HomeMy WebLinkAbout2026 Apps-Certs-License FoodDocusiqn Envelope lD: 5253AF58-F1 13-4 147-8E48-5F 1 DE7659630
**MUST BE POSTED ON PREMISES**
This License affirms that the specified premases, 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 approved
premises.
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I nterim Health Director la mes Gardiner
Signature of Interim Health Director lli""^1""*
2C649E740D
The Commonwealth of Massachusetts
Town of Yarmouth
Health Depadment
FOOD ESTABLISHMENT LICENSE
Cumberland Farms #2268
626 & 634 Route 28, West Yarmouth, MA
ISSUED TO:Certificate No.
BOHF-23-2236
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 the
public health.
License Expiration:
December 31, 2026
Eoard of Health:
Hillard Boskey, M.D., Chairman
Mary Craig, Vice Chairman
Charles I Holway, Clerk
Laura nce Venezia, DVM
Eric Weston Fee: $15O,OO
Restrictions / Conditions: Retail Food <5O,OOO Sq. Ft.
Details
lnternal Only
License Restrictions/Conditions
Retail Food <50,000 Sq. Ft.
Expiration Datet
12t31t2026
Business lnformation
Business Name*
Cumberland Farms#2268
Business Mailing Address (if different)
Business E.Mail*
ma-retail-licensing@eg-america.com
Business Legal Entity
Corporation
Business Address in Yarmouth .
165 Flanders Road, Westborough, MA01581
Business Phone #*
508-771-6183
Business Type*
Food Service
Corporation Name (if applicable)
Cumberland Farms lnc.
Tax lD (FEIN or SSN)-
FEIN
ls this a NAME CHANGE?
No
Owner / Manager lnformation
Owner's Name*
Cumberland Farms lnc.
Manager/Contact Person Name*
Jacqueline Thomas
FEIN
3586
Owner's Phone Number
508-270-8350
ilanager / Contact Person Phone Number*
(s08)771-6183
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
Emergency Telephone Number
(774) 278-1575
Please attach copies of certifications for all listed below:
List all Certified Food Proteclion Managers'
See Attached
List all employees with Allergen Certification.
Establishment Operations
Name and Title
Jacqueline Thomas Store Manger
Telephone Number
(508)771-6183
Length of Permit
Annual
Address
Email
MA-RETAtL-LtCENStNG@EG-AMERtCA.COM
Location is Permanent Structure?
Yes
Establishment Type
See Attached
165 Flanders Road Westborough, MA01581
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Continental Breakfast
Non-Profit
Residential Kitchen for Retail Sale
Frozen Dessert
Retail Square Footage*
Less than 25,000 sq. ft.
Common Victualler
Wholesale
Food Service
Retail Service
Vending Food
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Other Name Change Only
Affidavit
New construction, remodel or conversion requires an Occupancy Permit from the Building
Department in order to receive a valid Food Permit.
Submitted by Statf
I
Worker's Compensation lnsurance Affidavit
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tr
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.
Type of Business*
I am an employer with employees *
lnsurance Company Name
lndemnity lns. Co.
Policy # or Self-ins Lic. #
w1RC72609955
Food / Retail Service
Business
Retail
lnsurer's Address
436 Walnut Street
Expiration Dale
04t01t2026
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.
lacknowledge that lhave 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 thal I have read and understand the Notice
information above'
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