HomeMy WebLinkAboutApplication and WC ` � �'�'y��
� y TOWN OF YARMOUTH BOARD OF HEALTH 0 � `� ��o
� � APPLICATION FOR LICENSE/PERIV�T�-2012 � R �� � � ��-�� �
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* Please complete form and attach all necessary doc��t���ec m 'r 1����'! DEPT.
Failure to do so will result in the return of your application pac et.
ESTABLISHMENT NAME: �l�S CiC� �� �
LOCATION ADDRESS: t� MOc.��i'�+TEL.#: �" - `��I� ��v
MAILING ADDRESS: One CV r. 2 062A
OWNER NAME: H/oonsoc et, I macy, nc.
CORPORATION NAME(IF APPLICABLE : ��
MANAGER'S NAME: I��V' � t��V - TEL.#: (�
MAII.ING ADDRESS: Ct
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.
L 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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 maintaan a�le 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 provide new copies and maintain a�le at your establishment.
L 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
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, '
_____�TAURAN'�SEATINC�_TQTAL#�_ _ _�_ _ ___ - ---_ _ _ _ --_ __----T __�_— _ _--- ---li
OFFICE USE ONLY �
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMING POOL $SOea. '
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30
_>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 '
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 !
�<25,000 sq.ft. $80 �Z�'f�P _FROZEN DESSERT $40 �TOBACCO $95 ��`�O.�J' � �
NAME CHANGE: $15 AMOUNT DUE _ $ �'t 5.00
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*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ;
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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 Certi�cate of Worker's
Compensation Insurance. THE ATTACI�ED STATE WORKER'S COMPENSATION INSURANCE
AF�'IDAVIT MUST BE COMPLETED AND SIGNF.D, 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
elsPwhere.Tr_a,nsient oc�u��ncy shal? �ene�ally refer tn continua�as occup:incy nf rot m�re 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 OPEIVING: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.
OLTTSIDE CAFES: :
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.
;
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN f
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. '
i
AT.i• RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., I'AINTING, NEW ;
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR j
TO COMMENCEMENT. RENOVATIONS MA REQUIRE A SITE P N. !
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DATE: � �1 SIGNATURE: �� i
PRINT NAME&TITLE: � �ne P Amttrana i
. _oor rnator �
Rev.]0/25/I1
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One CVS Drive Woonsocket, RI 02895
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Dear Sir/Madam:
Enclosed please find completed appiication(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 anv chan�es made on the application re�arding trade name
and or mailing address, and include store numbeps on invoices
and permits as indicated on the application to insure correct
pavment to the proper store.
Please send the permit(s)/license(s) and anv future renewal
applications fo� this store, with the store number on it, to mv
attention at: One CVS Drive. Licensin�Dept , Mail Droz�
23462A. Woonsocket, RI 02895. After receiving the licenses, I
•��ill m�ke tre �ecessary ��pi�s for m yT 111�J �nd fo:���aru t�:e
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
.�,,A�u�-'
Joa e P.Amitrano
Licensing Coordinator
One Ci�S Drive/Mail�rop 23062A
Woonsocket,RI 02895
,4co� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DWYYYI�
� ,ti���„
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVE�Y OR NEGATIVEIY 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 stateme�t on this certificate dces not confer rights to the
certi�icate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA,INC. NAME:
99 HIGH STREET ,;������n PHONE a No:
BOSTON,MA 02110 � �1�� � ' E-Ma� �
ADORE S:
Attn:boston.certrequest(cDmarsh.com/Fax:212-948 377 � ..,�,,�;� INSURER S AFFORDING COVERAGE NAIC#
4''���
S02406-ALL-GAW-12-13 �" °'; �� Y�:� iNsuRER A.New Hampshire Insurance Co. 23841
INSURED INSURER B:Ch�IS C8SU811y COfil�fly 40258
CVS CAREMARK CORPORATION AND ITS HEALTH DEPT.
SUBSIDIARIES AND AFFILIATES iNsuReR c:Nationa�Union Fire Ins.Co.of Pittsburgh,PA 19445
ONE CVS DRIVE INSURER D:
WOONSOCKET,RI 02895
� INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-006095260-14 REVISION NUMBER:1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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 CONOITIONS OF SUCH POLIGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP UMITS
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
GENERAL UABILITY EACH OCCURRENCE $ 4,500,000
A X COMMERCIAL GENERAL LIABILITY GL 2705071(Premises/Operations) O1/O1/2012 01/01/201$ DAMAGE TO RENTED ���
PREMISES Ea occurrence $
CLAIMS-MADE �OCCUR MED EXP(My one person) $
X SIR: $500,000 PERSONAL&ADV INJURY $ 4,500,000
X LIQUOR LIABILITY INCLUDED GENERAL AGGREGATE $ 28�000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S INCLUDED
X POLICY PR� LOC $
A AUTOMOBILE LIABIUTY CA 4309147(AOS) 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT 1,000,000
Ea accideM
A X qNY AUTO CA 4309748(VA) 01/0i12012 01/01/2D13 ' BODILY INJURY(Per person) $
A ALL OWNED SCHEDULED CA 4309749(MA) 01/Ol/2012 01101/2013 BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PR�OePE�Rde DAMAGE $
X HIRED AUTOS X AUTOS
SELF-INSURED PHY.DMG. g
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A WORKERS COMPENSATION See Page Two for Pdicy Numbers O1/01/ZO12 01/01/2013 X WC STATU- OTH-
AND EMPLOVERS'LIABILITY
B ANYPROPRIETOR/PARTNEWEXECUTIVE Y�N E.I.EACHACCIDENT $ 2'�'�
C OFFICER/MEMBER EXCLUDED? � N/A
(Mandatory in NH) E.l.DISEASE-EA EMPLOYE $ 2,000,000
If yes,describe under 2���
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 107,Additlonal Remarks Schedule,if more apace is required)
ERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EXTENT REQUIRED UNDER THE
ASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIOUS LOCATIONS,STORE#161,735&944.
