HomeMy WebLinkAboutApp-Certs-LicenseDocusign Envelope lD: 7 O 5 ABE34 -7 AB7 47 27 -8B5A-9049DAEF8699
r'rliUST BE POSTED ON PRETTIISES*,*
This License affirms that the specified premises, structure, or portion thereof has met the necessaryconditions including any inspections required at the time of issuance,
It must be framed or laminated and prominently displayed in a clearly visible location within the approvedpremises.
Interim Health Director James Gardiner
Signature of Interim Health Director lil-hn*
A.The Commonwealth of Massachusetts
Town of Yarmouth
Health Department
FOOD ESTABLISHMENT LICENSE
McDonalds
1060 RT 28 S Yarmouth MA 02664
ISSUED TO:Certificate No.
BOHF-25-203
The purpose of 105 CMR 500.000 is to establish minimum standards for those persons engaged in the
business of preparing, processing, or distributing food for sale in Massachusetts.
105 CMR 500.000 shall be liberally construed and applied to promote the underlying purpose of protecting theublic health.
License Expiration:
December 31, 2026
Borrd of H€.lth:
Hillard Boskey, l'1.D., Chairman
Mary Craig, Vice Chairman
Charles T. Holway, Clerk
Laurance Venezia, DVM
Eric Weston Fee: $225.O0
Restri€tions / Conditions: Seating: 50
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CERTIFICATION
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EXAM FORM NUMBTT
11t22t202
DATE OF E
11t22i2028
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CENTTFICATE OF
ATTERGEN AWNREN ESS TNAI N I NG
Name of ReciPicnt: Dor ^rnov
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Certificatc Numbcr c,.'?ee
Datc of Complction' 1mnv2t
Date of Expiratiot 12tuia2t Ei:J*:E
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in o<orlano uitb 105 CMR 590.N9(C)(J)(o).
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ASSOCIATION.
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OF COMPLETION
IN RECOGNITION OF SUCCESSFUL COMPLETION IN:
Standard-CPR/AED
(Adult/Child/lnfant)
Automated External Defibrillator (AED)
DOINA IROVAN
The student has successfully met the requirements for certification by
completing the cognitive training and skills evaluation in the
specified course in terms of NCPRF@ and in accordance with
the corresponding ILCOR, OSHA, and AHA@/ECC guidelines (2020).
Date: Nov 1,2024 Renew: Nov 1, 2026 lD#:4DCB4 lnstructor: PaulJ. Scruton
Course Provided By:
THIS CERTIFICATE IS PROUDLY PRESENTED TO
NationalCPRFoundation" sisnature:
11t04t2025
THIS CERTIFICATE lS ISSUEO AS A iIATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPO'{ THE CERTIFICATE HOLOER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATTVELY AiIENO, EXTEiID OR ALTER THE COVERAGE AFFORDEO BY THE POLICIES
BELOW. TH|S CERTTFTCATE OF TNSURANCE OOES NOT CONSTTTUTE A CONTRACT BETWEET{ THE |SSU|NG TNSURER(S), AUT|{OR|ZEO
REPRESET{TATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER.
IITIPORTANT: ff the ceruflcate holder ls an AOOITIOI{AL INSUREO, lhe pollcy(l€) must bc endorscd. lf SUBROGATION lS WAIVEO, sublect to
thr telms and condlllong oI the pollcy, cartaln pollcles may rcqulre an erdor3ement. A statament on thls certlflcate doag not cohfer.lght3 to the
cenfficate holdcr ln lleu oI 3uch .ndol36menl(s).
t^ooutttiA McDonald's Operatods Workers' comp croup lnc
4350 W Cypress St - Suite 300
Tampa, FL 33607-4175
Cindy Williams
727 -796-6210
C will .com
II{SURER(S) AF FORO ING COVERAGE
MA McDonald's Operator's Workers' Comp Group lnc.
