HomeMy WebLinkAboutLicense-App-CertsDocusign Envelope lDr 09881490-8571-4303-85C0-8760EFF87A31
**MUST BE POSTED ON PREMISES**
This License affirms that th€ specified premises, structure, or portion thereof has met the necessary
conditions including any inspections rcquired at the time of issuance.
It must be framed or laminated and prominently displayed in a clearly visible location within the approved
premises.
A
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The Commonwealth of Massachusetts
Town of Yarmouth
Health Depaftment
FOOD ESTABLISHMENT LICENSE
South Shore Early Education & Childcare
367 RT 28 W Yarmouth, MA 02673
ISSUED TO:Certificate No.
BOHF-26-19
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
Beard ot Hcalth:
Hillard Boskey, M,D., Chairman
Mary Craig, Vice Chairman
Charles I Holway, Clerk
Laurance Venezia, DVM
Eric Weston Fe€i $3O.OO
Restrictaons ./ Condltions: Non Profit
Interim Health Director James Gardiner
Signature of Interim Health Director I u" e*l^^u
C erti[ico te of Achievement
This certificote is oworded to
NANCY GROSS
,oa5t
Notionol Reslouront Associolion
233 5. Wocker Dnve, Suite 3@0
Chicogo, lt 60606.6383
8@]65.2122 rn Chrcogo oreo 3 I 2.z l5.l O t O
R€slouronl.o{g I Serv5ole com
Congrotulotionsl You hove compleled
ServSqfe" Food Hondler
llrnpi'ryrss Fooci Sc'iehr Oiriirr,+ Ccur:e c:nci ;;,c,i'r
c^r,ili.^la N,,hr.-. 636681 0 "^,- 512212023 EI
F'ni,6,i^n .,^r^ 512212026
ACCREOlIED
ilst
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ServSqfe'
CERTIFICATION
JESSICA BRIZID
b ec€itult @nddi.€ drc lbdqdt d font' tor rho
*liA n cndibd by *E Al.lsl {A/rl.'itoi Noiq'ol
Cd{.l!@ k F6d Pdldiri (CFPI.
12t31
DATE OF E
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DAIE OF EXPINA]ION
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CERTIFICATE oF
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RGEN AwenENESS TnuNINGil
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{ I fNarhe of Recipient:
bertificate Number:I tl !
Date of Completion:
Date of Expiration:
LAURAWENERA
IUZTZTE
at21nu21
1r'.an20t2g
ffi
? 9: :r*n 4^on * betebl hsucd tbit otifuate!o/ romllcting an alhrt n auarcnat taining pigtzmnognizcd by tln Masodrar.q, l rtnr, nEnt "1-litti Ucotttttn arontonn,ttith I0S f:.1lR ictlo|oi(; tt.i )l tt ).
IrrudEpcsi ---
\.-NATIONAL .RESTAUR/{NTASSOCn'noN.
Thit ttrtfrioa uill bc uldfofntc (s)dqte fcomphtioa.
Me8cf,o-to fu nrureot A8ochdon
333 Tihpit Rord Sutt! lO2Soutltooi{h MA O1Z2
508-3{13-9905
wlL.trllnlatru'rn -aoc.o{x
8&,765.27n
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CERTIFICATE oF
ATTTR TN AwRRENES s TRATN ING
mu!
E}SffiEffi
MIIONAL (
RSSTAURANTAiSOCIATION
Dt .tfflot tril h wtidfoiru. (5) yd'fon dak oIanpt.tio".
Name of ReciPient: JEssrcr BREro^
Ce,'tifi cate Numbcr: so7332o
Date of comPlction: sa3r2o2r
Date of Expiration: r@t
Me.h-r! R.trilr,u ArEalio!
313 TwPrc Rod, Sria 1O
Soul$d@dqMA m772
5os-3@-r{5
, lllGoufuEco,l
M.7652t22
7h alou-umdpzon I tady k rd th;' cntifrat.
/c.anlt tntzn a .rg.n d@d.a." tdiningfiognn
ncognizcd b7 ttu MunAw* D4*nat of Putlk Htzhh
ia atrodanu uitt 105 CMR t90.009(C)(3)(a).
oA'tE (xfl/oD/iYYn
1t12J2026
THIS CERTIFICATE IS ISSUED AS A I'ATTER OF INFORJ ANON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE OOES NOT AFFIRIIA'IVELY OR NEGATIVELY AiIE}IO, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTTFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENfA?IVE OR PRODUCER, ANO THE CERTIFICATE HOLDER.
IiTPORTANT: lf the certificate holder is an ADDrTIONAL INSURED, the policy(hs) must have ADDITIONAL INSURED provisions or be ondorsed.
lf SUBROGATIOI{ lS WAIVED, subioct to tho terms and conditions of the policy, certaln policies may requirc an endo6ement. A statement on
this certificate does not confer rights lo the certlficate holder in lieu ofsuch endotsement(s).
PROOI'CER
Arlhur J. Gallagher Risk Management Services, LLC
1 Research Drive
Suite 3008
WestDorough [rA 01 58 1
,.r. tr; E-I 5UO-b5O-lrUUdEfl^rL I
- -,ADDRESS: (rm lvtd?elq.Com
IXSURET{S) Af FOROING COVERAGE
rllsuF€RA: Philadelphia lndemnily lnsurance Company 18058
ItsuRED
South Shore Community Ac{ion Council lnc
71 Obery Street
Plymouth MA 02360
souTsHG39 t suRERB: A.l.M- Mutual lnsurance Companies 33758
iQo.
COVERAGES
CERTIFICATE OF LIABIL]TY INSURANCE
CERTIFICATE NUMBER: 784490336
CANCELLATION
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS]EO BELOW HAVE AEEN ISSUEO TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD
INDICA]ED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WIH RESPECT TO WHICH THIS
CERTIFICATE MAY 8E ISSUEO OR I!4AY PERTAIN, THE INSURANCE AFFOF(DEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSANO CONDITIONS OF SUCH POLICIES, I.IMITS SHOWN MAY HAVE EEEN REDUCED BY PAID CLAIMS,
x COMHERCIAL CENERAL LIABII TY
GENA AGGREGATE LIM'T APPLIES PER.
x
O-THER:
EF& E,.o"
x
PHPK266153+004 4t1t2025 4t112026 EACHOCCURRENCE s 1,000.000
OAMAGE TO RENTED s 100,000
MEo ExP (Ary ono palson)s5,000
PERSONAL& AOV INJI.]RY 11,000,000
GENERAl AG6REGA'TE s3,000,000
PROOUCTS . COMP/OP AGC s3,000.000
slM/53M
AIIIOMOBILE I.IAAltlTY
OWNEO x SCHEDIJIEO
PHPK256153t004 4111202s 41112026
oOO1LY TNJURY (Por pqs6)
s 1,000,000
9
aoo[Y TNJURY {Por &nde.0 S
5
s2,000
X
EXCESS LIAS
x PHU8902653-004 1t1Qa25 41112026 910,000,000
9 r0.000 000
x
I ttoixERs cdP€,lsaltoN
Ano EIPLOYERS'llAg[nY
ANYPROPRETO&?ARTNER/€X€CUTIVE
OFFICERJX'EMSEREXCLUOEOT
DESCRIPTiOT,J OF OPERAIONS b6ld
wrz-E00.4001 241 -20254 1i,3112025 1213112026 oT*ER
51,000,000
E,I DISEASE. EA EMPTOYEE s1,000 000
FL DISEASE POLICYLIMIT s 1,000,000
PHPX266153+004 411t2025 EUPLOYE€THEFT
CAluE DEDUCTISLE
s500.000
55.000
CERTIFICATE HOLOER
South Shore Eariy Education & Childcare
367 Rt 28
W Yarmouth wIA 02673
USA
SHOULD ANY OF TXE ABOVE OESCRIBEO POLICIES BE CANCELLEO BEFORE
TIIE EXPIRATION DATE TIIEREOF, NOIICE wlLL BE DELIVEREO IN
ACCOROANCE IryNH THE POLICY PROVISIONS,
AUTIlORtrEO REPRESEXTA-rIVE
@ 1988.20'15ACORD CORPORAnON. All rights reserved
ACORD 25 (2015./03)Tho ACORO nam€ and logo are rcgislercd marks ofACORO
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1t'112026
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OE5CRTFt|O OF OPEFAnOxg / toc^tlorls r veHELEa (AaORD l0l, addlilon.l i.r.rt. S.h.d!L, .y b..t!..h..| It non .!8. 1. rqslod)
Evidencc of lnsuranc€
Details
lnternal Only
License Restrictions/Conditions
Non Profit
Expiration Date.
12131t2026
Business lnformation
Business Name'
South Shore Early Education & Childcare
Business Mailing Address (if different)
Business E.Mail*
casilva@sscac.org
Business Address in Yarmouth *
367 RT 28 W Yarmouth, MA 02673
Business Phone #.
508-927-5775
Business Type*
Food Service
Business Legal Entity
No
Corporation Name (if applicable)
Tax lD (FEIN or SSN)-
FEIN
ls this a NAME CHANGE?
Owner / Manager lnformation
Owner's Name*
South Shore Community Action Council lnc
Manager/Contact Person Name*
Colleen Silva
Name and Title
Lauren Lanciani-Davis
FEIN
*-*-5732
Owner's Phone Number
508-747-7575
Manager / Contact Person Phone Number'
508-747-7575, Ext 6216
Address
367 RT28 W Yarmouth, MA 02673
PLEASE LIST STAFF MEMBERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS
Name ol Certilied 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
508-927-5775
Please attach copies of certifications for all listed below:
List all Certified Food Proteclion Managers*
Jessica Brizida, Nancy Gross,
List all employees with Allergen Certification.
Jessica Brizida, Laura Weiners
Establishment Operations
Length of Permit
Annual
Telephone Number
508-927-5775
Establishment Type
Continental Breakfast
Email
llanciani-davis@sscac.org
Location is Permanent Structure?
Yes
Common Victualler
Ir
Non-Profit
Residential Kitchen for Retail Sale
Frozen Dessert
Vending Food
I
I
I
I
I
I
I
I
Wholesale
Food Service
Retail Service
Other
I
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.
l, the undersigned, attest to the accuracy of the information
provided in this application and I affirm that the food
establishment operation will comply with 105 CMR 590.000 and
all other applicable law, lhave 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, lcertify
under the penalties of periury that l, to the best of my
knowledge and belief, have filed all state tax returns and paid
taxes required under law.'
Colleen
Silva
Jan 20,
2026
Worker's Compensation lnsurance Affidavit
Type of Business*
I am an employer with employees -
Submitted by Statf
I
Business
Non-Profit
I do hereby certify, under the pains and penalties of periury, that
the information provided above is true and correct.'
Colleen
Silva
Jan 20,
2026
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.
lnsurance Company Name
A.l.M. Mutual lnsurance Companies
Policy # or Self-ins Lic. #
EEC-6004001241-2025
lnsurer's Address
P.O. Box 41 31 , Woburn, MA 0188841 31
Expiration Date
12t31t2026
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-hvo (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 RESPONSIBILIry
TO COMPLETE THIS APPLICATION EACH YEAR.
ALL RENOVATTONS TO ANY FOOD ESTABLTSHMENT (pAtNTtNG, NEW EQUtptuENT, 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*
tr