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HomeMy WebLinkAboutApp-License- Certifications The Commonwealth of Massachusetts Fee /4.1. Town of Yarmouth $285.00 Food Establishment License Number: BOHF-18-2463-04 Issue Date: 1/1/2022 Mailing Address: Location Address: SHAW'S SUPERMARKETS, INC 1106 ROUTE 28 SHAWS#3692 SOUTH YARMOUTH, MA 02664 251 LITTLE FALL DRIVE WILIMINGTON, DE 19808 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail Food Service 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 Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston ' Bruce G. Murphy,M PH, er., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-18-2465-04 Issue Date: 1/1/2022 Mailing Address: Location Address: SHAW'S SUPERMARKETS, INC 1106 ROUTE 28 SHAWS#3692 SOUTH YARMOUTH, MA 02664 251 LITTLE FALL DRIVE WILIMINGTON, DE 19808 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 *This license replaces license BOHTP-15-1727-03 Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston t) Bruce Murphy, i PH, R.Sv 0 Health Director ✓ ELI@MWD TOWN OF YARMOUTH BOARD OF HEALTH (-11%) APPLICATION FOR LICENSE/PERMIT-2022 FEB 0 3 2022 *Please complete form and attach all necessary documents by December 18 2021. Failure to do so will result in the return of your application.packet. , HEALTH DEPT. ESTABLISHMENT NAME: straw's Supermarkets 43892 TAX,'ia: LOCATION ADDRESS: 1108 State Rd,Yarmouth.MA,02664 TE L.#: (508)394-0995 MAILING ADDRESS: 251 Little Fails Or,Wilmington DE,19808 E-MAIL ADDRESS: BL ALB©cscgbbaicom OWNER NAME: Robert Backus President CORPORATION NAME(IF APPLICABLE): Shaw's Supermarkets,Inc MANAGER'S NAME: Kevin Gccd"dr TEL-#: (508)384-0995 MAILING ADDRESS: 1108 State Rd,Y.,morth,MA,02664 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/A 2. N/A 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 al 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. I. N/A 2. 3. 4. IOW PROTECTION WINAt -,,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. Kevin Goodrich 2. Zachary Duverger PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. Kevin Goodrich 2. Zachary Duverger 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. Kevin Goodrich 2. Zachary Duverger 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. N/A Lass than 25 seats 2. 3. 4. RESTAURANT SEATING: TOTAL# 0 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 B&B $55 CABIN S55 MOTEL $1 10 �R1N S55 CAMP S55 , SWIMMING POOL SI lOea. _LODGE $55 TRAILER= PARK $105 _WHIRLPOOL S l i fee. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 0-100 SEATS S125 _CONTINENTAL $35 _NON-PROFIT S30 >100 SEATS 5200 COMMON VIC. S60 WHOLESALE $80 —RESU).KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT <50 •.ft. $50 >25,000 ft. $285 VENDING-FOOD $25 <25,r<tr sq.& $150 ..._.FROZEN DESSERT S40 . ITOBACCO SII0 NAME CHANGE: S15 AMOUNT DUE = S 260.E **,"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•' 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR . _ CERT.OF INSURANCE ATTACHED 4 OR FEB 0 3 2022 WORKER'S COMP.AFHL)AVIT SIGNED AND ATTACHED_ FTHDPT. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES s 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 withi:a 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.varmouth.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 establislment 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 Ito 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: 12/30/2021 SIGNATURE: , ,� u.t ,, PRINT NAME&TITLE: Authorized Agent Rae.10/15/19 �® 6AT o7.-2,)2,( ADYY) A CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS g CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES n BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THIS ISSUING INSURER(S), AUTHORIZED p REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. > Iv IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 ,m certificate does not confer rights to the certificate holder in lieu of such endorsement(s), c a PRODUCER CONTACT NAme, a Aon Risk Services Central, Inc. PHCNE Minneapolis MN Office i ,iv �); (866) 283-7122 ( Ma), (800) 363-0105 41 SI 5600 west 83rd Street I 0 ^ E-MAII = 8200 Tower, Suite 1100 I FEBf LD 3 20" ADDRESS:. Minneapolis MN 55437 USA INSURER(S)AFFORDING COVERAGE I NAIC R INSURED - "- IIIBURERA: ACE American Insurance Company 22667 Albertsons Companies, Inc. INSURERS: ACE Property & Casualty Insurance Co. 20699 Including Safeway Inc. Albertsons LLC - New Albertsons L.P. & Subsidiaries INSURER Ci Steadfast Insurance Company 26387 250 East Parkcenter Blvd. INSURER D: Boise ID 83706 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570088550983 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 ?NSR AODL"SUER POUCY EFF POLICY EXP LTR TYPE OF INSURANCE ?NSD WYO POLICY NUMBERhµypp,,Yyyy? isms A X COMMERCIAL GENERAL LIABILITY Y V XSLG72489238 g.4867/711.08/O1/2022 I:ACH OCCURRENCE 53,000,000 CLAIMS-MADE X OCCUR SIR applies per poi'cy terns & condi :ions ThAMAGE TO RENTED $3,000,000 PREMISES(Ea occunenca) X Druggist Liab Mduded MED EXP(Any one person) EXC l uded PERSONALS AOvRNJURY $3,000,000 GEN'.AGGREGATE LAMB APPLIES PER: GENERAL AGGREGATE $18,000,000 a X POLICY ( jPE LOC PRODUCTS-COMP'OPAGG $6,000,000 m OTHER: lOiler Liability Lim Included o A Y Y ISA H25553792 08/01/202108/01/2022 COMBINED SINGLE!rum 'n AUTOMOeLLE LU46alT1' S5,000,000 „ aa^Went1 , ,.. X ANY YAUT...O....,..-.._.. .-..._... , _ .. .COOLY INJURY(Per person)...... 0 — z — OWNED SCHEDULED EMILY INJURY(Per accident) m —AUTOS ONLY AUTOS PROPERTY DAMAGEis WIRED AUTOS ^�NON-OWNED sr acddenr) C+ ONLY ..---AUTOS ONLY I' ` E Et X UMBRELLA LAB X OCCUR Y Y XEUG2794761A006 08/01/202108/01/2022 EACH OCCURRENCE $15,000,000 U EXCESS LAB CLAIMS-MADE SIR applies per policy to nls & condi tions A2GREGATE $15,000,000 — DED X,RETENTION A WORKERS COMPENSATION Amo WLRC67$13674 08/01/202108/01/2022 '( PER STATUTE OTH- A EMPLOYERS'LIABILITY YIN WLRC67818350 08/01/2021 08/01/2022— ER ANY PROPRIETOR f?ARTNEA I EXECUTIVE ,, E L EACH ACCIDENT S2,000,000 OFFICSNMEMHER EXCLUDED? NIA AOS C (Mandatory inNNi) Y Ewr008362506 08/01/202108/01/2022 EL,DISEASE-EA EMPLOYEE $2.000,000 N yes,tws','be under DESCRIPTION OF OPERATIONS bebw TX E LDISEASE-POLICY LIMIT S2.000,000— A Excess wC WCUC67818398 08/01/202108/01/2022 EL Each Accident S2,000,000 XS WC Aos EL Disease - Policy 52,000,000 mg EL Disease - Ea Emp' S2,000,0002 DESCRIPTION OF OPERATIONS:LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schoch*,rimy be attached N more specs Is required) Blanket Additional Insured for General Liability and waiver of Subrogation for General Liability status extend to those parties to whom the Insured has contractually agreed to provide this status. .,r Safeway Inc. is a qualified self-insurer for workers' compensation in the following states: AZ,CA,CO,HI,MT,OR,WA, Albertsons LLC is a qualified self-insurer for workers' compensation in the following state<_; AZ,CA,MT,OR. Druggist Liability is extended to include Dieticians, ifi.,m CERTiFiCATE HOLDER CANCELLATION .. i." SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE :51-- EXPIRATION EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TIE POLICY PROVISIONS. - Albertsons Companies, Inc. AUTHORIZED REPRESENTATNE 250 East Parkcenter Blvd Boise ID 83706 USA /'y'��� ,A � © f e_� a c7ea�siNaad CXAoatrar V., f&GL • 2198&2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORC