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HomeMy WebLinkAboutApp, License, WC & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-18-2463-03 Issue Date: 1/1/2021 Mailing Address: Location Address: STAR MARKET COMPANY, INC. 1 106 ROUTE 28 SHAWS #3692 SOUTH YARMOUTH, MA 02664 P.O. BOX 29096, MS#6531 PHOENIX, AZ 85038-9096 IS HEREBY GRANTED A LICENSE TO OPERATE: Retail; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions RETAIL FOOD SERVICE GREATER THAN 25,000 SQUARE FEET Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston /, 1`I Bruce G. Murp y, MPH, .S., /HO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-18-2465-03 Issue Date: 1/1/2021 Mailing Address: Location Address: STAR MARKET COMPANY, INC. 1 106 ROUTE 28 SHAWS #3692 SOUTH YARMOUTH, MA 02664 P.O. BOX 29096, MS#6531 PHOENIX, AZ 85038-9096 IS HEREBY GRANTED A 2021 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions *This license replaces license BOHTP-15-1727-03 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Br ce G. Murphy, MPH, R.S., CHI /Mallory R. Langler, R.S. Health Director/Assistant Health Director Sh aiv(S GF �qq • TOWN OF YARMOUTH BOARD OF HEALTH ' ; APPLICATION FOR LICENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: ,S Vla S -I# gc, c� TAX ID: LOCATION ADDRESS: ( ( O gUW( e a g s, stirtwm-f TEL.#: 5-1.)S-29 -09S- MAILING O 19S MAILING ADDRESS: iPcB me O1 L ' , (-1 S— (o ) h oCvl i)c, Z R50 38-7cJ'i( E-MAIL ADDRESS: N 1 S C .-C k) o� 2Acfe v.Na y , c(1Yy 1 OWNER NAME: Shaw rS SLt r rn a r k e f-s ,, (v� C CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: A "Pett'(0 TEL.#: MAILING ADDRESS: p 57c- 0-109 Co rf` 1 c-Loses) mice )c, A Z g 5T)3 Via 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. L 2. Pool operators must list a minimum of two employees currently certified in 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 file at our • ' • .. ' •. . 1. 2. DEC 2 2 2020 3.` 4. HEALTH nEPT 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. 1. �eK -Da,l, ( 6 2. w cod✓ C- PERSON IN CHARGE: 1.0.cil uk verge Each food establishment must have at least one Person In Charge (PIC) onsite during hours of operation. I. f\t K Theta O 2. CZ cLN • 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. L Alex. WAul° 2. � �. � ir1 C1 ooclk 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. N I IA (�e S c 1Gct rl 5 5�i �`S) 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# RR,R SSS CARIN 4;Ss MOTEL. 5110 r , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED I OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUI'AN For purposes-ofthe-I-imitations-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. POOLS • 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 sit in the pool area 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 Department'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 I-lealth 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-notiT 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 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 establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has-failed to renew his or her permitwithin thirtyj3O) days-of the previous-year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN TUC r" oA nDr CTCV D Cx1CUU A i A DD► If A T►nxiic‘ A xlrl ()CCU r►n ori redo\ TIN/ ►lcr+m Ancn ►o nnnn • ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or 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. POOLS • 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 sit in the pool area 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 Departmentihree(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 I-Iealth 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 CAFÉS: 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 establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty'(30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020. n * I i it i :e.... 01 ' ,, 1 i 1 4 A i IV 44.) Z a i , IC ....1 4 1 6 1 $ x 1 1 i b 2 I 0 ,.;, 8 I I I 0 il =NM 4) Lo 4 4 in CI I I A 1 I INII- 1 1 1140.1 0 < t r. §_ Cli. ,,. . -.- 1 I il; U 0 I i et i 4 Um Z 2 31 ellirr- le fi sm < I 11111 III N.? g, 409N g 1 ....., w III , ,. , ..,,, -, ca k ILI ....1 i c 1 x U < vl tii Q 111 :: t GI! 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U c 4 U _ U s _ �n°i 4 s ��: ' .0‘., The Commonwealth of Massachusetts wo..-== Department of Industrial Accidents Office of Investigations ttt d 1411 1e1 1 Congress Street,Suite 100 Boston,MA 02114-2017 IND s. www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Shaw's# 3692 Address: 1108 ROUTE 28 City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-0995 Are you an employer?Check the appropriate box: Business Type(required): 1. X❑ I am a employer with 111 employees(full and/ 5. ©Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑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]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, I with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section 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 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 American Insurance Company do AON Risk Services Central, Inc. Insurer's Address:5600 West 83rd Street,8200 Tower,Suite 1100 City/State/Zip: Minneapolis,MN 55437 Policy#or Self-ins. Lic.# WLRC67463511 Expiration Date:8/1/2021 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-year imprisonment,as well as civil penalties 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: 4/141 Date: 12/17/2020 Phone#:623-869-4326 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �-- ab DATE(MM/DD/YYYY) `4, CERTIFICATE OF LIABILITY INSURANCE 07/29/2020THIS 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 p REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. > Lu IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 ;1 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .c PRODUCER CONTACT 0 NAME: 'O Aon Risk Services Central, Inc. PHONE (866) 283-7122 FAX (800) 363-0105 y Minneapolis MN Office (AIC.No.Ext): (A/C.No.): 13 5600 west 83rd Street E-MAIL 8200 Tower, suite 1100 ADDRESS: _ Minneapolis MN 55437 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A ACE American Insurance Company 22667 New Albertsons L.P. INSURER B: ACE Property & Casualty Insurance Co. 20699 Including All Affiliated Subsidiaries & Associated Companies INSURER C: 250 E. Parkcenter Blvd. INSURER D: Boise ID 83706 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570083350112 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 INSR ADDL SUER POLICY EFF POLICY EXP— LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ru�D�yyyyt MIND LIMITS A X COMMERCIAL GENERAL LIABILITY XSLG71445914 8/0 /2--2-) 8/01_/2021 EACH OCCURRENCE $3,000,000 CLAIMS-MADE n OCCUR SIR applies per policy terms & conditions DAMAGEr07iENTED $3,000,000 PREMISES(Ea occurrence) X Druggist Liability Included MED EXP(Any one person) Excluded PERSONAL 8 ADV INJURY $3,000,000 a GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $18,000,000 X POLICY IIP$T LOC PRODUCTS-COMP/OPAGG $6,000,000 CO OTHER: Liquor Liability Included o N. A AUTOMOBILE LIABILITY ISA H25308384 08/01/2020 08/01/2021 COMBINED SINGLE LIMB (Ea accident) $5,000,000 X ANY AUTO BODILY INJURY(Per person) 0 OWNED —SCHEDULED BODILY INJURY(Per accident) N — AUTOS HIRED AU0TNOSY NON-OWNED PROPERTY DAMAGE 0 ONLY _AUTOS ONLY (Per accident) t d B X UNBRELLALIAB X OCCUR XEUG2794761A005 08/01/2020 08/01/2021 EACH OCCURRENCE $5,000,000 c) EXCESS LIAB CLAIMS-MADE SIR applies per policy terms & conditions AGGREGATE $5,000,000 DED X RETENTION A WORKERS COMPENSATION AND WLRC67463511 08/01/2020 08/01/2021 x PER STATUTE OTH- ENPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR I PARTNER/EXECUTIVEE.L.EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000— IIM n DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) Blanket Additional Insured for General Liability policy and waiver of Subrogation for General Liability policy status extend to those parties to whom the Insured has contractually agreed to provide this status. 31 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. New Albertsons L.P. AUTHORIZED REPRESENTATIVE Including All Affiliated Subsidiaries & Associ ated Companies ` �� � � Lr� 250 E. Parkcenter Blvd. Boise ID 83706 USA MI ©1988-2015 ACORD CORPORATION.All rights reserved. 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