� �� 260 South 2500 West,Suite 303 ��Egg, info�fliprogram.com PleasantGrove UT 84062 iNsurt AFPOROINOCOVERAOE Naca �HsurteRa: reatAmerican iance nsurance o. ! � �� INSURER 8: Rein Ciarfella,DBARein's Real Baking nisuRenc: i PO Box 3046 INBURERD: i aquoit MA 02536 ------._.._.:..------......._...._..._. . INSURER E: � _..__....._..................................................__...................__........_.........._.....................__....____._. _ .........._. INSURER F: j"'—""'—"' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE/1UIREMENT.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, � EXCIUSIONS AND CONDITIONS OF SUCH POLtC1ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �R TYPE OP INSURANCE I I POLICY NUMBER M LICY EFF MM�IDWYY LIMtiS ' '-- °��uTM I � EACHOCCURRENCE a 1,000,0 j X COMMERCUIL GENERAL IIABILITY ! X � PREMISES Ea oweraice s 300,000 � CLAIM3�MADE a occurt �� 5,000 MED E%P IM�'°�B psso��.N. S_..._—__._._� A � i PL3305436-F008213 o3io5rzots o�lo5no16 pERSONALdADVINJURY S 1,000,000 GEw�A6GREcnre S 2,000,000 GEN1AGCaREGA7ELIMITAPPLIESPER: � � i PRODUCTS-COMPlOPAGG S �I,OOO�OOO� x POLICY PR6 LOC S AUfOMO81LE WIBILITY � , . , � I i�'�.' aecddeM S . ANY AUTO BODIIY�NJURY(Px parson) 5 ALLOWNED SCHmULED i i AUTOS q(IfOS BODILY INJURY(Pet aeddent) S HIREDAUTOS NO!!-0WNE� � PROPERTYDAMAGE � AUTOS i eraeddeM s ! S UMBRELLA UqB OCCUR �(�``� � � I . EACH OCCURRENCE S ].,,__..;�; '__"'_.____"'_._.._.._'_____'_.__._.._._........__. EXCESSlIA6 �CIAIMS-MADE G AGGREGATE S i � DED RETENi'IONE I ! � � g WORI�RS COMPENSATION ; � : WC 3TATU- OTH- AND EMPLOYERS'LYIBIUTY ; . � . . °T � Y.�IMI ANY PROPRIETOR/PAR7NER/EXECUTNE Y!N� . OFFICFJMEMBER EXCLUDEUI N I A � E.L.EACNACCIDENT $ �� ___....; � (M°^d+�Y��NN) i � E.L.DISEASE-EA EMPLOYE S rcvas.aeaa+oe u,ae. - -- — E.l.DISEASE-POLICY LIMR S �i �:I � � ( � . I � DE3GRIPTION OF OPERATONS I LOCATION81 VEHICLES(Attx�ACORD 101,AGdlGonal Remarks Sehetlule,ff more spau is roqukM� � � Certificate holder hed been added as additional insured regarding the above mentioned policy per attached Additional Insured-Designated Person or Organization(CG20 26,ED.04 13) CERTiFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLEQ BEFORE Bass River Farmers Market-Carlene Veara �E EXPIRATION DATE THEREOp, NOTICE WILL BE DELIYERED IN ACCORDANCE WITH THE POLICY PROVISlONS. 311 Old Main Street Bass River � MA 02664 AUTHORRED REPRESENTATIVE �r�'�-��i�� m 1888-2010 A'�RD CORPORATION. Ail rights reserved. ACORD 25(2010/05) The ACORD name aod togo are regtstered marks of ACORD � j . ; - � , p 1 � � CG 20 26(Ed.04 13) THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. . ADDITIONAL INSURED—DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ;s : Schedule Name of Additional Insured Person(s)or Organization(s): Per individual CerGficate of Coverage. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A SECTION II-WHO IS AN INSURED is amended to include as an Additional Insured the person(s)or organization(s)shown in ihe Schedule, but only with respect to liabiliry for"bodily injury,""property damage"or " erso � p nal and advertlsin ' m'u caused in . . 9 whole 1 rY , or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1.in the perfo�rnance of your ongoing operations;or 2,in connection with your premises owned by or rented to you. However. 