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HomeMy WebLinkAboutApp, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $200.00 Food Establishment License Number: BOHF-15-1073-07 Issue Date: 1/1/2022 Mailing Address: Location Address: GLOBAL MONTELLO GROUP CORP. 511 STATION AVE ALLTOWN YARMOUTH SOUTH YARMOUTH, MA 02664 800 SOUTH STREET, SUITE 500 WALTHAM, MA 02453 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Retail This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions • RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET. *RESTRICTIONS: No grass-Nitrate sensitive area. Water usage, for the building use, is not to exceed 310 gallons per day on an annual basis. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce'G. Murphy M' ', R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-1075-07 Issue Date: 1/1/2022 Mailing Address: Location Address: GLOBAL MOTELLO GROUP CORP. 511 STATION AVE ALLTOWN YARMOUTH SOUTH YARMOUTH, MA 02664 800 SOUTH STREET, SUITE 500 WALTHAM, MA 02453 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless.sooner suspended or revoked and is not transferable. Conditions *RESTRICTIONS: No grass-Nitrate sensitive area. Water usage, for the building use, is not to exceed 310 gallons per day on an annual basis. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • Bruce G. Murphy R.S.,CHO Health Director "" TOWN OF YARMOUTH BOARD OF HEALTH EAAPPLICATION FOR LICENSE/PERMIT - 2022 NOV 30 20[i * Please complete form and attach all necessary documents by Pm• i ber 18 2021. Failure to do so will result in the return of your applicatio ' DEPT ESTABLISHMENT NAME: A 114o,o r\ Ya t nna (n TAX ID: Of-1-344-1 3o2$ LOCATION ADDRESS: 511 N .on AtiP., Yarmou-K i M A TEL.#:(5O8)39 y-22j2 I MAILING ADDRESS: &o 4At• ZOO, Walkha.M MA (2453 E-MAIL ADDRESS:?errvi;k( lalrr tj .cc rv\ OWNER NAME: ('l 1o\c Mod 110 (! au ('c • CORPORATION NAME (IF APPLICABLE): Gicky4A Mork 10 p 0_0c p. MANAGER'S NAME: Ko,AL25,2iry Lov,, TEL.#:(SZ$\q c(- ZP,2 MAILING ADDRESS: 8c03000, � �}. ,1�-e 3C0 ( ctA-�rka,wt M o2ggq'. A 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. 1. N/<} 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. /0/A 2. 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 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. V-c,iu(Mp 2. 2. PERSON IN CHARGE: Each foodestablishmentmust have at least one Person In Charge (PIC) on site during hours of operation. 1. K.G.MVrn (-tA 2. 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. 1. k�.�'hdh Lc)u(2_ 2. 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. OA 2. 3. 4. RESTAURANT SEATING: TOTAL# 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 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 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 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 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 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. NOV 3 0 2021 ® HEALTH DEPT. GLOBAL MONTELLO GROUP CORP.,800 South Street,Suite 500,P.O.Box 9161,Waltham,MA 02454-9161 ph:781-894-8800 fx:781-398-9000 November 29, 2021 VIA FEDERAL EXPRESS Town of Yarmouth Board of Health 1146 Route 28 South Yarmouth, MA 02664 RE: Permit Renewal Application To Whom It May Concern: Enclosed please find the Food Service, Retail Food and Tobacco renewal application for the gas/convenience store located at 511 Station Ave, Yarmouth, MA. Also enclosed is a check in the amount of Three Hundred and Eighty-Five and 00/100 ($385.00) Dollars for the payment of the fees associated. If you have any questions I can be reached at(781) 398-4237 or at Stacey.caldwell@globalp.com. Sincerely . Sta ey ald ell Contracts Administrator Enclosure oma° r. m El:AEI 8 'a - z cy a w c HEALTH DEPT '-E0- ce Z cn ✓ o m O 8 CD D c M c Z _ "_ • V c_ p� , c y X ' > ° w w .., o c o ° O N O E 4 3 ® a 112 N 5 ° ti Z0 y c w ® M Z coco Q ,- 1— 12 X w 0 a I o M- 0 40, ''. z c t o f N• n O z 3 a MUM 0 ,_ p c _co P W4i) 13-c 12 Q N o o a z 0 0 Q ,,, H ' O o V O "▪ ° Cs.1a Z O— ° > 1.1.. a 2. cL _ o s Z , ce• `• e S 16 _ _ o .e � 3 Z z a- Z �� 0 � 1 -o 0 Cle 8 4 W .2 V U r m w N O ` m5 N• LU 3 41/ U u n• u N O O H s w Q � 4 11 a z € a n 1' oo r o ° o O� 1hj ira d1oc o ill .4:11 uztn C o LO 5 Q o D y w E L i 0Z � 110 N uoe o v dg 8-2no E ° Al Nilir IS Ts gc. Z 1 _ _ _,_ _ L,LJ _ _ NOV 3 0 2011 HEALTH DEPT 44 I 11:g2 0 4- -13 F--1 0 .—. o ;meo 0 a) a) C ^, eCe N '� CU fpis E v cu c• it : . ..., . - o Q z ._ z 0 4.1 >. (-.3) 1111 .. .... . V N N fQ 2 T'-o Commonwealth of Massachusettc Department of Industrial Accidents Office of Investigations _'`all= t Lafayette City Center ill 4 i' 2 Avenue de Lafayette, Boston, MA 02111-175 NOV 3 °:-.,2j-7.U 21 � www.mass.gov/dia Workers'Compensation Insurance Affidavit: General $asinesses L Applicant Information Please Print Legibly Business/Organization Name:Global Montello Group Corp. Address:800 South Street, Suite 500 City/State/Zip:Waltham, MA 02453 Phone#:(781) 894-8800 Are you an employer? Check the appropriate box: Business Type(required): 1.® I am a employer with 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. 0 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.E 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 arc a non-profit organization, staffed by volunteers, 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. "1f 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#l. I an:an employer that is proiding workers'compensati n insurance for my employees. Below is the policy information. Insurance Company Name: � ( p Ywr y►tSU)�( ��Lti Insurer's Address: Vi • „te1-r _ — City/State/Zip: 1S �� 1 �1� 1 �( � tp Policy#or Self-ins. Lic. # Will" (AD - Litio(J l- UExpiration Date: 1 i j L.L. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 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. I do hereby cek/ ' under e pains and penalties of perjury that the information provided above is true and correct. Signature: VC/ �1 Date: /41, 'i1 L-1 Phone#: l Iv-Lie 9.... Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): lfBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther _ _ Contact Person: Phone#: www.mass.gov/dia DATE(MM/DDIYYYY) ACORD® CERTIFICATE OF LIABILITY INSURANCE �� 10/1/2022 9/30/2021 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 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 Lockton Insurance Brokers,LLC CONTACT NAME: CA License#0F15767 PHONE FAX (A/Three Embarcadero Center,Suite 600 E-MAILo Ext): (NC,No): San Francisco CA 94111 ADDRESS: (415)568-4000 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Liberty Insurance Corporation 42404 INSURED Global Montello Group Corp. INSURER B: 1369067 404 Wyman St,Ste 425 INSURER C: Waltham MA 02451 INSURER D: INSURER E: INSURER F: COVERAGES GLOPAQI CERTIFICATE NUMBER: 17045922 REVISION NUMBER: XXXXXXX 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. INSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD MD POLICY NUMBER (MM/DDIYYYY) IMM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX CLAIMS-MADE I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ XXXXXXX MED EXP(Any one person) $ XXXXXXX PERSONAL&ADV INJURY $ XXXXXXX GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXXXX POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ XXXXXXX OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT $ (Ea accident) XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX _ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX AUTOS ONLY AUTOS ONLY (Per accident) $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE _$ XXXXXXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION PER OTH- A AND EMPLOYERS'LIABILITY YIN N WA7-69D-460066-011 10/1/2021 10/1/2022 X STATUTE ER ANY OFFICER/MEMBER EXCLUDEDXECUTIVE N N/A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ; oo HTDEPT.I-1 _ \....... CERTIFICATE HOLDER CANCELLATION See Attachment 17045922 Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRI/S1/4 E ATIVE 11111:1S 4 ©1988-2015 ACORD CORPORATI . All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Global Montello Group Corp. CORPORATE OFFICERS Name&Address Title Eric Slifka Director,President and Chief Executive 800 South Street Officer Waltham,MA 02453 Sean T. Geary Secretary,Vice President of M&A and 800 South Street Acting General Counsel Waltham,MA 02453 Matthew Spencer Chief Accounting Officer 800 South Street Waltham,MA 02453 Gregory Hanson Chief Financial Officer 800 South Street Waltham,MA 02453 Mark Romaine Chief Operating Officer 800 South Street Waltham,MA 02453 NOV 3 0 2021 HEALTH DEPT