HomeMy WebLinkAboutApplications, WC and Licenses��� ��z
` � TOWN OF YARMOUTH BOARD OF HEAL � � �
� � � APPLICATION FOR LICENSE/PE �: 0 `
-E:. �� :: 4_ ' ��C 1 1 2008
�M� '� _',. �� ry.-..
* Please complete form and attach all necessary da m� ; y � c'e er 1 S 2008.
Failure to do so will result in the return o��ur p ication c �-o D E PT.
NAME OF ESTABLISHMENT: � � TEL. #
LOCATION ADDRESS: G .
MAILING ADDRESS: �it/� �N'S 7�,e— L'Uda,r/s�c,���- ,21. oa-��
OWNER NAME: SEE ATf'ACHED TAX ID (FEIN or SSN)� �
CORFORATION NAM IF APPLIC LE�: Massachusetts CVS Pham�cy,u.c
MANAGER'S NAME: �,l/ TEL. # � — 9
MAILING ADDRESS: ,� ,�/ �
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 Cardiopulmonaiy Resuscitation(CPR). Please list these employees belaw and attach copies of etnployee
certificatians 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.
l. 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.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during haurs of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich
Maneuver on the premises at all tunes. Please list your einployees trained in anti-chokmg procedures below and
attach co�ies 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.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGI�TG:
LTCENSE REQUIRED FEE PERMIT# LICENSE REQIJIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B �55 _CABIN $55 _MOTEL �55
_INN S5� _CAMP S55 _SWIl�Il�IINGPOOL �SOea.
_LODGE S55 _TRAILER PARK �105 WHIRLPOOL �80ea.
FOOD SERVICE:
LICENSE REQLJIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS S85 _CONTINENTAL �35 NON-PROFTI $30
_>100 SEATS �160 COMMON VIC. $60 WHOLESALE S80
RETAIL SER��ICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQiTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. �50 _>25,000 sq.ft. �225 VENDING-FOOD �25
�<25,000 sy.ft. �80 #6 y�,33 —FROZEN DESSERT �40 1 TOBACCO 555 _���C��
�va.�zEcx�vcE: �io AMOUNTDUE _ � 135•�O '
****"PLEASE TURti OVER AND CO'VIPLETE OTHER SIDE OF FORiVI**"**
/ �
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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 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 1/
Town of Yarmouth taaces 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 elsewhere. 4
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 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, shall generally be considered Transient.
POOL�
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days ;
pnor to opening. PLEASE NOTE:People aze NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER T'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of
closing.
�
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FOOD SERVICE �
d
CATERING POLICY: i
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt 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.
FROZEN DESSERTS: '
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 RETiJRN '
TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL I
DATE: DEC O 5 ZOOB SIGNATURE:
PRINT NAME&TITLE: D�a11112 L�Ck2y Licensing Coordinator
io.�z��os
, �
' � �'he ConznzUn�ealtlz of 1t�assuc�us��s
� . �epartmeni vf Industrrat A- ccitlents �
Office of Inx�estcgcxtinns
6D� �$'a�hrngtan Street �
,�` Bastan,h�! (1�111 ' �
y T�Vivii�tKtdSS.b QY�t�lti, 1 �
�'�rkers' Compensatian �nsur�nc� �c}avit: ��n�ral�u�ia��s��
!�,vi�ifcant Inform.ation Pi�se P�-int]Le�ib�v
Business/Organization Name: cvs/D����, �,�� '
_ ��.��
AddreSS: One CVS Drive, t�3aii Drop 23062p, �
Citc,/State/Zi •
, `� �-_S�tos�ns�ekar _ R7......� Rq , ...,,.., . .�,.,..,... _., ..�,,., . ..�,_. ��,u�..,,
��-lE�ll;£#:,,. ...(�0].'} `7��--'1_�,�....�.>.��.��.��,�.» .r _
Are you an employer? Chec�the apgropriatE box: Bu�iness�'I'ype.�requ'rred)
1.0 I azn a emplayer�rith � ernplovees(full and/ �. �.RetaiI �
or part-time).* 6. ❑ R�staurant/BarJEaiing Es��abl' hment
2.❑ I am a sole prapnetar or partnership and have no I
employees working for me m an ca ac 7• ❑ Office andJbr Sales{incl.jrea]estate,auto,etc.)
Y P �Y•
8. Nan �
jNo workers' comp.in.suran.ce regu�ed] ❑ -profif
3.❑ We af-e a corpora.tian and ifs afficers have exerciseci �; []�ntertainmeitt ,
their ri�ht of exemptian per c. 1 S2, �l(4),and we have I p ;
no em lo ees. ' �P- � ❑ Manut'ac�ing
p y [1vo�vorkers co insuzance re uiie i
4.❑ We are anQn-prafit organization,.sfaf�ed b3��oltenteers, 'lI.[]Health Care �
with no employaes. jNo workers' camp.insurance r�q,] 12.[� C)ther �
WAny applicant that chccks box#J mnsi aLso 6ll on�ihe sectioa helnw sbowing their woikers'compensatiosF policy infomiatia':
**If'the eorparace officers have exempced chcroselves;b¢t the coxporation:has ot2�eremployces,a workees'cornpensatiompalic�i�re�jni=ed and such an
org-3nization should check box ql. i
I
I am are e»zplayer that is praviEling warkers'campensatinn insuran�e for my�ern�ioyees. B�lox�is�lae��+(zey i�z.�f'or�u��,
Insurance Company Name: A�rican Hc� Assurance I
— �
Insurer's Address: 7c� Pine Street �
;
Ciry/StatefZip: t� w Y i - : ; I
.
Policy# or Seff-is�s_Lic.� 57��-39-_5n Eapiration D.axe: 09/01 C:;q
Attach a copy of the warkeFs' cflmgeu�a#i�n policy�de�laratian pabe(sho�ina the po�icy:nu�be an expiraEion date).