1.the insurance afforcled to such additional insured only applies to the extent permitted by law;and 2.if coverage provided to the Additional Insured is required by a contract or agreement,the insurance afforded to such additional insured will not be broader than that which you are required by the conUact or agreement to provide Torsuch additional insured. B• WiU�respect to the insurance aiforded to these Additional Insureds,tl�e following is added to SECTION III— LIMITS OF INSURANCE: If coverage provided to the Additional Insured is required by a coniract or agreement,the most we will pay on behalf of the Additional Insured is the amount of insurance: 1.required by the contract or agreement;or 2.available under ihe applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. � Copyright, ISO Properties, Inc.,2012 CG 20 26 (Ed.04/13)PRO Page 1 of 1 AC R� ,: on��wonmr� � CERTIFICATE OF LIABILITY INSURANCE 03l25/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RI(iHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMqTIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFPORDEO BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate holder is an ADDITIONAI INSURED,the policy(ies)must be endo►sed. if SUBROCiAT10N IS WAIVED,subject to the terms aod conditions of the policy,certain policies may require an endorsement. A stateroent on this certiflcete does not confer rights to the certificate holder in lieu of such endorsement�s). ��R FLIP Program Support Veracity Insurance Solutlons,LLC. P�E--------------- _..__.__.....___.�� _.... . (888)568-0548 F� ---_______..---..�.---- 260 South 2500 West,Suite 303 ac No: Pleasant Grove UT 84062 Ao��: info cQfliprogram.com yA� INSURE 5 AFfOqqNp CpyERppE � �p�� INSUI�D � MSURERA: �B8tAR18fiC811 18flC8 �SU�8OC8 O. � Rein Ciarfella,DBARein's Real Baking ��ur�R6: PO Box 3046 R13URERC: i Waquoit MA 02536 ��RERD: _--...----._.._....__---...._...........--.......- MBURERE: � � � ._..............._..._._...._._.........._._. ......_......._._............_......._.._......_......__..........__......._...�__.._._. ' . .. _._._..._.....__.._._._ COVERAGES INSURER F: � CERTiFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES-OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERtOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE�SSUED OR MAY PERTAIN,THE IPlSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PO�.�CIES,IIMiTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � 7'VFE OF qiBURAHCE POUCY NUI�ER POL FF M� . OENERAL LW&LITY � LMRS �. X � � � EACHOCCURRENCE S 'I,OOO, O �� COMMERCW.GENERAL LIABILRY !��--7-�– � 300,000 CLAIMS-MADE X 1. !��.I I � PREMI3ES�Ea owxrcnce S ' . A __ []occuR j � n+Eo�xacanyone�,,,,_ :� s�000 i I PL3305436-F008213 �03/o5/2ot5 j oazo5no18 �--- I I � PERSOWLLdADVINJURV a 1,000,000 ' GENERltLqGOREGATE S Z,OOO,OOO XENL AGGREGATEPLIRMOIT qppUES PER: � � i ! PRODUCTS-COMP/OPAGG $ Z,OOO,OOO POUCY T LOC � . . i , AVTOM081LE WIBILRY i ' � s � '. . ANYAU70 I��i 1' +' Eaax�eM �i s ��D SCHEpULED � � I ! BODIIY INJURY(Per parspn) S AUTOS N�,D�EO i � BODILY MWURY(P!r aedAent) $ ' � HIREO AUTOS A�ac ; . � PROPERTY DAMAGE ... � � eracdden[ S � � IM��RELLA LIAB ' S —. OCCUR � EACH OCCURRENCE S EXCEEB LIAB � ...........:�� ...__..'_"_—.__—.._... CUIM%'sMADE .—..--_.__.'_._'..._ �. ' AGGREGATE s DED RETENT10N5 � . . M�ORKERS COMPEN3#Tiqj� S AI�EMPLOYERS'LIABMY � � WC S7AlU- �p7}{_ , ANY PROPRIETOR/PARTNER/EXECUTNE Y/N� � i 'T�Y�I�.L�..__':.� _._"'_.'_ OFFICEIMEMBER EXC�UDED7 ❑j N/A�� ; E.L.EACH ACCIpEN7 g (MatMamry In NH) , � ��Y�.�e i+Kkr � � E.L.DISEA&E-EA EMPLOYE S � � E.L.DISEASE-POLICY L�MR S I i�---�- ; DESCRIPTION OF OPERATIONS/LOCA7ION8!VEHIClEB(Atlaeh ACORD 101.AtldMlonN R�merits 9elwtlWR iF morc spaee b rcqutretl) . Certificate holder hed been edded as additional insured regarding the above mentioned policy per attached Additlonal Insured-Designated Person or Organization(CG20 26,ED.04 13) CERTIFICATE HOLDER CANCELLATION SHOULD AMY OF THE ABOVE DESCRIBED POUClES BE CANCELLE�BEFORE Bass River Farmers Market-Carlene Veara THE EXP�RAT�ON DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 311 Old Main Street Bass River . MA 02664 AUTHORQEDREpREgB!'►pTNE � �� 1888-2010 ACORD RPORATION. All Hghts reserved. ACORD 2S(2010/05) The ACORD name and logo are registered marks of ACORD t i , { j , � : . � . � i � , CG 20 26 (Ed.04 13) THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. , ADDITIONAL INSURED—DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ,�; Schedule Name of Additional Insured Person(s)or Organization(s): Per individual Certificate of Coverage. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. � A. SECTION II-WHO IS AN INSURED is amended to include as an Additional Insured the person(s)or � organization(s)shown in the Schedule, but only with respect to liability for"bodily injury,""properly damage"or � "personal and advertisin in'u caused,in whole or in a b our acts or omissions or the acts or omissions of i 9 1 �Y" P � Y Y I, those acting on your behalf: 1.in tt�e perfurmance of your ongoing operations;or 2.in connec6on with your premises owned by or rented to you. However. 1.the insurance atForded to such additional insured only applies to the extent permitted by law;and 2.if coverage provided to the Additional Insured is required by a contract or agreement,the insurance aff orded to such additional insured will not be broader than that which you are required by the contract or a reement to rovide forsuch addi' 9 P bonalinsured. B• Wifh respect to the insurance afforded to these Additionai Insureds,the following is added to SECTION III— LfMITS OF INSURANCE: H coverage provided to the Additional Insured is required by a contract or agreement,the most we will pay on behalf of the Additional Insured is the amount of insurance: 1.required by ihe contract or agreement;or 2.availabie under ihe applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase The applicable Limits of Insurance shown in the Declarations. _�,. Copyright, ISO ProperGes, Inc., 2012 CG 20 26(Ed.04/13)PRO Page 1 of 1 t � • � . i , , � ' • a�,-,...,�....,,�� ADMINISTRATED BY '' �'�. ;Food Liability veracity Insurance Solutions,LLC �� 'Insurance Program Great American Insurance Group 2G0 South 2500 West Suite 303 � 301 E.Fourlh Street,25 S PleasaM Grove Utah 84062 htto://www.flioroaram.com/ Cinannati,OH 45202-4201 88&568-0548 513-579-6300 info fljproyram.com COMMERCIAL GENERAL LIABILITY COVERAGE PART—OCCURRENCE FORM CERTIFICATE PAGE � IT IS AGREED THATTHIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BEI.OW TO CERTIFY COVERAGE UNDER THE COMMERCIAL GENERAL LIABILITY INSURi4NCE MASTER POLICY LISTED BELOW. � _� � INSURANCE COMPANY:GREAT AMERICAN INSURANCE COMPANY POLICY NUMBER: ' NAMED INSURED:BEAUTY HEALTH S TRADE ALLIANCE PL 4435352 CERTIFICATE HOLDER: Rein Ciarfella, DBA Rein's Real Rye CERTIFICATE NUMBER: ADDRESS:PO Box 3046,Waquoit,MA 02536 POLICY PERIOD: a�osno�a to 03/05/2015 12:01 A.M.Standard Time at the Address W The CeAiflcate Holder F002934 i UMITS OF INSURANCE ` General Aggregate Limit(Other than Products-Completed Operations) $ 2,000,000 Products-Compieted Operations Aggregate Limit $ 2,000,000 Pe�sonal and Advertising Injury limit $ 1,000,000 General Each Occurrence Limit $ 1,000,000 Damage to Premises Rented to You Limit $ 300,000 Any One Premises Medical E�ense L'qnit $ 5,000 Any One Person