CERTIFICATE HOLDER CANCELLATION
THE TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATfN:BRUCE MURPHY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28
SOUTH YARMOUTH,MA 02f�4 AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
William G.Cornish ��,� � �y��,�
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: S02406
LOC#: Boston
���� �
ACOR� ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NAMEDINSURED
MARSH USA,INC. CVS CAREMARK CORPORATION AND ITS
SUBSIDIARIES AND AFFILIATES
POLICY NUMBER ONE CVS DRIVE
WOONSOCKET,RI 02895
CARRIER NAIC CODE
EfFECTIVE DATE: �
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2012 TO JAN 1,2013
Ins.Co. Policy# States Covered
B WC 019736709 AR,GA,HI,IL,IN,KS,KY,LA,MD,M0,MS,NM,OK,PA,SC,SD,TN
A WC 019736710 AL,AZ,CO3 DE,IA,ID,ME,MI,MT,NE,NH,NV,NY,OR,TX,UT,VT,WV
A WC 019736712 CA
A WC 019736711 MN
A WC 019736713 FL
A WC 019736706 ND,OH,WA,WI,WY
EXCESS WORKERS COMPENSATION PROGRAM
C WC 1192474 CT,DC,MA,NC,NJ,OH,RI,VA
Excess Workers Compensation Self-Insured Retentbns:
DC,MA,OH,RI: $500,000
CT,NC,NJ,VA: $1,000,000
COVERA6E A:Workers Compensation:StaWtory
COVERAGE B:Employers Liability Limits:$500,0001$500,OOOl$500,000
1�General Liability Additional Insured-Where Required Under Contract or Agreement language per endorsement 61712(12lO6):
SECTION II-WHO IS AN INSURED,is amended to include as an additional insured:
Any person or organization to whom you become obligated to include as an addi6onal insured under ihis policy,as a result of any contract or agreement you enler inlo which requires you to furnish insurance to ihat
person w organization of the type provided by ihis pdicy,but only with respect to liability arising out of your operations or premises owned by or rented to you. However,the insurance provided will not exceed the lesser
of:
•The coverage anlor limits of ihis policy,or
•The coverage andlor limits required by sad contract or agreement.
2)General Liabilily Eadier No6ce of Canceuation Provided By Us lar�guage per endorsement CG 02 2410 93:
Number of Days'Notice 90
For any statutorily permtted reason other fhan nonpayment of premium,ihe number of days required for notice of cancella6on,as provided in paragraph 2.of either the CANCELLATION Common Policy CondiGon or as
amended by an applicable state cancellatbn endorsement,is increased to the number of days sfrown in the Schedule above.
ACORD 101 (2008/01) �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: S02406
LOC#: Boston
AC R� ADDITIONAL REMARKS SCHEDULE Page 3 of s
AGENCY � NAMEDINSURED
MARSH USA,INC. CVS CAREMARK CORPORATION AND ITS
SUBSIDIARIES AND AFFILIATES
POLICY NUMBER ONE CVS DRIVE
WOONSOCKET,RI 02895
CARRIER � NAIC CODE
� EFPECTIVE DATE: . �
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
3)General Liability Advance of Cancellation to Entities Other The Named Insured LimRed to E-Mail Notification per Chartis Manuscript endorsement:
In the event that lhe Insurer cancels this policy for any reason other than non payment of premium,and
t The cancellation effective date is prior to this policy's expiratan dale;
2. The First Named Insured is under an existing contractual obligation to no6fy a cer6ficate hdder when this policy is canceled(hereina(ter,the"ceArficate Fblder(s)");and has provided to the Insurer,eifher directly or
through its broker of record,lhe email address of the contact at such entlty,
and the Insurer received this informatan after lhe First Named Insured received notice of cancellatlon of this policy and prior lo this policy's cancellation effecUve daie,via an elecUonic spreadsheet that is acceptable to
the lnsurer,
the Insurer will provide advice of cancellation(the"Advice°)via e-mail to such Certificate Holders.
Proof of the Insurer emailing the Advice,using the information provided under this policy by the First Named Insured,wi�serve as proof that the Insurer has fully sa6sfied its obligaUons under this endorsement.
This endorsement dces not affect,in any way,coverage provided under this policy or the cancella6on of this policy w the effective date thereof,nor shall this endorsement invest any rights in any entity not insured under
this policy.
The foNowing Definitions apply to this endorsement:
__ 1.Fi�stNs�lr�sured means the Named fnsured shoam an the Dedarations Page of this policy. -- -
2.Insurer means the insurance company shown in the header on the Declarations Page of this policy.
All other terms,conditans and exclusions shall remain the same.
ACORD 101(2008/01 j O 2008 ACORD CORP012ATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD