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Home My WebLink AboutApp, License & Certification In.IG 19�r-;s - = A 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: W03,cry S \(Atoo TAX iD: LOCATION ADDRESS: \oil 'aA ‘�nvk4A‘&.craovkkno40-- TEL.#: Sot-3q - \3a5 caLlanMAILING ADDRESS: p c 2 r q puss eic. , to box E-MAIL ADDRESS: taxlicenserenewalsa(.walgreens.com OWNER NAME: WaX,rra.en EcLS#C-rr\ °S•r.--C1C-• CORPORATION NAME (IF APPLICABLE): 0.\�x-¢JtxN MANAGER'S NAME: Sec--C-ccm TEL.#: Sea-'YS4-'\'�a5 MAILING ADDRESS: \ b2e - e.uk. ow.c POOL CERTIFICATIONS: t•J �Pt 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. 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 your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: NV 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 tile State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wi :use past years' r cords. You must provide new copies and maintain a file at your establishment. r 2020 TH DEPT. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. 1. '-- ALLERGEN CERTIFICATIONS: 1J IP' 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. I. 2. HEIMLICH CERTIFICATIONS: t� 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 Ilealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT II LICENSE REQUIRED FEE PERMIT// LICENSE REQUIRED FEE PERMIT// 4/.« <-nrani vas MOTE). $110 (..-.' The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-6297-06 Issue Date: 1/1/2021 Mailing Address: Location Address: WALGREEN EASTERN CO., INC. 1041 ROUTE 28 WALGREENS #10460 SOUTH YARMOUTH, MA 02664 P.O. BOX 901 DEERFIELD, IL 60015 IS HEREBY GRANTED A 2021 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 LESS THAN 25,000 SQUARE FEET Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric WestonIIIP ti.,. 1 Bruce G. Murphy, MPH, R.S., C' 0/ allory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts I Department of Industrial Accidents `� Office of Investigations —sail= t? = L 1 Congress Street, Suite 100 4 ="1_= Boston, MA 02114-2017 ;re www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: \0..\cC t rs \D Address: O City/State/Zip: �D� �o.xrnc,s ti'M OZ (hone #: 508 - 30,1k-\33Ts Are you an employer? Check the appropriate box: Business Type (required): 1.5Z1 I am a employer with tg employees (full and/ 5. Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2.❑ I 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]* 11.7 Health Care 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.n 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: C Insurer's Address: SQ -Q– C- 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 imposition of criminal penalties of a fine up to $1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. I do hereby certi , under the pains and penalties of perjury that the information provided above is true and correct. r�� Lisa Hora Date: \� Signature: License Team Lead- Phone #: � -'Sa`1 r aeg 847-527-4208 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 #: MEMORANDUM OF LIABILITY INSURANCE Current as of: July 1, 2020 PRODUCER Willis Towers Watson Midwest,Inc.fka Willis Of Illinois,Inc. THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N c/o 26 Century Blvd RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM. THIS MEMORANDUM DOES NC Nashville,TN 37230-5191 AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW. ANY USE, DUPLICATIO United States of America OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT I PROHIBITED. INSURED COMPANIES AFFORDING COVERAGE NAIC# COMPANY ZURICH AMERICAN INSURANCE COMPANY 16535 Walgreen Co.and Subsidiaries A 300 Wilmot Rd.,MS#3228 COMPANY INDIAN HARBOR INSURANCE COMPANY 36940 Deerfield,IL 60015-5223 B United States of America COMPANY AMERICAN ZURICH INSURANCE COMPANY 40142 C COMPANY SELF INSURANCE D COVERAGES THE PO'LCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THF 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 MEMORANDUM 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 HAV BEEN REDUCED BY PAID CLAIMS. COMPANY POLICY POLICY LIMITS LETTER TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS IN USD UNLESS DATE DATE OTHERWISE INDICATED A GENERAL LIABILITY GLO 9310091-17 7/1/2020 7/1/2021 X COMMERCIAL GENERAL LIABILITY GLO 9310184-17(Puerto Rico) 7/1/2020 7/1/2021 GENERAL AGGREGATE $ 5,000,0C CLAIMS MADE I X I OCCUR PERSONAL&ADV INJURY $ 4,000,0C X Blanket Additional Insured EACH OCCURRENCE $ 4,000,0C X Per Policy FIRE DAMAGE(Any One Fire) $ 500,0C X Blanket Contractual Liability MED EXP(Any One Person) $ X Liquor Liability $ $ A AUTOMOBILE LIABILITY BAP 9310096-17 7/1/2020 7/1/2021 X,ANY AUTO BAP 9310183-17 (Puerto Rico) 7/1/2020 7/1/2021 COMBINED SINGLE LIMIT $ 5,000,0C ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per Person) $ HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per Accident) $ PROPERTY DAMAGE $ B EXCESS LIABILITY US00079295LI20A 7/1/2020 7/1/2021 PER CLAIM $ 5,000,0C X(UMBRELLA FORM AGGREGATE $ 5,000,0C (OTHER THAN UMBRELLA FORM $ C WORKERS COMPENSATION/ WC 9310092-17(AOS) 7/1/2020 7/1/2021 WORKERS COMPENSATION A EMPLOYERS LIABILITY WC 9310094-17(WI) LIMITS STATUTORY A EWS 9310448-17(MA) A PARTNERS/EXECUTIVE X INCL. EL EACH ACCIDENT $ 2,000,0C A OFFICERS ARE: EXCL. EL DISEASE-POLICY LIMIT $ 2,000,0C EL DISEASE-EACH EMPLOYEE $ 2,000,0C D PRODUCT LIABILITY Self-Insured 7/1/2020 7/1/2021 EACH OCCURRENCE $ 2,000,0C AGGREGATE $ 2,000,0C ADDITIONAL INFORMATION OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS, LENDERS, MORTGAGEES,GROUND LESSORS, VENDORS,CUSTOMERS,CLIENTS,AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. The Memorandum of Insurance serves solely to list insurance policies,limits and dates of coverage.Any modifications hereto are not authorized.