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HomeMy WebLinkAboutApp-License-Certifications 0;2-Z TOWN OF YARMOUTH BOARD OF HEALTH illift APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessarydocuments byDecember 18, 2021. 00. P Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 54—Op - ,S hep c.c.tiUe rvn c..v--k-e *,2?-TAX ID: LOCATION ADDRESS: 63-- Lon 9 'For 1-)c.) v I° TEL.#: —o - 39q- / 0 3/ MAILING ADDRESS: 13�S .Hancor 4e-.... S-r tDc�tre, lM A o:,L-)b9 E-MAIL ADDRESS: SS.S4i,re. Ob.'-?-. 54-Drevvctrc�.c\e(-- dc) 64-0Pok>d5 op. c©rA OWNER NAME: ANe S4-o p cu- rt hop S upe t'AN.cA.c- 4-- C'_o, ) 4.-(...e CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: A/)>Lth)D 50_ A.4 os TEL.#: 39 ,_/;23'4Ste MAILING ADDRESS: /3&s t1ancoc- & ST &L."i`r-- YNO>s O9- bcl 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. Nil/k 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. 1. A Al-or-to 3 ct 4 os 2. . tom. 2 7 2021 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 4At-Dnt r) cc 0 n R 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. A l'1 1--06'I 1 o S +aS 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. Ai/PI 2. 3. 4. RESTAURANT SEATING: TOTAL# 0 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEEL D PERMIT# B&B $55 CABIN_ $55 _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# LI NSE REQUIRED FEE PERMIT#<5LICEEND EQG UIRE DD $25 PER <50 sq.ft. $50 >25,000 sq.ft. $285 TOBACCO$ 110 —<25,000 sq.ft. $150 _FROZEN DESSERT $40 AMOUNT DUE = $ NAME CHANGE: $15 S=5:-00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Art, Lotngev" S€\ 1 `CbbQcco 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 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 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 REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME & TITLE: Rev. 10/15/19 The Commonwealth of Massachusetts Fee ra-' Town of Yarmouth $285.00 Food Establishment License Number: BOHF-15-1036-07 Issue Date: 1/1/2022 Mailing Address: Location Address: THE STOP & SHOP SUPERMARKET COMPANY LLC 7 LONG POND DR (-55) STOP & SHOP SUPERMARKET#022 SOUTH YARMOUTH, MA 02664 ATTN: LICENSING DEPT. 1385 HANCOCK STREET QUINCY, MA 02169 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 GREATER THAN 25,000 SQUARE FEET *RESTRICTIONS: Quarterly and annual report required. As per the Board of Health meeting, October 21, 1991, Stop & Shop must submit an annual environmental report by February 28, as outlined by Coastal Engineering of Orleans, MA, in the composite report, dated, corrected October 27, 1991, as a condition for the annual licenses. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health -) ..,. ' Eric Weston Bruce G. Murphy, ' PH, R.S., CHO Health Director NATIONAL REGISTRY OF O�vDODs�� FOOD SAFETY PROFESSIONALS® CERTIFIES BRENDAN COLLINS HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE . FOOD SAFETY MANAGER irq UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: ..- 7,4100g7,0•0°‘....— LAWRENCE J. LYNCH, CAE ANSI III dtiat ISSUE DATE: NOVEMBER 6, 201 9 EXPIRATION DATE: NOVEMBER 6, 2024 ACCREDITED PROGRAM CERTIFICATE NO: 21644051 American National Food Protection and Me ratlance tor Fain or Protection =0656 TEST FORM: EZS46 6751 Forum Drive,Suite 220,Orlando,FL 32821 This certificate is not s alid for more (800)446-0257 F(407)352-3603 www.NRFSP.com than five years from date of issue. National Registry of Food Safety Professional? YnUUi d� National Registry ot Food tiatety hrofes;ional; otiflcation of Test Results CERTIFIED FOOD SAFETY MANAGER I #: xxx-xx- caled Test Score: 91fivitm o.ie BRENDAN COLLINS 'andidate Status: Pass est Date: November 6, 2019 6751 Forum Drive SWIG 220 Orlando,FL 32821 Toll Free(800)446-0257 Phone(407)352-3830 Certificate No:21644051 Fax(407)352-3603 Issue Date:November 6.2019 swwsRFSP.mm Expiration Date:November 6.2024 )ngratulations! Attached is your certificate and wallet card. Please notify BRENDAN COLLINS e National Registry of name or address changes at the address below. 