Professional Liability $ EXCLUDED Liability Dedudible None Identity Recovery Coverage Aggregate Limit $ 15,000 ' identity Recovery Coverage Deductible $ 250 \ FORM OF BUSINESS: ��e proprietor/Individual TOTAL COST OF INSURANCE: $ 299.00 (The cost is 100°lo earnedlnon refundable) CODE NUMBER: 11168 PREMIUM BASIS: Gross Sales EXPOSURE: up to$so,000 CLASSIFICATION: Concessionaries THIS INSURANCE IS SUBJECT TO ALL THE TERMS AND CONDITIONS,INCLUDING APPUCABLE ENDORSEMENTS,OF THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER PO�ICY.A COPY OF THE COMMERCIAL GENERAL LIABlLITY INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE.AJDITIONAL COPIES WILL BE PROVIDED TO THE CERTIFICATE HOLDER.PLEASE READ THE POLIGY AND ALL ENDORSEMENTS. NO ADMISSION OF LIABILITY MAY BE MADE EITWER VERBALLY OR IN WRITING FULL DETAIL OF ANY INCIDENT SHOULD BE SENT IMMEDIATELY BY EMAIL TO CLAIMSCcDVERACITYINS.COM OR BY LETTTER TO VERACITY INSURANCE SOLUTIONS LLC 260 SOUTH 2500 WEST SUiTE 303 PLEASANT GROVE UT 84062. FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule IL 88 01 (11/851. r^�' Mx �-F"{ V � ADMINISTRATOR'S SIGNA71lRE:� �w��I��Mt � ��p r';""' "�� 1�� . j �,,! Page 1 of 12 ". C , � r � Carlene Veara From: 'Rein Ciartella"<rc�reinsrea�aking.com> To: "Carlene Veara(Bass River Farmero Market)"�carlene�bassrivertarmersmarket.org> SaM: Thuroday,March 26,201511:35 AM Attach: FreeSempleslSendwich'10.JPG;R3 at Falmouth.jpg;R3atMalw�eys.JPG;11�02FFM.jpg;R3 WFM2073.JPG;14_04_10R3PWFM.JPG;100_9026.JPG; 14_04_19R3�WSFM.JPG;14_04_26R3FramRotaryCratt.JPG;1�9065.JPG;14 09_27NBWWFStacii Helena.jpep;MAHONEY'S PIC.JPG;ReinSmileBreadPlymouth.jpg; R26optionsGalore.pdf I Subject: 15/03/26-RC(Produd List;Websile;Sdiedule;Photos) . ' Carlene >Recived your paperwork and happy to have you as a vendor on Thursdays at thr >Bass River Farmers Market. I could not open your product list which I would >very much like to have to put on facebook and my informaNn. Could you >plase mail me a copy. �; Thanks! :) I � Sorry,it was a Pages file(I'm a Mac person). It was a complete potential list I compiled to submit to all markets and events,with many things I have not done yet(but have on my"Want To Do"list). The submitted list essentially details all the products I could i possibly envision for the upcoming season so managers have a way to determine what might be appropriate and what might conflict with other bakers. Here is the list as I sent it: j START SUBMITTED LIST I REIN'S REAL BAKING 2015 PRODUCT LIST This will necessarily be a general category list to some extent because within each category I will be producing multiple products (i.e.rye bread 15 varieties,Ciabatta 10 varieties,etc.). Various breads and bread products,including:Rye,Wheat,Ancient Grains(amaranth,barley,bulgur,buckwheat,einkorn,emmer, kamut,millet,quinoa,spelt,tet�,Ciabatta,Baguettes,Naan,Calzones,Fougasse,Soft Pretzels,Bagels,Croutons,various other breads utilizing whole grains,seeds,dried'fruits,-vegetables,cheeses,sauces,preserved sausage,bacon,etc. Pastries,including: Muffins,Cupcakes,Bars(Brownies,Hermits,etc.),Tarts,Demonter,Cookies,Quickbreads,Twists(cinnamon,etc.),Mini-Pies, Whoopie Pies,Mooncakes,Sfogliatelle,Gibassier,Canele. END SUBMITTED LIST As for what you put might want to put on the BRFM FB site I would say a more general list for now might be more appropriate, but you,of course,be the judge. A general iist of my current product line incWdes varieties of rye bread,ciabatta and baguettes as well as pastries such as quickbreads,muffins,cupcakes,bars,cookies and Demonter(pull aparts). If you would like more specifics do let me know. I've been working on new pmducts on a regular basis and,if the upcoming season goes anything like last year,I'll be introducing probably one new product every week or so. Today I'll be working on a new one for me-Whoopie Pies-but with a twist. I want to use the decadent ganache I used to fill the interior of my Irish Car Bomb Cupcakes(renamed Irish Spirit Cupcake)rather than the typical white"Fluff'stuff. I'm also gaing to try a modified version of a recent Swiss Meringue Buttercream Frosting for my Carrot Cupcakes,but with increased lemon juice and less`butter(better flavor,better mou#hfeel)as well as the same buttercream for the same cupcake but with Frangelico instead of lemon juice. Always trying new things in an attempt to improve products. So far I've done over 50 different:products. As the bottom Iine fluctuates I add new ones and drop tihose which don't do well enough. The market essentially dictates what I produce as I strive far a consistent and healthy bottom line. Working on the new website all the time now. We've got the nav baz,;homepage,sub-page list,general background,and logo just about completed. Lots of decisions and choices to make in terms of colors,layouts,styles. I've started to write the copy,a little each week,for some of the pages. Included in these designs witl be a compietely new logo,new labels,new signage,etc. Hoping to get most of the design accomplished 6efore the new season sfarts because3 have so little time available once I've got 3 markets a week to bake for. I've been looking at my season schedule and realize now that I may not be able to persona�y appear'at Bass River until July 4 week because my markets are Tuesday,Thursday and Saturday,which leaves me zero time to get out anywhere in between. On July 4 Saturday my Acushnet market is not happening sa the Thursday before I won't have to make dough or bake pastries(after already cutting,slicing,packaging,labelirig,sorting,loading,paperwork,etc.for Stacii). It'll be nice to drive in with Stacii and help out as well as see how the market does on whaf wi1T probably be a really,rea11y busy day. :) I'll also bring my camera and tripod to get some good photos(I like to document every market and event I go to). 3/26/2015 � � - � Page 2 of 12 � i s � � r � � - - . . ... . You are welcome to use a placeholder photo to put up on your Vendor page until you get a chance to take your own onsite photos as you did last year(unless maybe I come up with a better one you'd like to use). I'll attach some to this email so you get the idea. Some were taken by me and some were taken by media or managers. The keydetail to note is that my signage is changing completely(along withthe company name)so things will look very differenf once'that happens. I also included somepics of Stacii and Helena so you can see who they are. They are so cute together at New Bedford Working Waterfront! I'm so lucky to have such great help! :) �, Pm a(so attaching the latest logo designs,just so you can see how extensive my decision-making process has become! RC Rein Ciarfella Rein's Real Baking Handmade Stone Hearth Limited Production Classic Artisan Bread "The Best Rye Bread in North America°(T'M) rc,�reinsrealbaking.com ; Cetl-508-72&0164 <http•//www farmfresh.orgJfood/member:php?fn=1027> _ . .. I oi�i�l ilr Ito� ... � � . �. � . � . . . . . �8 :� . � . � . . � �.1'� . _ .. . :G' 3/26/2015 . � � --- -- - -------- --- � ; -- --------- �„�F_ REIN CIARFELLA ` 592 D/B/A REIN'S REAL RYE ��1t3 1 OLD VALLEY ROAD/POB 3046 . 