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Home My WebLink AboutApp-License-Certifications -_ TOWN OF YARMOUTH BOARD OF HEALTH hit APPLICATION FOR LICENSE/PERMIT - 2022 t%1RPI * Please complete form and attach all necessary documents by Decerr4ber 4,1 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: vm i e a # i(rfl - 22/i ' TAX ID: D'-}- 1.-f3 .l!/ LOCATION ADDRESS: 0 Z.(! Ma0n 7-. II (Jarmo OZL'73 TEL.#: 5O 7111/#) MAILING ADDRESS: r 6 5 Panders td WeStborot.t h, Cff 0/51r/ E-MAIL ADDRESS: A*+n• beeoCIT L)P107. /ca I ilu.r-cia urr. rlurr./-Q rvi+ (emi OWNER NAME: (v/Yl h,AV'jar)d Th rens, 1,16 CORPORATION NAME (IF APPLICABLE): , s- a , —,rons 1 ' MANAGER'S NAME: /0--Anne 1-1639 i TEL.#: 56) - r//-u/ MAILING ADDRESS: )6G) r)Q✓rjersAkve� .borou, hi // Diol 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. 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: 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. C -aln� peg, ,w„.11 Svbm, T ' 1. vp1 rec.rl yT 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. To -anterll4V1'i I cvb f T J-I(9 ,ipc,� 'weifr� 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# 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_LODGE $55 —CAMP $55 =SWIMMING POOL$110ea. 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 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 /-<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $OF FORM *****PLEASE TURN OVER AND COMPLETE OTHER SIDE ***** Zb 0 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 V 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 V 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. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATIOON(S) AND REQUIRED FEE(S) BY DECEMBER 1 S,2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND • PPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RES 1' E • SITE P N. DATE: 12 -if- 2421 SIGNATURE: � / /A PRINT NAME &TITLE: M(J t S (om phof'lC ( ' fal ism Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-5963-07 Issue Date: 1/1/2022 Mailing Address: Location Address: CUMBERLAND FARMS INC. 626 &634 ROUTE 28 CUMBERLAND FARMS #2268 WEST YARMOUTH, MA 02673 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 • r 1 B ce G. Mu .hy, PH, R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-5961-07 Issue Date: 1/1/2022 Mailing Address: Location Address: CUMBERLAND FARMS INC. 626 &634 ROUTE 28 CUMBERLAND FARMS #2268 WEST YARMOUTH. MA 02673 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 4111 Bruce G. Murp ,, MPH,R.S.,CHO Health Director i 1 he Commonwealth of Massachusetts Department of Industrial Accidents __ Office of Investigations (.'. =P1 N Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 `may www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: EG Retail America LLC do Cumberland Farms Inc. -- Address: 165 Flanders Road 1 DEC 1 3 2021 Westborough MA 01581 508-270-1443 City/State/Zip: 9 Phone #: Are you an employer? Check the appropriate box: Business Type(required): 1.® I am a employer with 3780 employees (full and! 5. • Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no ?. 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.❑ We are a corporation and its officers have exercised 9. 0 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 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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#l. 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- ..vi : that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi•at'•n. I do hereby certify, and: t pains an, en, ties of perjury that the information provided above is true and correct /1 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 Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia ® DATE(MM/oo2 ) :ACC:,�.__- CERTIFICATE OF LIABILITY INSURANCE 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.H d 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). c PRODUCER CONTACT'NAME: ,e Aon Risk Services Central, Inc. E (866) 283-7122 FAX (800) 363-0105 Chicago IL Office (NC.No.Em): (A/c.No.): 200 East Randolph E-MAILMA Chicago IL 60601 USA ADDRESS: INSURER(S)AFFORDING COVERAGE RAC* INSURED INSURER k. ACE Fire Underwriters Insurance Co. 20702 Cumberland Farms, Inc. roman a: ACE American Insurance Company 22667 165 Flanders Road Westborough MA 01581 USA INSURER C: Indemnity Insurance Co of North America 43575 INSURER D: emIMER 5: INSURER F: COVERAGES CERTIFICATE NUMBER:570086900738 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 POUCY EXP LTR TYPE OF INSURANCE MSD WVo POUCY NUMBER (bMUDD/YYYYI,(MI4D0/YYTY1 LOADS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE [J OCCUR DAMAGE S(RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY co GENL AGGREGATE LIMN APPUES PER: GENERAL AGGREGATE n �. POLICY n JEC1i ❑LOC PRODUCTS-COMP/OP AGG , OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT an (Ea accident) .. ANY AUTOz BODILY INJURY(Per person) o —OWNED —'—SCHEDULED BODILY INJURY(Peraaxlent) « -- AUTOS ONLY AUTOS PROPERTY DAMAGE _ A HIRED AUTOS —NON-OWNED —ONLY _AUTOS ONLY (Per accident) = t: UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED1 RETENTION C WORKERS COMPENSATION AND WLRC67818933 04/01/2021 04/01/2022 X I PER STATUTE j0_ttTH EMPLOYERS'UABLITY Y/N workers Comp - AOS It ANY PROPRIETOR/PARTNER I EXECUTIVEE1.EACH ACCIDENT $2,000,000 A OFFICER/MEMBER EXCLUDED? N N/A WLRC67819019 04/01/2021 04/01/2022 (M.neaony no p* workers Comp - wi E.L.DISEASE-EA EMPLOYEE $2,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000— a a DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remota Schedule,may be RebeMd M more space Is required) Mall E i DEc 19 7r w CERTIFICATE HOLDER CANCELLATION -.4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE gt EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. r Town of Yarmouth AUTHORIZED REPRESENTATIVE Town Clerk 1146 Route 28 a.] `�, 49w ;�'jeime South Yarmouth MA 02664 USA 4 Xr JIM- .11 91988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000074974 LOC#: A ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Central, Inc. Cumberland Farms, Inc. POLICY NUMBER See Certificate Number: 570086900738 CARRIER NAIC CODE See Certificate Number: 570086900738 EFFECTIVE DATE: 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 INSURER INSURER INSURER ADDITIONAL POLIOS If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY CY INSR ADDL SURA POLICY NUMBER EXPIRATION LIMITS LTR TYPE OF INSURANCE 1115D WVD DATE EFFECriEC77VE ERPIAPOIJAME (MM/DD/YYYY) (MM/DD/YYYY) WORKERS COMPENSATION a N/A WLRC67818970 04/01/2021 04/01/2022 workers Camp - CA,MA ACORD 101(2008/01) 0 2008 ACORD CORPORATION.AN rights reserved. The ACORD name and logo are registered narks of ACORD