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Home My WebLink AboutApplication and WC , ` ' TOWN OF YARMOUTH BOARD OF HEALTH.-_. �� . 7351' � � Al"PLICAI'ION FQR LTCENSE/PERMCT-�oia � DEC 0 4 2`�09 *Please complete form and attach all neces�y��ocurnents by De e tt0l�.r' � • Failure to do so will result in the retum af yaur applicatton NAME OF ESTABLISHMENT: j1 7�`� TEL. #,!4 '�39'�� LOCATION,ADDRESS: o�/ � � MAILING ADDRESS: O�v-? � �� ? , �' ,s OWNER NAME: FE or N • �- CORPORA.TION NAME ( PPLICABLE . � �i�� M,ANAGER'S NAME: ,� TEL. # �� ' � MAILING ADDRESS: 1� � POOL CERTIFICATIONS: The pool sapervisor must be certified as a Pool Qperator,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 emp loyees currently certified in basic water safety,standard First A.id and Community Cardiapulmonary Resuscitation(CPR). Please list these employees below and attach copies o�employee certifications to this form. The Health Department wi�l 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�vIANAGERS - 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 ta this application. The Health Department will not use pRst years'records. You must pravide new copies and maintain a file at your establishment. 1. 2. , PERSON IN CHARGE: Ea�l�food e�stablis�mient mus�hav�at�east ane Persoz�In Cl�rge_(PIC�on�ite d�ring_houxs of operation. _ _ L 2. HEIMLICH CERTIFICATIONS: All £ood service establishments with 25 seats or more must l�ave at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of�mplayee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at yoar place of business. 1. 2• 3. 4. RESTAURA.NT SEATING: TOTAL# ,__ OFF�CE USE ONLY LOAGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUTRED FE� PERMIT# LICENS�REQUIRED FEE PERMIT# B&B $55 ,CABIN $55 �MOTEL $55 `INl�i �55 �CAMP �55 _,_,SW1MIvIING POOL $80ea. �LODGE $55 ,TRAILERPARK $105 ^WHIRLPOOL $80ea. FOOD SERVICE: ' LICENS�REQUIRED FEE PERMIT# LIC�NSE REQUIRED �'EE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $$5 —CONTINENTAL $35 NON-PROFIT $30 Y>100 SEATS $160 �COMMON VIC. $b0 �WHOLESALE �8� RETAIL SERVICE: —RESID.KITCHEN SSO LIC�N5E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.8. �50 >25,000 sq.ft. �225 VENDING-FOOD �25 �<25,000 sq.8. $80 � U'� 63 I --�QZEN DESSERT $40 �TOBACCO - $55 �Ib,6ZI rra�cxaivGE: sis AMOUNT DUE _ � �35• �O ***�*�LEASE TURN OVER ANA COMPLETE OTHER SIDE OF FORM**"*" � � � f • S P , ADMINISTRATION � ' ,p�, •� ,. � Under Chapter 152, SeEtion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license-or permit to operate a business if a person or company does not have a Certificate of Worker's i � Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION IN$U1tANCE; j 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 rnust be paid prior tv renewal or issuance of your permits. PLEASE CHECK i 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, ordinaril�and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. � Transient occupancy shall generally refer to continuous occupancy of not more than thirCy (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 sha11 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, sha11 generally be considered Transient. �I POOLS POOL OPENING:A11 swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Departmerit to schedule the inspectiot�three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. ' POOL WATER 1`ESTING: 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 the�eafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days af closing. FOOD SERVICE CATERING POLICY: � Anyone who caters witban the Town of Yarmouth must notify the Yarmouth Health Depattme�xt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a montlily basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension ar revocation of your Frazen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: (lutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking5 Preparation,-or display��r��nci��oduct by�.retail�r f.�o ' ' is prohibited. _ ___ _ NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.I1'Y TO RETURN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO .ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY 1'HE BOARD OF HE.ALTH PRTOR ' TO COMMENCEMENT. RENOVATIONS MAY REQiJYRE A SITE PL ; DATE: � � SIGNATURE: PRINT NAME&TITLE: Dianne LackPv Licensing Coordinator 09!25/09 , � �r1�'�hal'fYte,��iCy� One CVS Drive �Woonsocket, R102895 G3(��C��M[�D DEC 0 4 ��ng HEAL I h utr� . December 1, 2009 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 anv chan�es made on the apnlication re�ardin�trade name and or mailin�address, and include store numbers on invoices and permits as indicated on the annlication to insure correct pavment to the proper store. Please send the permit(s)/license(s} and any future renewal _ applications for this store, with the store number on it, to mv atte�tion at: One CYS Drive, Licensin�Dept., Mail Drop 23062A, Woonsocket, RI 02895. After receiving the licenses, I will make the ' necessary copies for my files and forward the originals to the stores for posting. If you have any questions, please conta.ct me at 401-770-5772 or by fax 401-652-0608. Sincerely . ;_,r` , �� , � " �� :s� ..� . 5�_.. Dianne L. Lackey Licensing Assistant Legat Department .Marsh, Page 1 of ' MEMORANDUM OF INSURANCE DATE 12-Mar-2009 This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rights upon any viewer of this Memorandum.This Memorandum does not amend, extend or alter the coverage described below. This Memorandum may only be copied, printed and distributed within an authorized viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an entlty or person which is authorized by the insured named herein to access this Memorandum via http://www.marsh.com/moi?client=0860. The information contained herein is as of the date referred to above. Marsh shall be under no obligation to update such information. PRODUCER COMPANIES AFFORDING COVERAGE Marsh USA Inc. ("Marsh") Co.A lexington Insurance Company INSURED Co.B See Additfonal Information Section CVS Caremark Corporation &Ali Subsidiaries and AfFiliates, inciuding without limitation CVS Pharmacy Inc. Co.0 Co.D OVERAGES HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY PERTAIN, THE NSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND ONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF POLICY NUMBER POLICY POLICY LIMITS LT INSURANCE EFFECTIV EXPIRATIO LIMITS IN USD UNLESS DATE DATE OTHERWISE INDICATED ENERAL B - 6506290 (Prem/Ops) 01-Jan- O1-Jan-2010 ENERAL USD LIABILITY B - 6506291 (Druggist) 2009 01-]an-2010 GGREGATE 24 000 000 OMMERCIAL B 6506303 (Liquor) O1-Jan- OS-)an-2010 pRODUCTS - INCLUDE ENERAL LIABILITY 2009 COMP/OP ABOVE OCCURRENCE O1-Jan- GG • 2009 PERSONAL USD ' ND ADV 4,500,000 NJURY EACH USD 4.5M ' CCURRENCE (PREM); 4M DRUG FIRE DAMAGE USD (ANY ONE 1,000,000 FIRE MED EXP(AN ONE PERSON UTOMOBILE B - 6506148 (AOS) O1-)an- O1-Jan-2010 OMBINED USD LIABILITY B - 6506149 (MA) 2009 01-Jan-2010 INGLE 2,000,000 NY AUTO B - 6506150 (VA) 01-)an- O1-)an-2010 LIMIT HIRED AUTOS 2009 BODILY NON-OWNED O1-Jan- NJURY PER UTOS 2009 PERSON( elf Insured - Physical Damage BODILY NJURY(PER CCIDENT PROPERTY : DAMAGE EXCESS EACH �IABILITY CCURRENCE GGREGATE ARAGE UTO ONLY ABILITY PER CCIDENT ' THER THAN AUTO ONLY: EACH ' ACCIDEN AGGREGATE ORKERS - 3566698 (AR,GA,HI,IL,IN,KS,KY,LA, O1-Jan- OS-)an-2010 ORKERS Statutory OMPENSATION j MD,MO,MS,NM,OK,PA,SC,SD,TN) 2009 01-]an-2010 OMP LIMITS EMPLOYERS B - 3566699 (AL,AZ, 01-)an- 01-)an-2010 EL EACH USD ' LIABILITY O,DE,ID,IA,ME,MI,NE,NH,NV,UT,VT,WV) 2009 01-Jan-2010 CCIDENT 2 000 000 HE PROPRIETOR/ B - 3566700 (CA Only) 01-Jan- EL�DISEASE - USD tp://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrReject=accept&printable=tr... 3/12/20( •Marsh Page 2 of . PARTNERS/ B - 3566701 (Retro MN,NY,ND-EL ONLY, 2009 POLICY LIMIT 2 000 000 EXECUTIVE I) O1-)an- EL DISEASE - USD FFICERS ARE; 2009 EACH 2,000,000 EXCLUDED EMPLOYEE A PROPERTY 757386 30-Ju1- 30-Ju1-2009 LL RISK OF USD 2008 DIRECT 50,000,000 PHYSICAL LOSS OR DAMAGE NCLUDING FLOOD AND EARTHQUAKE, UBJECT TO POLICY ERMS AND ONDITIONS EXCESS E - 4780447 OS-Jan- O1-Jan-2010 C - EMPLOYER ORKERS 2Q09 STATUTORY LIABILITY; OMPENSATION � USD CT, DC, MA, NC, 500,000 N� OH RI VA ORKERS D - 3566702 (OR only) 01-Jan- O1-Jan-2010 C - EMPLOYERS OMPENSATION 2009 STATUTORY LIABILITY: USD 2 000 000 The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any modifications hereto are not authorized. MEMORANDUM OF INSURANCE DATE 12-Mar-2009 This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rlghts upon any viewer of this Memorandum.This Memorandum does not amend, extend or aiter the coverage described below. This Memorandum may only be copied, printed and distributed within an authorized vfewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shail mean an entity or person which is authorized by the insured named herein to access this Memorandum via http://www.marsh.com/moi?client=0860. The informatfon contained hereln is as of the date referred to above. Marsh shall be under no obligation to update such information. PRODUCER INSURED Marsh USA Inc. CVS Caremark Corporation &All Subsidiaries and ("Marsh") Affiliates, inctuding without limitation CVS Pharmacy Inc. ADDITIONAL INFORMATION PROPERTY: i ADDITIONAI. PARTICIPATING INSURERS: Axis Surpfus Insurance Company Policy # EAF 728076-08, Lloyd's of London Policy #DP658108 ADDITIONAL INSURED, LOSS PAYEE, OR MORTGAGEE Any party which the Named Insured is contractually required to include as an Addttlonal Insured, Loss Payee, or Mortgagee is granted such status under this policy as such interest may appear. Coverage under the policy applies ' oniy to the extent of the coverage required by such contractual requirement and for the Iimits of liability speclfied in such contractuai requlrement, but in no event for insurance not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the policy. The existence of more than one Insured, Additionai Insured or other interests shall not serve to increase the timits of liability of the policy. PERILS: "All Risk" of direct physical loss or damage including Earthquake, Flood, and Wind, subject to policy terms and conditfons. PROPERTY COVERED Real and Personal Property, Extra Expense, Improvements and Betterments, Structures in the Course of Construction, Newly Acquired Locatfons and as more fully described in the poHcy. PROPERTY VALUATION � Replacement Cost except Stock and Time Element as more fully described in the policy. ' Boiler& Machinery coverage is excluded. :tp://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrRej ect=accept&printable=tr... 3/12/20( - Marsh Page 3 of • Terrorism Coverage is excluded. GENERAL LIABILITY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION: COMPANIES AFFORDING COVERAGE: B - New Hampshire Insurance Company C- American International South Insurance Company D - Insurance Company of the State of Pennsylvania E - National Unlon Insurance Company of Pittsburgh, PA TEXAS WORKERS COMPENSATION DEDUCTIBLE POLICY: Policy # 3566703 (vfa New Hampshire Ins. Co.). Effective January 1, 2009 - January i, 2010 Limlts: WC- Statutory/ Employers Liability $2MM FLORIDA WORKERS COMPENSATION DEDUCTIBLE POLICY: Policy # 3566718 (via New Hampshire Ins. Co.). Effective January 1, 2009 - ]anuary 1, 2010 Limits: WC- Statutory/ Empioyers Liability$2MM WORKERS COMPENSATION POLICIES - LONGS DRUGS STORES ONLY Policy # WC 3566746 Ins. Co.: New Hampshire Ins. Co. States Covered: CA Effective January 1, 2009 - January 1, 2010 Llmits: WC - Statutory/ Employers Llability $2MM Policy # WC 3566747 Ins. Co.: Ins. Co. of the State of PA States Covered: OR Effective]anuary 1, 2009 - January 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM Policy # WC 3566748 Ins. Co.: New Hampshire Ins. Co. States Covered: TX Effective January 1, 2009 - )anuary 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM Policy # WC 3566749 Ins. Co.: New Hampshire Ins. Co. States Covered; AZ, CO, HI, KS, MI, NV, PA, UT, VA Effective)anuary 1, 2009 - January i, 2010 Limits: WC - Statutory/ Employers Liabflity$2MM Terrorism coverage lncluded on General Liability, Automobile Liability, Workers Compensation and Excess Workers Compensation pollcies. Virginia Garage Liability coverage is included on General Liability poficy 6506290 SELF-INSURED RETENTIONS: Generai Liability - USD 500,000 Prem/Ops USD 1,000,000 Druggist Excess Workers Compensation: USD 500,000 - DC, MA, OH, RI USD 1,000,000 - CT, NC, NJ, VA The Memorandum of Insurance serves solely to fist insurance policies, Ilmits and dates of coverage. Any modifications hereto are not authorized. :tp:Uwww.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrRej ect=accept&printable=tr... 3/12/20(