Failure to secure covera�e as required uuder Section 25A af IvIGL c. 1�2 can lead to the imgosifion o�cr' ' 1 penaiues of a
fine up ta $1,500.00 and/or ane-y�ar imurisonment; as well as civil penalties in the ror�t�f a�TOP�Q ORI�ER anti a fine
of up to$25Q.00 a day against the violator. Be advised that a eo�sy�f this statem�nt may be forward�k to e C?�ce af
Investigations of the DIA for insurance coverage verification.
i
I dv hereby certi.f}�, r flre pai s att alt�es of per,jurk�tfiux'tlxe irsfornaration prrrw�ed above is�ue and correct
Si ature: Date; �
Phone#: _�'�10.�',.�0 �
�
G�ffccial use onl��. Do n,ar►vrite in this arerz;;�i be co»i�leted by ciiv�r town afficurL ! I
i
City os Town: !
PermitlLi�ense# �' i
Issuing Authority(circie on:ej: �
1.Board of Heaith 2. �uitding Uepnrtm�nt 3. �tvlTown Cterk 4.L"ste�ssia�b Board 5. Sele�tmen's C?f'�ice
6. �thea�
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Cantact Person: �hone#: i
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www.ntass.gou/dia
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One CVS Drive Woonsocket, RI 02895 �� �``�`H � �' �
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'"�� � 1 2008
December 4, 2008 �`='��-��H pEpT
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 regardin�trade name and or '
mailing address, and include store numbers on invoices and nermits
as indicated on the avnlication to insure correct navment to the
proper store.
Please send the nermit(s)/license(s) and any future renewal
applications for this store, with the store number on it, to my
attention at: One CYS Drive, Licensin�Dent., Mail Dron 23062A.
Woonsocket, R102895. After receiving the licenses, I will make the
necessary copies for my fi�es 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
:'� � ., �,�,
Dianne L. Lackey
Licensing Assistant
Legal Department
• � � As of 12/4/2008
� Massachusetts CVS Pharmacy, L.L.C.
Corporate Officers
Name: Zenon P.Lankowsky
Title: President
Bus Address: One CVS Drive
Woonsocket,RI 02895
Name: Carol A.DeNale
Title: Vice President/Treasurer
Bus Address: One CVS Drive
Woonsocket,RI 02895
Name: Thomas S.Moffatt
Title: Secretary
Bus Address: One CVS Drive
Woonsocket,RI 02895
Name: Linda M.Cimbron
Title: Assistant Secretary
Bus Address: One CVS Drive
Woonsocket, RI 02895
Name: Melanie K. Luker
Title: Assistant Secretary
Bus Address: One CVS Drive
Woonsocket,RI 02895
CVSSTLLC Page 1 of 1
1
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i . . .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #09-023 FEE: S55.00
This is to Cenif��that Massachusetts CV� Pha�r__m_acX, .C' cllh/a CV /Ph rmacy#735
976 Route 28 South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODI Jf'TS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
This, e it is ant ai c om tv�vith Article VI of the San'ta Code of The Cammon���ealih of Massacht►setts,and
expi�es�ecen�ier�1.�08 un�ess sooner suspended or revo�ce�.
December 31.2008 BOAItD OF HEALTH: .`;E¢pR.tt S�ll�� �..lY., (�tCxtt
CR�au�s .�. ��i�i, `Uice �
✓to.�xt�.��rcuun, C!�ex�
Q.fu�c �'ieefc�a�ccfn, ✓2..N.
�.
ruce . urp y,M , . .,
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH �
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-033 FEE: S80.00
In accordance with regulations proniulgated under authorit��of Chapter 94,Section 30�A and Chapter
11 i,Section S of the General Laws,a permit is hereby granted to:
Massachusetts CVS Pharmac , LLC, 976 Route 28, South Yarrnouth, MA
Whose place of business is: CVS/Pharmacv#735
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2009 BOARD OF HEALTH: .1�feE'en S�, J2.JV., �.'l�ai�enur�e.
C'fi'ec�e4 .�. .9fe�i/�en `tJiee C.`�fav�rtuut
VARIANCE EFFECTIVE 08;'I5,'02: �/�� �.�,Y4�� (?�
Carpeting allo���ed in food aisles; ��¢¢f��.Jv.
Tiles required around all cooler areas. �.
December 31.2008 Bruce G.Murphy,MPH, . ,CHO
Director of Health
� ,,� �€ , -� I
�` O� _qk �, �,C-s� IS V l� LJ
$; �� TOWN OF YARMOUTH BOARD OF�-AI�`3'� ��1
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APPLICATIUN FOR LICENSEJPERM�1'-2$0$ " ; D�C 0 5 2007
r � .�►:z,; ,���°�f
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*Please complete form and attach all necessary doc�finents by December �-1�17TH DEPT.
Failure to do so will result in the return of your application packet.
NAME OF ESTABLISHMENT: t,�(/-s �
LUCATION ADDRESS: � ��G TEL. #�—��',�,�
MAILING ADDRESS: cvs/pharmacy
One CVS Dr Mail Drop 23062A
�WNER NAM�: woonsock�-�-`-9`-- -�'�x T�(F�IN or SSN1:
CORPORATION NAM ( F APP ICABL�)TMassachusetts CVS Phamiacy,r.r_,c
MANAGER'S NAME:��� ,fl��l�ii TEL.
_._
MAILING ADDRESS: Cvs/pharmacy
One CVS Dr Mail Drop 23062A
POOL CERTIFICATIQNS�'�'oonsocket,�02895
T6e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desienated __
P Operator(s)and attae�a copy of the certificatian to ti�us form.
_
1. 2,
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. T�te �ealth Department will not use p$st years' reeo�ds. Yoa �trs� provide new
copies and maintain a fde at your place of business.
I. 2;
3. 4.
FOOD PROTECTION MANAGERS - CERTffICATIONS:
All food service establishments are required to have at least one fiill-time employee who is certified as a Food ',
Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certification to this applieation. The Health Departrnent�viH not nse past years'rPco�ds. '
You must provide new copies and maintain a file at your estabGshment.
I. 2.
--_��R�4�T�LI�'I�AB��:_ --------- --- -
---- - -- _ ---- _ --
_----- ---- - - _ --
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ',
1. Z.
HEIMLICH CERTffICATIONS:
All faod service establishments with 25 seats or more must have at least one employee train�d in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employ�e c�rtifications 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.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PER'vlll'# LICENSE REQUIRED FEE PER'1dIT?= LICEI�'SE REQL'IItED FEE PER'�II7=
_B&B S50 _CAB1N S�0 _MOTEL S50
_tNN S50 C�Ai1TP S50 S�VI'�LVIING POOL S75ea.
_LODGE �SO _I�RAILERPARK S100 _V�7IIRLP�OL S75ea.
FOOD SERVICE:
LICEI�TSE itEQUIRED FEE PERMIT# LICEI�iSE REQUIRED FEE P£It��11IT tt LIC£NSE REQUIRED FEE PER'�IIT=
_0-100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25
_>100 SEATS S150 CO�ION VIC. S50 V4�IOLESALE 575
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMIT* LICENSE REQL�IRED FEE PERyIIT r LICENSE REQL'IRED FEE PER'�IIT�
_<50 sq.f�. $45 >25,000 sq.ft. 5200 _VENDING-FOOD S20
�<25,000 sq.ft. 575 �J�a?j _fROZEN DESSERT S35 /TOBACCO S50 ��
xa��c�v�E: sio AMOUNT DUE _ $ /o?5.00
*"***PLEASE TL'R\OVER�\D CO�ZPLETE OTHER SIDE OF FOR�Z*****
-� :-,_ -::.:.._.�.,. ,: } I
. . .. � '^�-� �
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ADNIINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license;or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensatio�,Insurance. THE ATTACHED STATE WORKER'S COMP�NSATION INSURANCE
AFFIDAVIT�MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED v `
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPR4PRIATELY IF PAID: j
YES ✓ NO . . . , ..
MOTELS AND OTHER LODGING ESTABLISHMENTS (
i
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be �
j
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel us�. �
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. !
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an �
aggregate of not more tha.n ninety(90) days within any six(6)month period. Use of a guest unit as a residence or f
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. €
* NOTE: Enclosed Motel Census must be completed and returned with this appiication.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins��ted
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( days f
pnor to operung. �
,
POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total coliform and standard plate count '
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of '
closin�. '
FOOD SERVICE
CATERING POLICY• l
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmeirt by filing the required ;
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtaine�i at the 4
I�ealth Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pennit uirtil 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 ofHeatth.
OUTDOOR COOKING:
- fflutdoar couking,pregaratio�vr display vf any foo�product by a retaii or foo�service-e�ltabkshmerrt isprohibited. - - !
i
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN �
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RE�iOVAT'IO'_VS MAY REQU RE A SITE PL . '
�
DATE: �� 3 O SIGNATURE:
PRINT NAME&TITLE: DiallCle L-aCk2y licensing Coordinator `
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' Nlarsh Page 1 of 3
MEMORANDUM OF INSURANCE DATE
23-Nov-2007
This Memorandum is issued as a matter of information oniy 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 internai use. Any other use, duplication or
distribution of this Memorandum without the consent of Maesh is prohibited. "Authorized viewer" shall 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 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.6 See Additional Information Section
CVS Caremark Corporation &All Subsidiaries and_ Go.0
Affiliates, including without limitation CVS Pharmacy Inc.
Co.D
COVERAGES '
HE POLICIES OF INSURANCE LISTED BELOW HAVE BE'EN 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
. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB)ECT TO ALL THE TERMS, EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF POLICY NUMBER ' POLICY POLICY LIMITS
LT INSURANCE EFFECTIVE EXPIRATION LIMITS IN USD UNLESS
DATE DATE OTHERWISE INDICATED
GENERAL B - 583-59-69(Prem/Ops) O1-Jan- 01-Jan-2008 GENERAL USI
LIABILITY B - 583-59-70(Druggist) 2007 01-Jan-2008 GGREGATE 15 OOO,QOC
COMMERCIAL 01-Jan- PRODUCTS - INCLUDEI
GENERAL LIABILITY 2007 COMP/OP ABOVE
OCCURRENCE GG
PERSONAL USI
ND ADV 4,000,00(
INJURY
EACH USD 4.51
OCCURRENCE (PREM); 41
DRUG'
FIRE DAMAGE
(ANY ONE
FIRE
MED EXP (AN
ONE
PERSON
UTOMOBILE B - 583-67-33 (AOS) O1-)an- O1-Jan-2008 COMBINED U51
LIABI�ITY B - 583-67-34 (MA) 2007 01-Jan-2008 SINGLE 1,000,00C
ANY AUTO B - 583-67-35 (VA) O1-Jan- 01-]an-2008 LIMIT
HIRED AUTOS 2007 BODILY
NON-�WNED 01-Jan- INJURY (PER
UTOS 2007 PERSON
Self Insured - BODILY
Physical Damage INJURY (PER
CCIDENT
PROPERTY
DAMAGE
EXCESS EACH
LIABILITY OCCURRENCE
GGREGATE
GARAGE UTO ONLY
LIABILITY (PER
CCIDENT
OTHER THAN AUTO ONLY;
EACH
ACCIDEN
AGGREGATE
httn�//www.mar�h.c�m/MarshPnrtal/P�rtalMain?PT1�=AnnM�iPi�hlic�accent(�rReiect=a... 1 1/23/2��7
�
' Ivlarsh ', Page 2 of 3
ORKERS C - 292-08-02 O1-Jan- O1-Jan-2008 WORKERS� Statutory
COMPENSATION /(AR,GA,HI,IL,IN,KS,KY,LA, 2007 01-Jan-2008 COMP LIM TS
EMPLOYERS MD,MO,MS,OK,PA,SC,SD,TN) 01-]an- 01-Jan-2008 EL EACH , USI
LIABILITY D - 292-08-03 (AL,AZ, ' 2007 O1-Jan-2008 CCIDENT' 2 000 OOC
HE PROPRIETOR/ CO,DE,IA,ME,MI,MT,NE,NH,NV,TX,UT,VT) O1-Jan- EL DISEASE - USI
PARTNERS/ B - 292-08-04 (CA Oniy) 2007 POLICY LI �IT 2 000 00(
EXECUTIVE D - 292-08-05 (Retro MN,NY,ND-E� 01-Jan- EL DISEASE - USI
OFFICERS ARE: ONLY, WI) 2007 EACH 2,00O,OOC
EXCLUDED '
EM PLOYEE'
A PROPERTY 8756280 30-)ul- 30-Ju1-2008 LL RISK F USI
2007 DIRECT 50,000,00(
PHYSICALIi
I.OSS OR I
DAMAGE I
INCLUDIN�
FLOOD AN
__ __ _ EARTHQtJAKE; _
SUBJECT TO
POLICY
ERMS AND
CONDITIONS
EXCESS E - 375-80-57 -01-Jan- 01-Jan-2008 WC - EMPLOYER
WORKERS , 2007 STATUTORY LIABILITY
COMPENSATION U51
500 OOC
WORKERS F- 292-08-06 (OR only) 01-Jan- OS-)an-2008 WC - EMPLOYER
COMPENSATION 2007 STATUTORY LIABILITY
USI
2 000 OOC
The Memorandum of Insurance serves solely to list insurance policies, (imits and dates of coverage. Any
modifications hereto are not authorized.
MEMORANDUM OF INSURANCE DATE
23-Nov-2007
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 aiter the
coverage described below. This Memorandum may oniy be copied, printed and distr�buted wfthin an author:zed
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" shali mean an
entity or person which is authorized by the insured named herein to access this Memorandum via
http://wwvr.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 INSURED
Marsh USA Inc. CVS Caremark Corporation &Ail Subsidiaries and
("Marsh") Affiliates, inciuding without limitation CVS Pharmacy Inc.
ADDITIONAL INFORMATION
PROPERTY:
ADDITIONAL PARTICIPATING INSURERS: Axis Surpius Insurance Company Policy # EAF 728076-07, Lioyd's of
London Policy #DP605107
ADDITIONAL INSURED, LOSS PAYEE, OR MORTGAGEE
Any party which the Named Insured is contractually required to include as an Additional Insured, Loss Payee, or
Mortgagee is granted such status under this policy as such interest may appear. Coverage under the policy appiies
only to the extent of the coverage required by such contractual requirement and for the limits of liability specified in
such contractual requirement, 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, Additional Insured or other interests shall not serve to increase the limits
of liability of the policy. '
PERILS: "Ail Risk" of direct physical loss or damage including Earthquake, Flood, and Wind, subject to policy terms
and conditions.
httn://www.marsh.com/MarshPortal/PortalMain?PID=AnnMoiPublic&accentOrReiect=a... 11/23/2007
� ,
' Marsh ' Page 3 of 3
PROPERTY COVERED ' '
Real and Personal Property, Extra Expense, Rents, Improvements and Betterments, Structures in the Cburse of
Construction, Newly Acquired Locations and as more fully described in the policy. '
PROPERTY VALUATION
Replacement Cost except Stock and Time Element as more fuily described in the policy. '
Boi�er & Machinery coverage is excluded. ',
Terrorism Coverage is excluded. ,
GENERAL LIABILI7Y; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION: I',
COMPANIES AFFORDING COVERAGE: !,
B - American Home Assurance ' �
C - American International South Insurance Company '�
: _ __ _ _
D-New Hampshire_In�urance C4mR�tty __� , - ----
-----__---__ __—_ _
E - National Union Insurance Company of Pittsburgh, PA ',
F - Insurance Company of the State of Pennsylvania !
Terrorism coverage included on General Liability, Automobile Liability, Workers Compensation and ExceSs Workers
Compensation policies. ,
Liquor Liability is included on General Liability policy Gl 583-59-69 I,
$4,000,000 Aggregate Limit I,
$4,000,000 Each Common Cause Limit i,
Virginia Garage Liability coverage is included on General Liability policy GL 583-5969 II
SELF-INSURED RETENTIONS: I��
General Liability - I
USD 500,000 Prem/Ops I
USD 1,000,000 Druggist �
Excess Workers Compensation: ',
USD 500,000 - DC, MA, OH, RI I
USD 1,000,000 - CT, NC, NJ, VA '�� '
USD 2,000,000 - FL �
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Anyi
modifications hereto are not authorized.
' �
http://www.marsh.com/MarshPortal/PortalMain?PID=AvpMoiPublic&acceptOrRetect=a...j 11/23/2007 '
� I
harma °
V p �►
Expect something extr�� I,
One CVS Drive,Woonsocket,RI I�2895•401-765-1500
December 3 2007 I'�
, �
Dear Sir/Madam: III
Enclosed please find completed application(s) andlor invoice(s) along wi�h
payment in the appropriate amount to cover the cost of the renewal for th
CVS/pharmacy store(s) in your area. Please note an chan es made on he
a�plication re�-ardin�trade name and or mailin�address, and include ,
store numbers on invoices and permits as indicated on the application tb '
insure correct paVment to the proper stor�
Please send the ermit s /license s and an uture renewal a lication '
for this store, with the store number on it, to mv attention at: One CYS I;
Drive, Licensin�Dept., Mail Dron 23062A, Woonsocket, RI 02895. A er
receiving the licenses, I will make the necessary copies for my files and I
forward the originals to the stores for posting. I
If you have any questions, please contact me at 401-770-5772 or by fax 4�O 1-
I
652-0608. �
Sineerely �,
, �r
�j
,` �, ii
i�f , I
� �;��������_
-j
,.�
Dianne L. Lacke I
y
Licensing Assistant '
Legal Department 'I
� , "� , �
�
" TOWN OF YARMOUTH
i BOARD flF HEALTH I,
PERMIT TO OPERATE A FOOD ESTABLISHMENT �i
PERMIT NUMBER: #08-023 FEE: $75. 0
In accordance with re�ations promulgated under authority of Chapter 94,Secrion 305A and Chap�er
111,Section 5 of the eneral Laws,a permit is hereby granted to:
' Massachusetts CVS Pharmac LLC 976 Route 28 South Yarmouth MA I
Whose place of business is: CVS/Pharmae #735
Type of business: Retail Food Service less than 25 OOQ s uare feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2008 BOARD OF HEALTH: �E¢�¢tt Sf�t�, J�..JV.,
C'f�ax�ee .�.J'�ifl�.e� `?J' C.'ttai�tnurrt
VARIANCE EFFECTIVE 08/15/02: �F�!��S���p�y� (�
Carpeting allowed in food aisles; (,�K/t��Y¢etl�llft� ✓�,,./V.
Tiles required aroiind all cooler areas. .
- . Decem�,er 12.2U07. , ruce .Murphy, . ., HO
Director of Health
__ _ _
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH ,
PERMIT NUMBER: #08-019 FEE: $50.04
This is to Certify that V
976 Route 28 South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For
AS PER THE YARMOUTH BOA�ZD OF HEALTH TOBACCO REGULATIO .