It suiEo MCBee Enterprises, LLC
McDonald's Restaurants
50 Oliver Street, Suite W-18
North Easton, MA 02356
Ptrone: (508) 230-2190 Fax: (508) 230-2355
IIISURER B
[isuREi c
R CERTIFICATE OF LIABILITY INSURANGE
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED IO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD
INDICATEO, NOTWTHSTANOING ANY REOUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUAJECT TO AIL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOW"J MAY HAVE BEEN REDUCEO BY PAID CLAIMS
POLICY NUMBER LtMllS
COMMERCIAI GENERAT LIAB IITY
CLAIMS ]\IAOE
GEN'L AGGREGATE LIMIT APPLIES PER
LOC
PREMISES l€a *cud.nce,s
MED ExP tAny oE p{.or)5
PERSONAL 6 ADV INJURY 5
_-:'.= n -- -:a- i:. -T=S
PROOIJCIS . COMP/OP ACG 5
s
AU'OMOBILE LI,ABILTTY
NON.OWNEO
COMA NEO SINGLE LIMIT
s
aOOTLY lNJl-rRY (P.r peren)
B@|LY rNJl,rRY {Pd.ccirs0 s
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ATO EMPIOYERg UAETUTY
ANY PROPRIETOR,PARI!{ER/EXECL'N!€
OFFICER/T'ET?6ER EXCL(DEO'
DESCRIPTION OF OPER TIONS b.low
N i4AWC-17973(26)01t01t26 01t01t27
X s 1,000,000.00
E L DISEASE - EA€MPLOYEE s 1,000,000.00
E.L, OISEASE, PCL CY LIMII s 1,000,000.00
ol3cnPTrofl ol oPEratrols r Loc llolrs / vlslcLel {ait&h Acoio loi, a.ldii6d iiErt. scn dub. r 'lrff.pE r...qrr.d)
See Attached Schedule of Locations
CERTIFICATE HOLOER CANCELLATION
Proof of lnsurance
Phone Fax;
SHOULD AIIY OF T|lE AAOVE DESCRIBEO POLICIES BE CAIICELLED BEFORE
THE EXPIRATIOX OATE T}IEREOF, NOTICE WILL BE OELVERED IN
ACCORDANCE WITH THE POUCY PROVISIOT{S,
AUTHORIZEO REPR'SEIITATIVE
Donna Zarb
O 1998-201,1 ACORD CORPORATION. All rights resewed.,
The ACORo narn€ and logo are reqistered marks o, ACORO page jL_ o, rZ_ACORO 25 (2014/01)
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ACORD-
AGENCY CUSTOMER ID:
LOC
ADDITIONAL REMARKS SCHEDULE Page _2_ol _2_
lvlcBee Enterprises, LLC
l\,4cDonald's Restaurants
50 Oliver Street, Suite W-18
North Easton, l,4A 02356
MA McDonald's Operato/s Workers' Comp Group lnc
MAWC-17e73(26)
MA McDonald's Operato/s Workers' Comp Group lnc EFFECTMEDATET 0110112026
ADDITIONAL REMARKS
THIS ADDIONAL REMARKS FORM IS ASCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFIGATE OF LIABILITY INSURANCE
Slore #
Store #
Store #
Store #
Store #
Slore #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
Store #
1
356
1212
1272
30'19
7503
8026
10335
11288
11540
15140
15470
't7879
20400
25927
25930
25931
25933
26537
28493
28495
284S8
28500
28948
30189
35759
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
McBee Enterprises, LLC
lvlcBee Enterprises, LLC
McBee Enterprises, LLC - Auntie,
McBee Enterprises, LLC - Boston I
McBee Enterprises, LLC . Pretzel I
McBee Enterprises, LLC - Fresh C
McBee Enterprises, LLC - Fresh C
McBee Enterprises, LLC
McBee Enlerprises, LLC
50 Oliver, W-1B, N. Easton, l\,4A 02356
352 Riverdale Rd, West Springfield, MA 01089
908 N. l\4ontello Street , Brockton , MA 02401
654 lyannough Rd, Hyannis, I\,lA 02601
263 Teaticket Highway, Falmouth, MA 02536
1060 Rt 28, South Yarmouth, l\,,1A 02664
222 Broad St, Bridgewater, M402324
178 Summer Street, Rte. 3 , Kingston , MA 02364
370 MacAdhur, Bourne , MA02532
429 MemorialAve, West Springfield, MA 01089
318 Liberty Street , Hanson , MA 02341
2392 N Main St, Springfield, MA 0'1107
175 North Street, Hyannis, MA02601
782 State St, Springfield, MA01109
96 N. Main Street, Carver , MA 02330
41 Washington St.. Canton, MA 0202'l
270 W Stockbridge Rd, Lee, MA 01238
MATurnpike E Between Exits 2 & 3, Blandford, MA01008
862 East St, Ludlow, MA 01056
MATurnpike Chariton East Between Exits I & '10, Charlton, MA 0'1507
660 Liberty St, Springfield, MA01'104
MATurnpiko Charlton East Service Area 5E, Charlton, MA 01508
862 East St / Ludlow E Travel Plaza, Ludlow, MA 01056
250 West Rd - Lee E ftavel Plaza. Lee, iilA01238
250 West Rd - l9 Service Area 1E, Lee, MA 0'1238
MA Turnpike Charlton East Between Exits g & 10, Charlton, MA 0l507
5 Long Pond Rd, lncludes Boston Pizza & Pasta, Plymouth, MA 02360
1361 Liberty St, Springfield, MA01'104
ACORD 101 (2008/01)
The ACORD name and logo are registered marks ol ACORD
@ 2O06ACORD CORPORATON, All.ight res.n.d.
Details
lnternal Only
License Restrictions/Conditions
Seating: 50
Expiration Date*
12t3112026
Business lnformation
Business Name*
McDonalds
Business Mailing Address (it different)
50 Oliver street
Business E-Mail*
caylin.barboza@us.stores.mcd.com
Business Legal Entity
Other Legal Entity
Business Address in Yarmouth *
1060 RT 28 S Yarmouth MA02664
Business Phone #-
5082302190
Business Type*
Food Service
Other Legal Entity
McBee Enterprises
Corporation Name (if applicable)
Tax l0 (FEIN or SSN)-
FEIN
ls this a NAME CHANGE?
No
Owner / Manager lnformation
Owner's Name'
Mark McBee
Manager/Conlact Person Name*
Doina lrvion
Name and Title
Renata Barboza
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS
Name of Certified Food Protection Manage(S)
All food service establishments are required to have at least one (1) PERSON lN CHARGE on site
during hours of operation
FEIN
Owner's Phone Number
508-230-2190
Manager / Contact Person Phone Number"
508-230-2190
Address
50 Oliver St suite WB
Emergency Telephone Number
857-891-1834
Please attach copies of certifications for all listed below:
List all Certified Food Protection Managers'
Renata Barboza and Doina lrovan
Lisl all employees certified in Anti-Choke-
Doina lrovan
List all employees with Allergen Certification'
Doina lrovan
Establishment Operations
Email
caylin.barboza@us.stores.mcd.com
Location is Permanent Structure?
Yes
Telephone Number
508-230-2190
Length of Permit
Annual
Establishment Type
I
I
II
Continental Breakfast
Non-Profit
Residential Kitchen for Retail Sale
Number of Seats lnside*
Common Victualler
Wholesale
Food Service
Number of Seats Outside'
50 0
Total Seats Frozen Dessert
50 I
Monthly results must be submitted to the health department.
tr
tr
r
I
I
Mobile
Vending Food
I
l, the undersigned, attest to the accuracy of the information
provided in this application and laffirm that the food
establishment operation will comply with 105 CMR 590.000 and
all other applicable law. I have been instructed by the Board of
Health on how to obtain copies of 105 CMR 590.000 and the
Federal Food Code. Pursuant to MGL Ch. 62C, Sec, 49A, I certify
under the penalties of perjury that l, to the best of my
knowledge and belief, have filed all state tax returns and paid
taxes required under law.'
Caylin
Barboza
Dec 24,
2025
Retail Service
Other
Submitted by Staff
I
Name Change Only
I
Affidavit
New construction, remodel or conversion requires an Occupancy Permit from the Building
Department in order to receive a valid Food Permit.
I do hereby certify, under the pains and penalties of perjury, that
the information provided above is true and correct.r
Caylin
Barboza
Dec 24,
2025
lnsurance Policy lnformation
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
lnvestigations of the DIA for insurance coverage verification.
Worker's Gompensation !nsurance Affidavit
Type of Businesst
I am an employer with employees *
lnsurance Company Name
Arthur J Gallagher
Business
Retail
lnsurer's Address
4350 W Cypress St suite 300 Tampa FL 33607
Expiration Date
o1to1t2027
Policy # or Sellins Lic. #
MAWC-17973
Food / Retail 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 seventy-two (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 CAFES: Outside cafes (i.e., outdoor seating with server 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.
I acknowledge that I have read and understand the information
above.*
Notice
PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY
TO COMPLETE THIS APPLICATION EACH YEAR.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT (PAINTING, NEW EQUIPMENT, ETC.) MUST
BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.
RENOVATIONS MAY REQUIRE MA ENGINEER SITE PLAN.
I acknowledge that I have read and understand the Notice
information above*
I