1385 HANCOCK ST QUINCY, MA 02169 eventing Contamination and Cross Contamination(Competent) )surfing Personal Hygiene and Employee Health(Competent) :tively Managing Controls in a Food Establishment(Mastered) )nitoring the Flow of Foods(Competent) isuring Product Time and Temperature(Competent) inducting Cleaning and Sanitizing(Mastered) tnaging:Physical Facility Design&Maintenance:Preventing&Controlling Pests(Mastered) National Registry of Food Safety Professionals® I 6751 Forum Drive Ste 220 I Orlando,FL 32821 I Phone:407.352.3830 I Fax:407.352.3603 _t `I fi � � : � i !t ii R -� s�yift = �-s � n � t-� = ff.'s 1'i n_ p .rte 1f 3". o '_a •c J r s• •-:r. '--- '7-1. :' ..-: .-Y_ r 1 )i)). �,i^ O Cill4 C El ' ' . •I .•,., !rck'� 1 N ••~ ` 1 , z r< 4.1>i,4 i.4 •,_. •"-•^1--; ,-,z.••'• '..' n ,,,, „ ,_. ,,.. _ c,„ ,... L.L2. .....„ sz,. .„. :_, ,:::.• „.,. „...,, ,. .,: s,,, ..., ,....., ...., =_ � ..iiie>1' ,.,,- d n ,._iPl*::1 4.t.44 Co.. ti rr r� all �-' �- Cd P:) -� -N ii• 'al M N F-+ u ..., l j J A M� �� C J\ r , I N N >. ),,A C 0 '6411 O �� � r� ,ta:�� i)). N CA "IC 4'1 0 //, 1.1111 4. `��a� J r 1 , J T i 1 ' Jam. 'r - 7-, Z ' -' � '"� 0_, q4.)..2., .2 z ... .N Nir •a Ciiii) ,."-V .d: rcv vo ` 4 J/U�+7 ,.r : i'.: if c.r : i-.: + U `'r�1,'k s.` : '.a S U c k. j.a S v c.z• s i'.a ' lak ,' Commonwealth of Massachusetts Letter ID:L1414921792 Wilet Department of Revenue Notice Date:October 30,2020 3 Geoffrey E Snyder,Commissioner Account ID-CGL-10044051-295 dt mass.govidor RETAILER LICENSE FOR SALE OF CIGARETTES "Iihlit1IitillII'111.111llll IiiIIhPi'hl'iiItnlltllll ATTN LICENSING DEPT STOP&SHOP SUPERMARKET CO LLC STOP&SHOP#001 1385 HANCOCK ST QUINCY MA 02169-5103 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.govimasstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE -essp.c se, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 UARetailer License for Sale of Cigarettes m4 y� '►.tAr .oc- This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. STOP& SHOP SUPERMARKET CO LLC Account ID: CGL-10044051-295 SUPER STOP& SHOP 2422 Location ID: 10044051-0285 474 STATION AVE License Number: 1742563328 SOUTH YARMOUTH MA 02664-1219 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 30,2020 Expiration Date: September 30, 2022 /' c00�� NATIONAL REGISTRY OF ` - , �,,` FOOD SAFETY PROFESSIONALS® i, CERTIFIES _t i HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE J - (114_�-a,_,. — ms . CERTIFIED FOOD SAFETY MANAGER UNDER THE yY CONFERENCE FOR FOOD PROTECTION STANDARDS PRI=SIDEN i: 1' f LAWRENCE. . LYNCH, CAE ISSUE DATE:JANUARY 24, 2018 a' ",'° "�` EXPIRATION DATE:JANUARY 24, 2023 46'5 CERTIFICATE NO: 21 422246 TEST FORM: EZS38 6751 Forum Drive,Suite 220,Orlando,FL 32821 This ce t.cote i not,a:id for more P 1 S00)446-0257 F(407)352-3603 www.NRFSP.com than Gce,e,rs from date of:me. Naticnal Registry of Food Safety Professionals" „<;:::;1,1,)),,,, Notification 1 of Test Result s �i National Registry of Food Saiety P otesstonais CERTIFIED FOOD SAFETY MANAG?2 (gt'1 r,:-',. _ ' i „d. II) ANTONIO SANTOS -r. XXX-XX- t�t ,1^'1,-'-' Sealed Test Score. 98 \ g,7,7TED Candidate Status: Pass --=, -%. meat Date: January 24, 2018 6751 Forum[nave Suite 120 Orlando,FL 3282t Certificate No 21422246 Toll Free(800)446-0257 Issue Date.January 24,2018 Phone 007)352-3830 Fax(407)352-3603 Expiration Date.Januar}24,2023 www.NRFSP.com Congratulations! Attached is your certificate and wallet card. Please notify ANTONIO SANTOS the National Registry of name or address changes at the address below. 61 FARREN ST SOMERSET, MA 02725 Preventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health(Mastered) Actively Managing Controls in a Food Establishment(Mastered) Monitoring the Flow of Foods(Mastered) Ensuring Product Time and Temperature(Compete/1t) Conducting Cleaning and Sanitizing (Mastered) Physical Facility Design &Maintenance Preventing&Controlling Pests (Mastered) National Registry of Food Safety Professionals® I 6751 Forum Drive Ste 220 I Orlando,FL 32821 I Phone:407.352.3830 I Far:407352.3603 tiY e.iu= ws Yi n q e� ws Yr n / sAu= `s ��t n .1c.i ws fir'• ll qc,i ws Z. n9;4114'4 " •41 .c:?a, , ce • ZSMr. Ohill A rn o A r ✓ ', 1 O p„'b O ;JMI lv . ,.. c, cel A L „Gc� J @ A A 11� J AA A. PZj '•N Cm) 'S cli Z Z C;01 8 MI 41001.�/. lim A �a rte+ CD II 41> 4114 .1 ro CD O n Ia tri O ;10. b Cn n "'� rroo Ca A o• r~i. td n. ' o o A� CD • b ),..1....,_ ilaggi ;74. L „i/� J O l ` ..� J 1T1 • a1G u ". !. �O z 0 ` irn, :, yy r ^�0 1 0 0 0• Z /lam 01. Go N V X11 r •1� • �� J 11� J .rfi. A JMil y 4( C/J:7-S i VI IVI 0 ^If �A N 2 ,.4 orgo-C) :a t; L +4.a04 R. Fl 1 A "Igo,,` _ <. — . F ✓ r7) CA 4 , ‹..11Z1 4•/a Z ... CI) •Y '''j ; 1 .. A(2-. r .4r:S; t-4ti\C y(i U s.=� �'.e ti U c vn� !, ,. U . c.+z��i'.i U T c vn nl e s U_r c=� w=i • lowle, -,G— ft "'SSS i TTT^^^ The Commonwealth of Massachusetts Department of Industrial Accidents )j Office of Investigations w41,C 5. ifs 600 Washington Street Boston, MA 02111 www.nuzss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Stop &Shop Supermarket Company LLC Address: 1385 Hancock St City/State/Zip: Quincy MA 02169 Phone #f: 800-288-8415 Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with employees(full and/ 5. El 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. 8[No workers' comp. insurance required] ID 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.n Manufacturing no employees. [No workers'comp. insurance required}** 4.❑ We are a non-profit organization, staffed by volunteers, 11,E1 Health Care with no employees. [No workers' comp.insurance req.] 12.n Other *Any applicant that checks box 01 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 01. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ahold Delhaize America Holding, Inc. and its subsidiaries Insurer's Address: 1385 Hancock St City/State/Zip: Quincy MA 02169 Policy#or Self-ins.Lic. # 576 Expiration Date: 8/1/2022 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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_ I do hereby certify, der the pains and penalties of perjury that the information provided above is true and correct 3Signature: Date: 9/7/2021 Phone#: 617.689.4921 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 rnass.go,. i a ACORD8 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �� 12/08/2020 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 CONTACT Marsh USA Inc. NAME: 1717 Arch Street PHONE FAX _LNC,No,•Ext): (A/C, No): Philadelphia,PA 19103-2797 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN101295509-GAWXW-20-21 INSURER A:ACE Amencan Insurance Company _ 22667 INSURED INSURER B:ACE Fire Underwriters Ins.Co. 20702 The Stop 8 Shop Supermarket Company LLC - -- _ Attn:Rick Shaughnessy INSURER C:Indemnity Ins Co Of North America 43575 1385 Hancock Street Quincy,MA 02169 INSURER D:NiA - - N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-006635424-02 REVISION NUMBER: 2 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. --- -- —. ___ -- -- - — LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER POLICY EFF POLICY EXP {MMIDDiYYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG71574349 12:012020 12101-2021 EACH OCCURRENCE $ 2,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES Ea occur ence) $ 2,000,000 MED EXP(Any one person) :$ 5,000 PERSONAL&ADV INJURY $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- I -__j JECT �— LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY ISAH25308840 12,01,2020 12:01;2021 COMBINED SINGLE LIMIT $ 2.000,000 (Ea accident X ANY AUTO ,'SELF INSURED FOR PHYSICAL' BODILY INJURY(Per person) $ OWNED SCHEDULED "DAMAGE AUTOS ONLY 1 AUTOS BODILY INJURY(Per accident),$ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY $ Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE 'S ' DED ' RETENTIONS S C WORKERS COMPENSATION WLRC67$1244A(AOS) 12:01;2020 12;0112021 PER ,0TH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N SCFC67812529(Wl) 12:'01;2020 12;2012021 B ANYPROPRIETORjPARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 1,000,000 A OFFICER/MEMBER EXCLUDED? N/A,N (Mandatory in NH) WLRC67812566(TN) 12:0112020 12/01'2021 1,000,000 E.L.DISEASE-EA EMPLOYEE I$ If yes.describe under - ----- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1.000.000 A EXCESS WORKERS COMPENSATION WCUC67812487 12:01,2020 12.01 2021 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of insurance CERTIFICATE HOLDER CANCELLATION The Stop and Shop Supermarket Company SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn:Rick Shaughnessy ACCORDANCE WITH THE POLICY PROVISIONS. 1385 Hancock Street Quincy,MA 02169 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Masashi Mukherjee hLQuoe►,i ,.te_ . ©1988-2016 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD