HomeMy WebLinkAboutApplication and WC / 1
�� � TOWN OF YARMOUTH BOARD OF HEALTH �5` ��A2M��`i_`���
� � APPLICATION FOR LICENSE/P RMIT-2 14 `�"��'U��� i
a�, . $a _ ,. �
'` * Please complete form and attach all nec :", . � ' }� . "errr��13��
Failure to do so will result in the r ' o , �„ a� li ati " acket.
=�� .�..�"�' , �: p I�J41.T�i�'T.
ESTABLISHMENT NAME: AX : `�
LOCATION ADDRESS: 9��l v��Z.. �S �,t, l>/�M��.� ., 4 TEL.#: �d - �
MAILING ADDRESS: Q. S . M I � O �7 �r So S �
E-MAII,ADDRESS: "�l�l�rc�v¢. . !�on i�ran2-� 0 !`u'sC_�2Q-crl/at���� C�M ';
OWNER NAME: Vr �"'\IC Dl�armar�i ���, U.a�-��o-577z Fi�x: ua l-6 SZ-b�o oB
CORPORATION NAME (IF APPLICABLE :
MANAGER'S NAME: � l�C�.. TEL.#: [ - �- 0�'�7
MAILING ADDRESS: N¢. V'^ 1. m 1 �� c.l�a-�- a '
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 basic water safeiy, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 times. Please list
the employees below and attach copies of their 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.
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 i
provide new copies and maintain a file at your establishment. �
L 2.
PERSON 1N CHARGE: �
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. II
l. 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 Esta.blishments; 105 CMR 590.009(G)(3J(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. i
1. 2. i
i
HEIMLICH CERTIFICATIONS: '
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich j
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�le at your place of business. ',
1. 2• i
3. 4. I
I
RESTAURANT SEATING: TOTAL#
� � �_�
OFFIGE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
B&B $55 ' CABIN $55 ' MOTEL $55 �
INN $55 CAMP $55 SWIMMING POOL $80ea.
_LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 '
>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 '
— —RESID.KITCHEN $80 ,
RETAIL SERVICE: I
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sy.ft. $225 . VENDING-FOOD $25 '
�<25,000 sq.ft. $80 —FROZEN DESSERT $4� �TOBACCO $95
NAME CHANGE: $is AMOUNT DUE _ $�C`� �
*****PLEASE TURN OVER AND COMPLET�OTHER SIDE OF FORM***** vV-� �
- "�l�b . � �
. �
' , ADMINISTRATION
r
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal o�
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 V NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy sha11 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 i
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. i
G
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 i
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.varmouth.ma.us under Health Department, Downloadable
Forms. i
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 waiter/waitress service), must have prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
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 13,2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIV�ENT, 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 SI E PLAN.
_.
DATE: �- l�o ► SIGNATURE:
PRINT NAME& TITL : ' ensing Coordir�ator
Rev. 10/08/13
SEP-24-2013 TUE 06.33 AM CVS RISK MGMT FRX �0. 401 770 6989 P, 03
C�:R71FfCATE DF kXCEsS INSURANCE
5TA7E OF h7A
To: Qe��t of Industrla{Accider�ts
Or1�Gon{�r�ss Straef
10��'�(oflr Suite ��p
�ostan,NtA Q2114
DATE:
SIr�Madunte:
Th1s cerflil�lhat a yVo�kore Compansatlon Excass IrrsurancQ Pollcy hes been Issued 4nd delfvered to the emptoyer nemad below,and
that by Gasuencn�n�i d+riivery a(eald pollcy and tha flfing o(thla cert((Icgio of ineurance,lt!s arJrnitiod lhut said vxce�s pollcy Wan�(fectlVd
ot�ihe da#a staled baloW and thai d�a t:uv�rege provldod thernln Ia sppiicable lo beneflta under the Workors CompensaUon Ac!of tho elate
, ��.,_.��A_._...�„a�d thal s�ld pollcy shall rema(n In fu11 forcp and effect un!(I 90 daya aflor racal�t by(he dEvlslon a!iabor o!notic�of
!!s cancelldtion or expfratfon and/vr non-renewal.
; Namn of�mptoyer Insured _. GVS�emRr(�Coror�j ,
Addr�as 1 GVS pR,WO�NSdCr�T,R102895•8196 ��� �
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NamR ot Inaurer NRTCC3NAI,tll�iON F1RE iNS CO . :
Addrese �.Z.5.�1ffl�:�,�t sTl3��1�YY YORK•NY�00�8 �„ � •
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poIlcy umit$sTA1"UTOt2Y Poflc Lfmlt$� '
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}f more U�ah one Inr�urer ia provlding covaraga,you m�st pravM�separete certliiaatea for each insurer, 4 •
(1-alu CERTIi'1CAT� �F INSURANC� N�f7HER AFFIRAM7IVELY NUR NEOA7IVE�Y AMENbS, �?CiENPS Oft ALT�1�S TH� •
Ct)VERA(3Ec(g)AF'rORUf,I)pY't"HE POLICY(tCS)USTED Ot�1'HIS CERTIFICA7�. '
NAZ"IONAL UNlON INS CO
f ranca Company '
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Authcrriz�d 1lgent
• 17S Vyacer Slraet New York,NY t003i3 `
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�epartme�t#of Inctrtstrial Accide��s
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wruw.�ea�s.gnvldau
Workers' Compensatio�n][nsura�►ce Affidavi�: General�usi�esses
Applicant Infarnr�ation �'I�se Pri��Le�ib�v, �
Busi�ass/Organization Nam�: CVS/Pharmacy #00735 :
976 Route 28 '
f�lf�C�'�SS:
` South Yarmouth, MA 02664 508-394-8596
czryrs���iz�p: rno��#: ;
Are you�n emplayer?Check ths appropria#e�x: Business Type(req�ireci�.
2.� I am a employer witb emptoyees(futl and! 5. [�Retail '
arpart-tims).* b. �{RestawantlBarfEatingEstabIishme�#
2.❑ �am a s�le proprie�ar ar partnership atzd kzava na �. Q pf�iice aazdtor Sales(incl.real e�tate,auto,etc.)
emptoye�wc�rking for me in an}�capacity.
[l�it�workers'comp.insurancc requi�red] 8. �Non-pro�t ,
3.❑ We are a corporafiion and its officers have�xercised 9_ [�Entertainment ;
t�eir right of ex�ption per c. I 52,§I{4},anc�we have i 0.[�iv�anufact�arin�
na employees,jNcr wa�kkers'cvmp.i�surancerequirred]* �,
4.❑ We are a na�-pro�it ar�anization,staffed;b�vQlunte�rs, I2.0 L�he#h Care f
wit13 no employees. [Na workers'eomp.insuran.ce req.j '
'�Y aFPticant tha2 checks baa�ttl mnst atsa fdl out the s�etion below showiz►g their wark�'campcnsarioa policy inforcnati,an;
»*t£the coz�parate o�cers l�ave e:c�tc3 themselv�,but�e corpoc+�tion rias other empioye�s,a workers'campcusarion policy is required�inr3 such an
arganization shouid chcck box#{l.
I am un�plvyer that is pr�vdding wor&ers'camper�ution ir�surance f�r my empdaye�s. Betow is the pvlacy informat�'ran. ,
�aS�anceeompanyName; New Hampshire Insurance Company ;
175 Water Street �
Instuer's Addres�: �
,
City/�tatelZip: New York. NY 10038 ;
019358776 O1/O1/2014
Palicy#or Self-i�s.Lie.# Expizatian�3ate:
Attach a copy of t�te workers'compems�tion pol�cy c�eclaratiun p�ge(s�wiug t��p�l�y mumber aa�d e�piratic�n date}, ;
�
Failure to secure coverage as re�quired ur�der S�ctifln 25A ofMCr�,c. 152 can lead to the impasition of criminal penalties of a i
fine up to$1,50U.Q0 and/or one year imprisonment,as well as civil penal�ies in ti�e fon�t of a STUP WORK dRDER and a f�rie '
of ug to$250.00 a day against�ie vialatflr. Be advised that a copy of t2us statemen#may be forwarded to�he O�es of '
In�estigations of'the DIA for insurance cavera�e verificatic�n.
I do hereby c ,utader the xar�s and r�enahies a.fP�ury+iltut ihe infvrmat��n prava�ed above r.s true ar�d cnrrecL
�ig�ire• . _ � T}2te: 12/12/2 013
Phone#: O 1-7 0-5 2 '
Of,f�cial use vnly. Do nvt write in thrs"area,ta be completerd by cYty vr tawn officiat
City or'Fowa: �A�1N�cJ� PermitlLicense# '
Tssr�in cire2e ene):
1. ard af]E�ealf 2.BuiIding Dep�rtm�nt 3.CityfTocvn Clerk 4.Licensing�rard 5.Selectmen's Uffice
6.
Cantact Person: Phone#: �b�'��-2??�� �'jZ�l�
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wvrw.u►ass.gov/dia
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One CVS Drive �Woonsocket, RI 02895 _ ,
t:�� � 9Z�)3
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Dear Sir/Madam: ',
Enclosed please find completed application(s) and/or invoice(s)
along with payment in the appropriate amount to cover the cost
of the renewal for the CVS/Pharmacy store(s) in your area.
Please note any chanqes made on the application reqardinp trade name '
and or mailinq address, and include store number on invoices and
permits as indicated on the application to insure correct pavment to the
proper stores. ',
Please send the permit(s)license(s) and anv future renewal applications
for this store, with the store number on it to mv attention at: One CVS
Drive Licensinp Dept Mail Drop 23062A Woonsocket, RI 02895.
After receiving the license, I will make the necessary copies for my files and ,
forward the originals to the stores for posting.
If you have any questions, Please contact me at 401-770-5772 or by ':
fax 401-652-0608
Sincerely
����
loanne P. Amitrano '!
Sr. Licensing Coordinator
One CVS Drive/Mail Drop 23062A
Woonsocket, RI 02895
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„�.�'� •
AC�� DATE(MhllDDlYYY�
CERTIFICATE OF LIABILITY INSURANCE 1?126/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOI.DER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 certificate does not confer rights to the
certificate holder in lieu of such endorsement s).
PRODUCER CONTACT
MARSH USA,INC. NAME:
99 HIGH STREET PHONE F�
ac No:
BOSTON,MA 02110 E-MAI�
Atln:CVSCaremark.CertRequest@marsh!Fax:212-948-5338 a�oRess:
INSURER S AFFORDING COVERAGE NAIC#
S02406-ALL-GAW-1415 - � iNsuReR n:New Hampshire Insurance Co. 23&41
iNsuReo iNsuaER e:National Union Fire Ins Co Pittsburgh PA 19445
SUBSID ARIES AND AFFOILI�AT SN AND fTS ��N ^� ���A
(j �t INSURER C:
ONE CVS DRIVE INSURER D:
WOONSOCKET,Ri o2ass HEALTH DEPT: INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYc-oosos526a2o 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
�NDICATED. 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS
�� TYPE OF INSURANCE POUCY NUMBER MM/DD/WYY MM/DDMlYY
A ceN�uaeiuTr GL 6819521 01/01/2014 01/01/2015 Ep,CH OCCURRENCE g 4,500,000
X D,4Mn E T ENrED 1,OOQ000
COMMERCIAL GENERA�IIABILITY PREMISES Ea occurrence $
CLAIMS-MADE �OCCUR MED EXP(My one person) S
X SIR: $500,000 PERSONAL&ADVINJURY $ 4,500,000
X LIQUOR LIABILITY INCLUDED GENERAL AGGREGATE g 28,000,000 '
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ INCLUDED
X POLICY PR� LOC $
B AUTOMOBILE UABILITY CA lOf)2798(AOS) 01101/2014 0110112015 COMBINED SWGLE LIMIT .�,Q��.Oe�
Ea ac^ident _
B X ANY AUTO �A�062�99 NA) 01/01/2014 01/01/2015 BODILY INJURY(Per person) $
B ALL OWNED SCHEDULED CA 7062800(MA) Ot/01/2014 01/01/2015 BODILY INJURY(Per accider�t) $
f
AUTOS AUTOS
X X NON-OWNED pet�acadenDAMAGE $ ,
HIRED AUTOS AUTOS
SELF-INSURED PHY.DMG. s
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A WORKERS COMPENSATION S22 P2�@ TWO fOf POIICy NiJfI1b2B 01/01/2014 01/01/2�15 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNERlEXECUTIVE Y�N E.L.EACH ACCIDENT $ 2�000�000
OFFICER/MEMBER EXCLUDED? � N�A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EXTENT RE�UIRED UNDER THE
LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIOUS LOCATIONS,STORE#161,735&944. '
i
CERTIFICATE HOLDER CANCELLATION
THE TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:BRUCE MURPHY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD Of HEALTH ACCORDANCE WITH THE POUCY PROVISIONS.
1146 ROUTE 28 '
SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina ��ien;�.. 1?Zt�ju�se.�r�
O 1988-2010 ACORD CORPORATION. AU rights reserved. ;
ACORD 25(2010/05) The ACORD name and togo are registered marks of ACORD '