9� • WAflUOR,MA 02536-3048 G�� S^ . 608-728-0164 — - Date • Pav to tl�e o �>6�.��-�_-- - _� � �C1�� Chder of . ��sl'r�— � I� _ �.�_� _ __�_.1�`' __ __. _. __ ___ I�oilars � �; ROCI��LAI�TDTRUST __. ___-- — -— -- a„� .,� ; � ; i F,��: ��— � __ ----- _ ,,_ . . . . _ ___. � �: �' 0592 ' ,..�,. �,.,,�, x, ..u,,..F�.�,�,.,� - - --------- - ---____----- .,,� u._��.x �n�. .: .:�„m��.. . � -------- --- �� - -_---- --- =�� N._.� ---=----=� REIN CIARFELLA 591 I � D/B/A REIN'S REAL RYE ��113 1 OLD VALLEY ROAD/POB 3046 9� WAQUOIT,MA 02636-3046 '� 608-728-0164 --- -_-__ � Date ` Pay to t�.e _ �� _� _� � . �\ Order of --S U Zt�(L�°�-�-_�1��'Z.� $�DU i � � ', , ��' � p__ � ! �,� .f.(� ��.t,�-� �'`� . � j ., ___�.. __ __ �_ _—_T 1 UC✓ __.. DO�IdYS a �, ` _ ,� — ---- ':� ; ROCI�:I.�L�TDTRUST - °� � . ., ,+ i �,;�'�S`__v�,��o�� , - -- -- � - - -_____._--- . . _ � ��___—..r. j �: �' 059 L L __� ____ _ -___ � ,.� �-�..�_ .__- i 1 � ' . � The Commonweatth of Mtzssachuseits Department of Industria�Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ; Applicant Information Please Print Legiblv , i Business/Organization Name: �E( 1.� fS �.��L ��(G�,�f(�y M" Address: � ��,�� ✓AL�� • City/State/Zip: I,�R(��IO t� I''I!� �1�1 � � Phone#: ��'��'Ut b�/ Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with employees(full and/ 5. ❑Retail _ _- . � , �� , . ,., ent .,,„ w „ , „. ,�,� w�, .r�v �.<:�- �stablishm y " �.: ' am a �le proprietor ar partner�hip and ha�e no r�. � Office and/or Sales(incl.real estate,auto,etc.) j employees working for me in any capacity. � [No workers' comp.insurance required] g• ❑ Non-profit 1 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 volunteers, �r�� with no employees. [No workers' comp. insurance req.] 12.[�Other � ��1Z— •Any applicant that checks box#1 must also fill out the section below showing thcir workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employces,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: Insurer's Address: i City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: � 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 unposition of criminal penalties of a fine up bo�l.500.(f0 and/or one-year imprisonment.as we13 as-sivil penalties in the form of a STOP WORK ORDER and a fine of up to S2�0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certi under the pains andpenalties ofperjury that the information provided above is true and correc� ) j Si ature: 2 2� � � 1 1'�1�=L� Date: � 1�� / � Phone#: `7 C)� �'`i a �� (?( �D �� Official use only. Do not write in this area, to be completed by ciry or town offieial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Suilding Department 3.City/Town Clerk 4.Licensing Boarcl S.Sclectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia � � THE COMMONWEALTH OF MASSACHUSETTS i TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NLTMBER: #15-013 FEE: $50.00 1 � This is to Certify thaT Rein Ciarfella cilb/a RP;n'�R al B king � 1 Old Valle oad,��114i�.,MA i i IS HEREBY GRANTED A LICENSE l ; For NAME OF EVENT: Bass River Farmers Market j DATE OF EVENT• Thursday�through to Se�tember 17 2015 1 LOCATION: 311 Old Main Street South Yarmouth MA FOOD SERVED• Various breads and bread products• Various nastries. i � This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires September 18.2015 unless sooner suspended or revoked. May 15.2015 BOARD OF HEALTH: J lYiZl�1�A;G��t, ��,�v�tRn �53u�s��, _.lYL.1�., `�Ii.ce C.Pcc�wcrruut Fu�e�i J• � C,Piav[Pea J. Bruce G. Murphy,MP R. ., CHO Director of Health __ _ _ __ __ _ __.__.._....__.,.�-.. ;