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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-1335-07 Issue Date: 1/1/2022 Mailing Address: Location Address: DOLLAR TREE STORES, INC. 7 LONG POND DR(-55) DOLLAR TREE#4227 SOUTH YARMOUTH, MA 02664 500 VOLVO PARKWAY CHESAPEAKE, VA 23320 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 / • 4 Bruce G. Murphy,/ P ,R.S. CHO Health Director - The Commonwealth of Massachusetts D..,,--eepartment of Industrial Accidents W Office of Investigations {Q:SiT �' 1 Congress Street, Suite 100 wy' Boston, MA 02114-2017 %. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: X k\( '(1J -jL\n- t Address: b b \ ttPd, N • City/State/Zip:C\ S� '\9,40 Z one #: Z(e. L\:- \"-A-{ Are ou an employer? Check the appropriate box: Business Type(required): I. I am a employer with employees(full and/ 5. Oretai I 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.❑ 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]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 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: >ac-� ��11T1 \ � ..)__(A\ C,Ye. Insurer's Address: %2ja— SC.,n JC., - (A City/State/Zip: S9 ��\, L Policy#or Self-ins. Lic. # LDS Lkt bcAu P Expiration Date: CA\\r \ 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 c tify,tin, • , • 'tuns and penal'• of perjury that the information provided above is true and correct. Si Ina re: r ._/.. °Y/(/l/ ._._ Date: VATA)--\ Phone#: I 1CSA- 1 - 60(0-C6 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.mass.gov/dia �r^-"."") ® DATE(MM/DD/YYYY) A�Rcr CERTIFICATE OF LIABILITY INSURANCE 08/27/2021 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 U BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 2 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. F- ro 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 2 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .c PRODUCER CONTACT -o NAME: AOn Risk Services Central, Inc. PHONE (866) 283-7122 FAX 800-363-0105 Ili a MSC#17382 (AC.No.Ext): (A/C.No.): Aon E-MAIL p PO BOX 1447 ADDRESS: i Lincolnshire IL 60069 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Safety National Casualty Corp 15105 Dollar Tree, Inc.; INSURER B: ACE Property & Casualty Insurance Co. 20699 Dollar Tree Stores, Inc. — - 500 Volvo Parkway INSURER C: Chesapeake VA 23320 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570088950109 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y GL6676008 09/01/202109/01/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR SIR applies per policy terms & conditions DAMAGE TO RENTED $1,000,000 PREMISES(Ea occurrence) MED EXP(Any one person) Excluded PERSONAL 8 ADV INJURY $1,000,000 C) GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $15,000,000 G X POLICY JELOC PRODUCTS-COMP/OPAGG $2,000,000 m co0 OTHER: o N- A A CA 6675765 09/01/2021 09/01/2022 COMBINED SINGLE LIMIT Lo AUTOMOBILE LIABILITY $3,000,000 (Ea accident) .. X ANY AUTO BODILY INJURY(Per person) o OWNED —SCHEDULED BODILY INJURY(Per accident) 0) AUTOS ONLY _AUTOS CO HIRED AUTOS NON-OWNED PROPERTY DAMAGE V ONLY —AUTOS ONLY -(Per accident) w E d A UMBRELLALIAB X OCCUR XEL4061307 09/01/2021 09/01/2022 EACH OCCURRENCE $3,000,000 0 X EXCESS LIAB J CLAIMS-MADE AGGREGATE General Liability AGGREGATE $11,000,000 X DED RETENTION A WORKERS COMPENSATIONAND L054059207 09/01/2021 09/01/2022 x PER STATUTE OTH- EMPLOYERS'LIABILITY Y/N AOS Exci TX ER ANY PROPRIETOR i PARTNER!EXECUTIVE EL.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED, N N/A P54059208 09/01/2021 09/01/2022, '_. _ (Mandatory in NH) WI E.L.DISEASE-EA EMPLOYEE $1,000,000 It yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000— A EXCESS WC SP4065498 09/01/2021 09/01/2022 EL Each Accident $1,000,000 Excess WC - OH EL Disease - Policy $1,000,000 SIR applies per policy terms & conditions EL Disease - Ea Emp. $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddItional Remarks Schedule,may be attached if more space is required) Evidence of Coverage. ffi IN M CERTIFICATE HOLDER CANCELLATION Lal SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _ POLICY PROVISIONS. 1 Dollar Tree Stores, Inc. AUTHORIZED REPRESENTATIVE 500 volvo Parkway Chesapeake vA 23320 USA t.W �. I aft a ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD