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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-5965-07 Issue Date: 1/1/2022 Mailing Address: Location Address: CUMBERLAND FARMS INC. 1301 ROUTE 28 CUMBERLAND FARMS #2262 SOUTH YARMOUTH. MA 02664 165 FLANDERS ROAD WESTBOROUGH,MA 01581 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: 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 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G.Murp , MPH, R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-5967-07 Issue Date: 1/1/2022 Mailing Address: Location Address: CUMBERLAND FARMS INC. 1301 ROUTE 28 CUMBERLAND FARMS #2262 SOUTH YARMOUTH, MA 02664 165 FLANDERS ROAD WESTBOROUGH, MA 01581 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. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . 1 Bruce G. Murph , MPH,R.S., CHO Health Director The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations tti 9 =��= 1�; Lafayette City Center )7:0qty 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: EG Retail America LLC c/o Cumberland Farms Inc. Address: 165 Flanders Road City/State/Zip: Westborough MA 01581 Phone#: 508-270-1443 Are you an employer? Check the appropriate box: Business Type(required): 1.® 1 am a employer with 3780 employees (full and/ 5. © Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 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]* ' � � 13 2021 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care 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 Insurer's Address: One Financial Center, 22nd Floor City/State/Zip: Boston, MA 02111 Policy#or Self-ins. Lic. # WLR 067818970 Expiration Date: 04/01/2022 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. B .vl that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi at's n. I do hereby certify, and: tipains an, ',en, ties of perjury that the information provided above is true and correct. � 04/02/2021 Signature: Date: Phone#: 508=270-1443 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1,0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0 Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia A C, CERTIFICATE OF LIABILITY INSURANCE ATE( 2D/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CODERS 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 DIMMED,the poticydes)must have ADDITIONAL daSURED provisions or be endorsed.If m SUBROGATION IS WAIVED,subject to the terms and contildons of the policy,certain policies may require an endorsement.A statement on this z certificate does not confer rights to the certificate holder in lieu of such endorsement(s). E PRODUCER CONTACT O Aon Risk Services Central, Inc. PHONE (8� 283-7122 FAX (800) 363-0105 m Chicago IL Office (Arc.Me.Ea* ( No.)` '0 200 East Randolph 1moile€ss: _ Chicago IL 60601 USA INSURER(S)AFFORDING COVERAGE NAIC I ILSRXNED INSURER A: ACE Fire Underwriters Insurance Co. 20702 Cumberland Farms, Inc. MUNE B: ACE American Insurance Company 22667 165 Flanders Road Westborough MA 01581 USA fie: !ndewlty Insurance Co of North America 43575 INSURER CI: INSURER Vetaim F: COVERAGES CERTIFICATE NUMBER:570098900738 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE ERSTE]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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN R}}EDDUUCCED BY PAID CLAIMS. Limits shown are as requested VER' EEL SUETLIR TYPE OF INSURANCE MBD w POuCY MUMMERtPOLICY-SDTYYYn A rrryl, LEES COISIERCIAL OMER&L Ae i EACH OCCURRENCE I CLAe.13i7AOE flOCCUR PRELIMS(Fa occurrence) IED EXP(Any an paean) `— PERSONALS ADV maim, M GENLAGGREGATELNITAPPLES PER GENERALAGGREGATE $ PaECY 1 1 n LOC PRODUCTS-CaIProP AGG OTHER: g "� AUTOMOBILE LIABA.nY COVERED SPEXE[JET (Ea accident% .. _—ANY AUTO BENET INJURY(Per moon) 0 .— OWNED —SCHEDULED BODQY INJURY(Par accident) o — HolA It ONLY D PROPERTY DAMAGE may _AUTOS ONLY (�a enl) a a UMBRELLA LOB OCCUR EACH CCCURRENCE C.) — EXCESS UAE ^ CI ALS-MADE AGGREGATE 0E01 !RETENTION C WORM=COMPENSATION No wLRC67818933 154701/202T04/01/26 X I PERs1ATUtE I 10ER EMPLOYERS' rrYIN workers Comp - AOS AANY PROPRIETOR/ �tEa/TNE EXCLUDELO NIA WLRC67819019 04/01/2021 04/01/2022 ELEACt1ACC� $2,000,000 (Byss, fiv ORS Comp q workers Co - WI EL DISEASE-EAErPLOYEE 12,000,000 OESCRdese TTalneN OF OPERATIONS Nob. EL WuEASE•POLICYLEIT 52,000,000-- DESCRIPRON OF OPERAT ONS i LOCA110103 I VEESCLES(ACORD 501.Addlwe/nrr rks SAW*may be aaubd a easw apace Is M ama- 25 W. a3.I CERTIFICATE HOLDER CANCELLATION itil SHOULD NIT OF THE ABOVE DESCRIBED POLICES BE CANCELLED ED BEFORE THE EXPRIBION DQE THEREOF. NOTICE RRL BE DELIVERED IN ACCORDANCE MR TIE . POLICYFna Iasi. TON% of Yarmouth Ammons rIBRUMBfTATive Town Clerk 1146 Route 28ii W at 16 South Yarmouth MA 02664 u5A li ®1988-2015 ACORD CORPORATION.All fights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000074974 LOC i/: .AGORLIfe ADDITIONAL REMARKS SCHEDULE Page _ of AGENCY NAMED INSUFIED Aon Risk services central, Inc. Cumberland Farms, Inc. POLICY NUMBER see certificate Number: S70085900738 CARRIER NAIC CODE see certificate Number: 570086900738 EI-TECnVEIMTE- ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURERDEC 1 3 2021 INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. _O KY POLICY INSR ADDL SUER POLICY NUMBER AYE p PIRXIION LIMITS LTR TYPE OP INSURANCE IVSD WVD DATE DATE DEAUDDIYYYY) (WAVD IYYYY) WORKERS COMPENSATION g N/A IMAC67818970 04/01/2021 04/01/2022 workers Comp - CA,MA ACORD 101(2008/01) 02008 ACORO CORPORATION.Al rights Iassrved. TAO ACORD moss and 10110 ars Is1Mlwsd macs of ADHD •••• • Cumberland F ARMS December 7, 2021 �-- 0 ; 132021 Yarmouth Health Department 1146 Route 28 n r. South Yarmouth, MA 02664-4451 Attention: Board of Health Re: 2022 Renewals - Food Permit Cumberland Farms Store #2268 (Food Service) 626 Main St., W. Yarmouth Cumberland Farms Store #2262 (Retail Only) 1297 Route 28, S. Yarmouth Respectfully submitted on behalf of Cumberland Farms, Inc. As mentioned on the telephone, we have a new Manager at store 2268 W. Yarmouth — Ms. Jo-Anne Hegg. Note: Jo-Anne's Servesafe/Allergen certifications are expiring this month but she is scheduled to renew soon. Accordingly, we will need to submit under separate cover. Thank you for this courtesy. Kindly let us know if your office requires anything further. Thank you and Happy Holidays. Sincerely yours, CUMBERLAND FARMS, INC. Mk% Paula Foley Senior Compliance Specialist Licensing Group Office of the General Counsel Enc 5t /L/-SL/G / �,l(Y1�l V�l f6 ► hr ,jMtr Cumberland Farms, Inc. �jll V1/4,.PP/l 165 Flanders Road, Westborough, MA 01581 508-270-1400 www.cumberlandfarms.com . .,�._ a I TOWN OF YARMOUTH BOARD OF HEALTH , i ...T,►• ` APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessary documents by Decemb\er 18ixin3 2-1 Failure to do so will result in the return of your application packet; ESTABLISHMENT NAME: (�IJ1n berland PI r nS ' 22612 TAX ID: 0-1 28y 36FL LOCATION ADDRESS: /247 Rovre Z$ r S. 9ttrtnovrh 021,1,41 TEL.#: Se*-7/OV-5137 MAILING ADDRESS: 165 F/Qnd e's' AD GV�Sthoro 11 h j M A- 61 51/ E-MAIL ADDRESS: i tt is Lic'n S,'n�j a'7: ' .44 AA ,- „..,, ,,,, Al OWNER NAME: C_urnberlandarrns� 1114 CORPORATION NAME (IF APPLICABLE): Cwr berAvid Arms, bit. Av. &I/alha,'r's MANAGER'S NAME: DDStncr/Planar: /)cscar eiDuing Mit TEL.#: Ccll: 5'0T-3W-2565 MAILING ADDRESS: 11/5 f o rs al tugstivh, mil_D15�/ pg.) J-00-225-9/762 x& s eL'v1'irli Deer, are/0A POOL CERTIFICATIONS: i 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: I`r rai L- 011 19 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. 2. AlaPERSON IN CHARGE: ,//a Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: n is 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. 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# 0 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 —SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285ENDING-FOOD $25 7<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ ZIiV *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** asorsirr — �._ 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 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 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._ ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ AI'E • SITEjPLAN. DATE: /�--1-202 / SIGNATURE: I / / /j 1 I PRINT NAME &TITLE: ad(a i%' t j`0-1��1 i cptrodi(!" Rev. 10/15/19 LICerGA1