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Home My WebLink About2022 App-License-Certifications The Commonwealth of Massachusetts Fee is.' Town of Yarmouth $150.00 Food Establishment License Number: BOHF-18-2362-04 Issue Date: 1/1/2022 Mailing Address: Location Address: WALGREEN EASTERN CO. 918 ROUTE 6A WALGREENS #19695 YARMOUTH PORT. MA 02675 P.O. BOX 901 DEERFIELD, IL 60015 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 (7---- ( c-7*Th ,, ,-- , Bruce G. Murphy, MP R.S., CHO/James G. Gardomer Health Director/Assistant Health Director """ TOWN OF YARMOUTH BOARD OF HEALTH . APPLICATION FOR LICENSE/PERMIT -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. ESTABLISHMENT NAME: kititcru,ns # ql bq S TAX ID: 7b-l2 ei 'OZ LOCATION ADDRESS: 61vi P- ,k, G A rarmaq vhA czbl s TEL.#:(sin)762 -ZL1y MAILING ADDRESS: PO Qox'Iol DuvA'J& L+ (,00hs / i s E-MAIL ADDRESS: J'.•xticertsurenr.��isC�1�- s OWNER NAME: ivalci-ram cc,ck.rnco.,tru. CORPORATION NAME (IF APPLICABLE): kthtgrut.„ E'sICrr, Co.,'etc, MANAGER'S NAME: $vvla -(vow\irlt.A TEL.#: (SD%) $62. -21► 9 MAILING ADDRESS: po go)' qo I 0 LerF.142 I 6..ao/B 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 Dep st years' records. You must provide new copies and maintain a file at your place of business:-j. 1. 2. UEC 1 `' 2fl?1 3. 4. HtALTH ®tPt 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. Sorry a Tv ow.itiu,h re_t, 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. 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 CAMP $55 —SWIMMING POOL$1 I0ea. 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 sqq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 �<25,000 sq.ft. $150 16•.o —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ I So• *****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 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 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: tt I zs. I Z\ SIGNATURE: irktA,J, PRINT NAME & TITLE: rn1)Vt l 6-o 1-i c..ns., seo,4.I t. Rev. 10/15/19 (� The Commonwealth of Massachusetts Department of Industrial Accidents VONE6 Office of Investigations . _ '' 1 congress Street,Suite 10 r "� Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibly Business/Organization Name: Wt,Irr«.,n, ' IhbC S Address: os (: c„rt. IN b A i los,,,,,,„14, v,. R ozb 7 s City/State/Zip: Phone#: (cot) 31,2 - 2 ti 4 • Are you an employer? Check the appropriate box: Business Type(required): 1.® I am a employer with ( 7 employees(full and/ 5• 0 Retail or part-time).* 6. I_] 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 [Ti Enters iinl.;er their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing DEC 1 ��21 no employees. [No workers' comp. insurance required]** • 4.❑ We are a non-profit organization,staffed by volunteers, 11•❑ Health Care L_HEALTH 6 with no employees. [No workers' comp. insurance req.] 12.0 Other 12 1 Div) isvv, s *Any applicant that checks box#I 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: P ku.s S eA, ,,t•I-mot., Insurer's Address: • City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: • 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and,penalties of perjury that the information provided above is true and correct. Signature: Date: l t/2 411 Phone#: i t ? 1 S'- Z Y"o Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts �; -----�` Department of Industrial Accidents . =_'"=I,-t" (Iftice of Investigations v. ~A;-=4't 1 Congress Street, Suite 1 G0 -TO- , i =�' — • Boston, MA 02114-2017 `., ,, www.mass.gov/dia i Workers' Compensation Insurance Affidavit: General Businesses Applicant Information • Please Print Legibly Business/Organization Name: (Ji.IrAns •t$' lr\t,c,S Address: c ►cs t2ou rc. 4ei to A i U,-,N.c,„fh w.R ,,z+.7 S City/State/Zip: Phone #: (Cot) 362 - 2 ti i Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with 1-7 employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no . employees working for me in any capacity.. 7• 0 Office and/or Sales(incl. real estate, auto, etc.) [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9, ri Fntert intent DEC their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing 1 no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care HEALTH 6€P with no employees. [No workers' comp. insurance req.] 12.❑ Other 12c,t,-A Dr'`) , Swt,-I^..a . *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corpdrate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box HI. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Plws,, St4.. c,t}4.4ew..2 Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: 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 VIA for insurance coverage verification. • I do hereby certify,under the pains and.penalties of perjury that the information provided above is true and correct. Signature: Date: l 1 2 4/i-I Phone#: -il _31S- 1117o 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 • UEU 1 3 2021 I-� ^.I Tt i nr-r-,7 MEMORANDUM OF LIABILITY INSURANCE Current as of: _ July 1, 2021 PRODUCER Willis Towers Watson Midwest,Inc.fka Willis Of Illinois,Inc. THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO c/o 26 Century Blvd RIGHTS UPON ANY RECIPIENT OF THIS MEMORANDUM. THIS MEMORANDUM DOES NOT Nashville,TN 37230-5191 AMEND, EXTEND OR ALTER THE COVERAGE DESCRIBED BELOW.ANY USE,DUPLICATION United States of America OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRITTEN CONSENT IS PROHIBITED. INSURED COMPANIES AFFORDING COVERAGE NAIC# COMPANY ZURICH AMERICAN INSURANCE COMPANY 16535 Walgreens Boots Alliance,Inc.and Its A Subsidiary Companies COMPANY AMERICAN ZURICH INSURANCE COMPANY 40142 300 Wilmot Road,MS#3228 B Deerfield,IL 60015-5223 COMPANY SELF INSURANCE United States of America C COMPANY D COVERAGES 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 MEMORANDUM 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. COMPANY POLICY POLICY LIMITS LETTER TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS IN USD UNLESS DATE DATE OTHERWISE INDICATED A GENERAL LIABILITY GLO 9310091-18 7/1/2021 7/1/2022 X COMMERCIAL GENERAL LIABILITY GLO 9310184-18(Puerto Rico) 7/1/2021 7/1/2022 GENERAL AGGREGATE $ 10,000,000 AI 'CLAIMS MADE n OCCUR PERSONAL&ADV INJURY $ 10,000,000 X Blanket Additional Insured EACH OCCURRENCE $ 10,000,000 X Per Policy FIRE DAMAGE(Any One Fire) $ 500,000 X Blanket Contractual Liability MED EXP(Any One Person) $ 0 X]IILiquor Liability $ $ A AUTOMOBILE LIABILITY BAP 9310096-18 7/1/2021 7/1/2022 X ANY AUTO BAP 9310183-18 (Puerto Rico) 7/1/2021 7/1/2022 COMBINED SINGLE LIMIT $ 10,000,000 _ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per Person) $ HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per Accident) $ PROPERTY DAMAGE $ EXCESS LIABILITY PER CLAIM $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ B WORKERS COMPENSATION/ WC 9310092-18(AOS) 7/1/2021 7/1/2022 WORKERS COMPENSATION A EMPLOYERS LIABILITY WC 9310094-18(WI) LIMITS STATUTORY A EWS 9310448-18(MA) PARTNERS/EXECUTIVE X INCL. EL EACH ACCIDENT $ 2,000,000 OFFICERS ARE: EXCL. EL DISEASE-POLICY LIMIT $ 2,000,000 EL DISEASE-EACH EMPLOYEE $ 2,000,000 C PRODUCT LIABILITY Self-Insured 7/1/2021 7/1/2022 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 ADDITIONAL INFORMATION OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS, LENDERS, MORTGAGEES,GROUND LESSORS, VENDORS,CUSTOMERS,CLIENTS,AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES INCLUDE AN AUTOMATIC WAIVER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. The Memorandum of Insurance serves solely to list insurance policies,limits and dates of coverage.Any modifications hereto are not authorized. WALGREEN EASTERN CO.,INC. OFFICERS AND DIRECTORS CORPORATE PHONE TITLE NAME SSN DATE OF BIRTH DRIVER'S LICENSE PLACE OF BIRTH HOME ADDRESS ADDRESS NUMBER Ownership — 5 Plymouth Ct. 200 Wilmot Rd. President&Director Lisa Badgley 349-74-2748 10/26/1969 B324-5246-9905 Pinckneyville,IL Lincolnshire,IL 60069 Deerfield,IL 60015 (847)914-2500 0% 371 Ravine Park Dr. 300 Wilmot Rd. Vice President John Saylor 289-64-4032 3/28/1969 S460-4756-9090(IL) Cinncinnati,OH Lake Forest,IL 60045 Deerfield,IL 60015 (847)914-2500 0% 1263 Williamsburg Ln. 108 Wilmot Rd. Vice President Alan Nielsen 355 60-6325 7/8/1965 N425-0186-5194(IL) Watseka,IL Crystal Lake,IL 60014 Deerfield,IL 60015 (847)914-2500 0% Vice President& 354 Hirst Ct. 108 Wilmot Rd. Secretary Joseph Amsbary,Jr. 236-80-8190 4/11/1965 A5214826-5104(IL) Huntington,WV Lake Bluff,IL 60044 Deerfield,IL 60015 (847)914-2500 0% 500 Greenleaf Ave. 300 Wilmot Rd. Treasurer&Director Brian Brown 349-60-1189 5/24/1975 B650-0767-5148 Fort Wayne,IN Wilmette,IL 60091 Deerfield,IL 60015 (847)914-2500 0% 31 Coldstream Cir. 300 Wilmot Rd. Assistant Treasurer Susan Halliday 340-56-9981 10/8/1960 H430-7936-0887(IL) Waukesha,WI Lincolnshire,IL 60069 Deerfield,IL 60015 (847)914-2500 0% D V Li- ci,9 I C� I{ii,, MI N I'll u'l C,1 Location# Doing Business As Addressl City County State Zip5 License Type License Number Govt Body License Amt 10460 WALGREENS#10460 1041 ROUTE 28 SOUTH YARMOUTH BARNSTABLE MA 2664 FOOD/MILK BOHF-15-6297-05 L $ 150.00 19695 WALGREENS#19695 918 ROUTE 6A YARMOUTH BARNSTABLE MA 2675 FOOD/MILK BOHF-1-2362 L $ 150.00 $ 300.00 34463971 11/29/21 MG