This�er$it ie�ant��i��8�tfor�ii�with Artiele VI of the San� Code of T'he Commonwealth of Massach etts,and
exp s ec er e s sooner suspended or revokae�. ,
December 12.2007 BOARD�F HEALTH: .`�(,¢�ett S�Q�, ✓`Z..Ar.,
C!�iaucee.e �.���'eiR�ex, `?�' C!fl�aixr�uat ,
- l�ext s.J`3.►,uscr�n, t',l'e�,cl�
Urut ,
B ce .Murphy, . ., H
Director of Health
I �
����� ,
' .O`:aR� TOWN OF YARMOUTH BOARD OF HEAI.�Hr�' ��. o r� � � � �J (� �
�2 c APPLICATIUN FOR LICENSE/P�RIYI�T-20 '7�L
o ,-, ���,, _
`` '�� ,� � D E C 1 8 2006
* Please complete form and attach a11 necessary docu�ne��b"y Decem er 31, 2006.
Failure to do so will result in the return of your application pa e{t�EALTH D�PT.
NAME OF ESTABLIS��VVIEENT: �IS I'1 r -� TEL. # (��3�i��5�1(p
LOCATION ADDRESS: (� Y1'1G► Qv
NtAII,rNG ADDRESS: � CVS 1Dct- �� ,N�� ` /1 �JX�U7f — c�6tslr�.!)Ut.h n�", �L'� O��a�" ,
OWNER NA��: __Massachusetts CVS Pl�arn�cy,LLC T T (FEIN or SS1Vl•
CORPORATION NAME(IF APPI�ICABLE): M�n�cvs Pt�►,�Y,Li,c e 1
MANAGER�S NAME:��Q.,phP� �-�-0 r i c rC�.r'1 TEL. # � D�S-� .I l�q�(
MAII.ING ADDRESS:_o„e cvs�;�e
Licensing Dept-23062A
POOL CERTIFICATIOl�'oonsooket,�o2s9s
The pool supervisar 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 ification to this form. '
1. � 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 Heaith Department will not use past years' records. You must prnvide new
copies and maintain a file at your place of business.
l. 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 5�0.000.
Please attach copies of certifica.tion to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishmen�
l. 2.
P�RSE3N-IN-EHAgGE: -- . _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation.
1. 2.
HEIl�iLICH 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-cholcmg 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 fde at your place of business.
1. �,� � 2.
3. 4.
RESTAUR.ANT SEATING: TOTAL# �''
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B �50 _CABIN �50 _MOTEL $50
INN $50 CAMf' $50 _SWIlvIl��IINGPOOL$75ea.
_LODGE $50 _TRAII,ER PARK $100 ' WHIItLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIIZED FEE PERMTT# LICENSE REQUTRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE �75
RETAQ,SERVICE: �RESID.KITCHEN $75
LICENSE REQUIRED FEE PERMI'T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
T,<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDiNG-FOOD $20
�QS,OOOsq.R $75 ����� _FROZENDESSERT $35 I TOBACCO $50 ?��L�3
NAME CHANGE: $10 AMOUNT DUE = S I LS_OO
"•*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••""
�'�T
` . �
ADMINIS'TRATION �
�
f
Under Cha.pter 152, Section ZSC, Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal
of any ticense 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 MUS�'BE COMPLETED AND SIGNED, OR
CERT. OF 1NSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth tu�es 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 shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transieut occupants must have and be able to demonstrate that they maintain a principal place afresidence 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 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, shall generally be considered Transient. '
POOLS
POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection f ve(5�days
pnor to openuig. ;
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count `
by a State certified lab, 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.
i
FOOD SERVICE
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 obtamed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the
above terms have been rnet.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with wa�ter/waitress service),must have prior approval from the Board ofHealth.
�
OUTDOOR COOKING: �
4utdQor co�kin�_nrepazation,Qr display_s�f an�fQo��roduct by a�etail_Qr food s�rvi��est�blis_htrn�is pr�Itibit�. _ __ �
;
NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[IRN
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENO�TATIONS TO ANY k'OOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
, DA�: DEC 0 6 2006 SIGNATURE: � ',
PRINT NAME&TITLE: �Therese Fluette Licensing Assistant ''
ion�io6
T
V pharmacy°
Expect something extq�a.°
One CVS Drive,Woonsocket,RI 02895•401-765-1500
� � G3I� � , �'
�� � � �'% -
` i
December 8, 2006 D E C 1 8 2006 9
� HE,���i�H u�c�_r„�
Dear Sir/Madam:
Enclosed please find completed application(s) andJor 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 changes made on the annlication regardinQ trade name and
or mailing address, and include store numbers on invoices and ne�mits as indicated on '
the anplication to insure correct pavment to the nroper store.
Please send the nermit(s)/licen�e(s) and anv future renewal apt�lications for this store, :
with the sto�e number on it, to mv attention at: One CYS Drive.Licensin�Dep�.Mail
Dron 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 contact me at 401-770-5772 or by fax 401-652-0608. '
Sincereiy
�
�;���-�t_ ,�T� ,.��t��
Dianne L. Lackey
Licensing Assistant ;
Legal Department
i
� ' . �
` ACORD�, �ERTIFIGATE C3F:LIABtLIT�( 1NSURAN�E' °aTE'MM'°°m,
12/29/06
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
200 CLARENDON STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
BOSTON,MA 02116 �pN O � ZQO7 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
TEL(617)421-0200 COMPANIES AFFORDING COVERAGE
. � � � '. COMPANY
S02908-ALL-LINES-07/08 A AMERICAN HOME ASSURANCE CO
INSURED COMPANY .
CVS CORPORATION AND ITS SUBSIDIARIES B AI SOUTH INSURANCE CO.
AND AFFILIATES
ONE CVS DRIVE COMPANY
WOONSOCKET, Rf 02895 C NEW HAMPSHIRE INSURANCE CO.
COMPANY
D NATIONAL UNION FIRE INS.CO. OF PITTSBURGH,PA
C�VERI►GES `I'tiis certifcate s�pe�sedes anrl replaces any previously issued eertificate. 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, 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, i
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DDlYY)
GENERAL LIABILITY GENERAL AGGREGATE $ 15,000,000
X COMMERCIAL GENERAL LIABILITY
PRODUCTS-COMP/OP AGG $ INCLUOED
A CLAIMSMADE �OCCUR 583-59-69(Premises/Operations) 01/01/07 Q1/Q1/Q$ PERSONAL&ADV INJURY $ 4,000,��0
01MJER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4�5����
X FIRE DAMAGE(Any one fire) $ .
MED EXP(My one person) $
AUTOMO&LE LIABILITY COMBINED SINGLE LIMIT $ � 1,OOO,OOO . �
X ANY AUTO
A ALLOWNEDAUTOS 583-67-33(AOS) 01(01/07 01l01/08 BODILYINJURY
A SCHEDULEDAUTOS 583-67-34(MA) 01/01/07 01/01/08 (Perperson) $
a X HiRE�auros � 583-67-35(VA) 01/01/07 O1/01/OH� BODILY INJURY �
X NON-OWNEDAUTOS (Peraccident) �
X ELF-INSURED PHY.DMG.
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT �
AGGREGATE $ ,
EXCESS I.IABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM �
B WORF�RSCOMPENSATIONAND 2g2-0g_02-SEE 2ND PAGE 01/01/07 01/O'UO8 X WCSTATU- OTH-
EMPLOYERS'LIABIUTY TORYLIMITS ER :
C 292-08-03 SEE 2ND PAGE 01/01/07 01/01/08 EACHACCIDENT $ 2,000,000
A THE PROPRIETOR/ X INCL 292-08-04(CA) O'I/O'I/O7 O'I/O'I/O8 DISEASE-POLICY LIMIT $ Z,OOO,OOO �
PARTNERS/EXECUTIVE 2g2_08-05 MN, NY,WI
C OFFICERSARE: EXCL � � 01/01/07 01/01/08 DISEASE-EACHEMPLOYEE S 2,000,000
E OTH R wC&EL 292-08-06{OR) 01/01/07 01/01/08 SAME AS WC ABOVE
p EXCESS WORKERS'COMP. XWC375-80-57 01/01l07 01/01/08 S.I.R.$500,000-DC,MA, OH, RI
S.I.R.$1MM-CT, NC, NJ,VA
S.I.R.$2MM-FL
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESlSPECIAL ITEMS
CERTIFICATE 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 LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.
VARIOUS LOCATIONS,STORE#161,735&944.
��Ri'1�#CATE iiUl.[)fR : M'G-(70(341528.fi-07 GANG�i:t�E?FON:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE '
EXPIRATION DATE THEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
THE TOWN OF YARMOUTH 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
ATTN: BRUCE MURPHY
BOARD OF HEALTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILJTY OF
1146 ROUTE 28 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
SOUTH YARMOUTH,MA 02664 AUTHORIZEDREPRESENTATIVE M USAIN ��
Edward R Ford
ACORQ�5 j'11f451 � ttC�t3 GORPO1�tTIQN 1988
DATE(MM/DD/YY)
,�►DDITIt)NAL:INFC)RMATtC,II� �YC-OOQ415285-07 12/29/06
PRoouceR COMPANIES AFFORDING COVERAGE
MARSH USA INC. coMaa,Nv
200 CLARENDON STREET
BOSTON,MA 02116 E ILLINOIS NATIONAL INSURANCE CO.
TEL(617)421-0200
COMPANY
F
S02908-ALL-LI N ES-07/08
INSURED COMPANY
CVS CORPORATION AND ITS SUBSIDIARIES
AND AFFILIATES G
ONE CVS DRIVE
WOONSOCKET, RI 02895
COMPANY
H
T�XT
WORKERS COMPENSATION CON'T:
POLICY#292-08-02-(AR,GA,HI,IL,IN,KS,KY,LA,MD,MO,MS,OK,PA,SC,SD,TN)
POLICY#292-08-03-(AL,AZ,CO,DE,IA,ME,MI,MT,NE,NH,NV,TX,UT,VT)
____ ____ ___ . _
GERT#FI�ATE I�Q�Ei�
THE TOWN OF YARMOUTH
ATTN:BRUCE MURPHY
BOARD OF HEALTH
1146 ROUTE 28 :
SOUTH YARMOUTH,MA 02664
MARSH USA INC.BY
Edward R Ford C�i.oa��!`, Td'�
Pa
. • � The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02I11
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information �'lease Print Legiblv
Business/Organization Name: CVS/p�ha�nacy
AdC�x'ess: One CVs Drive; Mail Drop 23062A
City/State/Zip: w�nG��r, lu o2s95 Phone #: (c,o�) �6�.?.500
Are you an employer? Check the appropriate box: Business Type(required): - ,
1.� I am a employer with employees(full andl 5. � Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I arn a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• �Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainxnent
their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing
no employees. [No workers' comp. insurance required)*
4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp.insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill out the secrion below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: American Har�e Assurance
Insurer's Address: 70 Pine Street
City/State/Zip: New York. NY 10270
Policy#or Self-ins.Lic. # 575-39-5o Expiration Date: Ol/o?/07
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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
Investigations of the DIA for insurance coverage verification.
I do hereby cerlify, under the pains and penalties of perjury that the informatBon provided above is true and correcz
Si�nature: Date•
Therese M. Fluette, Licensing Assistant
Phone#: (4rn 1 77�5��h
Official use only. Do not write in this area,to be completed by city or town officia�
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
Marsh Page 1 of 3
MEMORANDUM OF INSURANCE DATE
06-Jan-2006
This Memorandum is issued as a matter of information only to authorized viewers for their intemal 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
entity or person which is authorizedby the insured named herein to access this Memorandum via
http://www.marsh.com/moi?client=0860.The information contained he�ein is as of the date refecred to above.
Marsh shatl be under no obligation to update such information.
PRODUCER COMPANIES AFFORDING COVERAGE
Marsh USA Inc.
("Marsh") Co.A Lexington Insurance Gompany
INSURED Co.B See Additional Information Section
CVS Corporation &Its Subsidiaries a�d A�liates 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 INSURANCE AFFORDED BY THE POLICIES DESGRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
CO TYPE OF POLICY NUMBER POLIGY POLIGY LIMITS
LT INSURANCE EFFECTIVE EXPIRATION' LIMITS IN USD UNLESS
DATE DATE OTHERWISE INDICATED
GENERAL B - 575-39-50 (Prem/Ops) 01-Jan-2006 01-]an-2007 GENERAL USD
�LIABILITY B - 575-39-55 (Druggist) 01-Jan-2006 O1-Jan-2007 GGREGATE 12 Q00 000
COMMERCIAL PRODUCTS - INCLUDED
GENERAL LIABILITY OMP OP AGG ABOVE
OCCURRENCE PERSONALAND USD
DV INJURY 4 000 000
EACH USD
OCGURRENCE ' 4 000 000
FIRE DAMAGE
(ANY ONE
FIRE
MED EXP (ANY
ONEPERSON
UTOMOBILE B - 600-48-80 (AOS) 01-]an-2006 O1-Jan-2007 COMBINED USD
LIABILITY - 600-48-81 (TX) 01-Jan-2006 01-]an-2007 SINGLE LIMIT 1 000 000
NY AUTO B - 600-48-82 (MA) 01-Jan-2006 OS-Jan-2007 gODILY IN]URY
HIRED AUT05 B - 600-48-83 (VA) 01-Jan-Z006 O1-Jan-2007 pER PERSON
NON-OWNED 'BODILY INIURY �
UTOS (PER
Self Insured - CCIDENT
Physical Damage • PROPERTY ,
DAMAGE
EXCESS EACH
LIABILITY OCCURRENCE
GGREGATE
ARAGE UTO ONLY
LIABILITY (PER
CCIDENT
OTHER THAN AUTO ONLY:
, � � ___
EACH'
� � � ; ACCIDENT !
AGGREGATE. '
ORKERS C - 661-11-65 ' 01-Jan-2006 O1-Jan-2007 WORKERS Statutory ;
OMPENSATION /'(AR,GA,HI,IL,IN,KS,KY,LA, 01-Jan-2006 O1-Jan-2007 COMP LIMITS
EMPLOYERS MD,MO,MS,OK,PA,SC,TN) O1-]an-2006' O1-Jan-2007 .EL EACH USD'
LIABILITY D - 661-11-66 (AL,AZ, O1-Jan-2006 OS-Jan-2007 CCIDENT 2,000 000
HE PROPRIETOR/ CO,DE;ME,MI,NH,NV,TX,UT,VT), ELDISEASE - ' USD'
http://www.marsh.com/MarshPortaUPortalMain?PID=AppMoiPublic&acceptOrRej ect=acc... 1/6/2006
Marsh Page 2 of 3
PARTNERS/ B - 661-11-67 (CA Only) POLICY LIMIT 2 000 000
EXECUTIVE D - 661-11-68 (Retro MN,NY) EL DISEASE - USD
OFFICERS ARE: EACH 2,000,000
EXCLUDED EMPLOYEE
A PROPERTY 8754341 30-Ju1-2005 30-Ju1-2006 LL RISK OF USD
DIRECT 25,000,000
PHYSICAL LOSS
OR DAMAGE
NCLUDING
FLOOD AND
EARTHQUAKE,
SUB]ECT TO ,
POLICY TERMS
ND
ONDTTTONS
EXCESS E - 375-78-53 O1-Jen-2006 O1-Jan-2007 C - EMPLOYERS
ORKER& TATUTORY LIABILITY:
OMPENSATION USD 5D0 000
ORKERS F- 589-94-38 (OR only) O1-Jan-2006 O1-]an-2007 WC EMPLOYERS
OMPENSATION - STATUTORY LIABILITY-
DED USD
1 000 000
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of covera.ge.Any
modifications hereto are not authorized.
MEMORANDUM OF INSURANCE DATE
06-Jan-2006
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 wnsent of Marsh is prohiblted. "Authorized viewer" shall mean an
entity or person which is authorized by the lnsured 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 INSURED
Marsh USA Inc. �CVS Corporation &Its Subsidiaries and Affiliates
("Marsh")
ADDITIONAL INFORMATION
PROPERIY:
ADDITIONAL PARTICIPATING INSURERS
United States Fire Insurance Company #2441885022, Axis Reinsurance Insurance Company #RAF708478-05 and
Nutmeg Insurance Company #SX0000408.
ADDITIONAL INSURED, L•OSS PAYEE, OR MORTGAGEE
Any party which the Named Insured is contractually required to include as an Additional Insured, Loss Payee, or
Mortgagee is granted such status under this policy as such interest may appear. Coverage under the policy applies
only to the extent of the coverage required by such contractual requirement and for the limits of liability specified in ''
such contractual requirement, but in no event for insurance not afForded by the policy nor for limits of liability in
excess of the applicabie limits of liability of the policy.
The existence of more than one insured, Additional Insured or other interests shall not serve to increase the limits
'of liability of the policy.
PROPERTY COVERED
'Real and Personal Property, Business Interruption, Extra Expense, Rents, Improvements and Betterments,
Structures in the Course of Construction, Newiy Acquired Locations and as more fully described in the policy.
'PROPERTY VALUATION
Replacement Cost except Stock and Time Element as more fully described in the policy.
GENERAL LIABILTTY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION: '
http://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrRej ect=acc... 1/6/2006
Marsh . Page 3 of 3
COMPANIES AFFORDING COVERAGE:
B - American Home Assurance
C- American International South Insurance Company
D - New Hampshire Insurance Company
E - National Union Insurance Company of Pittsburgh, RA
Terrorism coverage included on General Liability,Automobile Liability, Workers Compensation and Exeess Workers
Compensation policies.
Liquor Liability is included on General Liability policy GL 575-39-50
$4,000,000 Aggregate Limit
$4,000,000 Each Common Cause Limit
SELF-INSURED RETENTIONS:
General Liability-
USD 500,000
USD 1,000,000 Druggist -
Automobile Liability - Massachusetts Only -
USD 500,000 �imit Excess of USD 500,000 Self Insured Retention
Excess Workers Compensation:
IJSD 5�0,000 - DC, MA, OH, RI
USD 1,OU0,000 - CT, NC, N), VA
USD 2,000,000 - FL
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage, Any
modifications hereto are not authorized.
http://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrReject=acc... 1/6/2006 ',
TOW�1T OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLISffiV�NT
PERMI'I'N(TMBER: #07-031 FEE: 75.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
11 l,Section 5 of the eral Laws,a permit is hereby granted to:
Massachusetts CVS Pharma , LLC, 976 Raute 28, South Yarmouth, MA
Whose place of business is: C�TSiPharmaev#735
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Pernut e�ires: December 31 2007 Bo�tD oF�ALTH: B is�$. ,�$., '
��s�, .�v, v�e���
VARIANCE EFFECTIVE 08/15l02: /lit�c��.Bnor,v�t, (�
Carpeting allowed in food aisles; n�/N��
Tiles required around a11 cooler areas. . �it�t���, Q./V.
March 23.2007 Bruce G. urphy ,RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSEI'TS
TOWN OF YARMQUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-023 FEE: $50.00
This is to Certify that M stachu ett V Pharmacv, LLC d/b/a CV /Ph rmacy#735
97b Route 28. South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE ISTRTRITTiON OF TOBA O PRn1��TC'T�
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULt�TION.
Tlus. t is an t�with Article VI o the S �y Code of The Commonwealth of Massachusetts,and
exp e�s�ece�ier�_�(�(�t�m e�s sooner suspend�or revo�Ced.
March 23.2007 BOARD OF HEALTH: B �. (���//��•. .
���� R.�., v�e�,��
� R�t�e� �
l�c�A?�$�
�4� R
B ce G. urph H,R .,
� I?irector of Heal
' � �.i�S�d'1 cr7 c�s-� ?3s
���';d R.� TOWN OF YARMOUTH BOARD OF HEA�,.�H G'� [� C� I� Q �!1 I� �o
� -'� APPLICATION FOR LICENS.�:��'��][21���Q6 Q 7 2005
°; ,!s ���� , � � DEC
* Please complete form and attach all neces�a.ty"do _ , �' ts by December ��AL�
Failure to do so will result in the retu�rn°ofyow application pack TH DEpT,
NAME OF ESTABLIS��VIENT: " � �1 � TEL. # .��'-39�'- �zl�
LOCATION ADDRESS' ��1(r, /�v�� - �:�_, �S�t.� ��t r rr�c��t�� �1� O�[o(o�
MAn,nvG a�nxEss:l�',� C �S 1����� - �, ;��,sc .���(. i������ k�T �eJ c�a�1s`� �
OWNERNAME:���l.t f�1, ��(� rn�nr.� J�a C i/�� Tnc � TAX ID�FEIN or SSNI:
CORPORATION NAME IF APPLICABLE):
MANAGER'S NAME: :}�j}��r't - �-�i C� r TEL. #,.5�'���9�/�'��3�
MAlLING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool 4perator(s)and attach a copy of the certificat�on 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 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 p�st years' records.
You must provide new copies and maintain a file at your establishment.
L 2.
_ PERSON IN�HARGET _ ___ ---_ _ !
Each food establishment must have at least one Person In Charge(PIC} on site during hours of operation.
1. 2. �
HEIlb��H 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
at�a�i evpies 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.
RESTAIJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PF.RMIT#
B&B $50 CABIN $50 _MOTEL $50
�INN $50 _CAMP $50 _SWIIvIlVIIN(3 POOL$'75ea.
_LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
0-100 SEATS $75 CON'I7NEN'PAL $30 NON-PROFIT $25
>100 SEATS �150 COMMON VIC. $50 WHOLESALE $75 ,
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMTP# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERNIlT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
I <25,OOOsq.ft. $75 �•O�I _FROZENDESSERT $35 / TOBACCO �25 ab06_o;�a-
NAME CHANGE: $10 AMOUNT DUE _ $ 1��.00
"""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**""
i
�
, '
ADMINISTRATION
Under Chapter 152, Sectian 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '
�
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's '
Compensation Insurance. THE ATTACHED STATE WORI�ER'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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETIJRN
TI� COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. 4
SEASONAL ESTABLIS���VIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- ,
10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO
COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
. _ _ �
ADDTTIONAL REGULATIONS �
POOLS `
POOL OPENING:All swimming,wading and whirlpools which have 6een closed�or the season mus�be mspecte
�
by the Health Department prior to opemng. �
I
�
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count '
by a State certified lab, 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. i
E
E
i
FOOD SERVICE `
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
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.
FROZEN DESSERTS: �
—_ �r�z�n d��s�rt�must berte�ste�on a-manthly�asi��y��tate c�rtifie�t�� Test r�sui�ts-must-�s�ntt�th�Headth_ _
Department. Failure ta 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 ofHealth.
OUTDOOR COOKING: '
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited.
�
i
DATE: � I � ���'C� 5 SIGNATLJRE: ti.�,ti�m.-x�= �. �--���-�xC� I
PRINT NAME&TITLE: ��anne E. Durand (
oor rnator f
� �
09/28lOS �
i
I
harm °
p acY
NOV 2 3 2005
Dear Sir/Madam:
Enclosed please find completed application(s) and/or invoice(s) along with payment in
the appropriate amount to cover the cost(s) of the renewal for the CVS/pharmacy store(s)
in your area. Please note anv chanQes made on the annlication regarding trade name
and or mailing address, and include store numbers on invoices and nermits 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 for this store,
with the store number on it, to mv attention at the address below. 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, contact me at 401-770-3315 or by fax 401-652-9170. '
Sincerely,
, , �t.�t�Ccc.�C%
Dianne Durand
Licensing Coordinator
Legal Department
��--o-- The eommonwealth ofMassachusetis
�- ==
- Departr�nent of I�dustnial Accidenls
� � �����
� . 600 WashiRgton Stree� 7`"`Floor
J Bosto�e,Mas� �2111
_ v�
,
work�s'C��sahoH Lsw�atce bi�/Elcch�cal
.., <ti .� , � ��. M ,r � -
.
,',. _ .�,,a � . r. _._�.�... . _� ,w t �,e �a^t��
�" t'�^�....� A'„�G . � -.. .__. .„,
t^ �ry
718II1C: /�� � V�- �
�- �7� �r�t � �
��r �5����-, 1�rrnr;u�� �• J2�.,�9 ao• c�aC�c�y �� 7�a��;39� ,��aC�
work site location rfnll addressL•
❑ I am a homeowner perfomung all wark myself. Project Type: ❑New Ga�structia��Remodel
I am a sole and have�a�e w in an Buil ' Addition
an empbyer�oviding wo;keis'co�ea�an fa�my employees working on this jo&
��..� �' �'�� ►��r� ►��-�-�cz�-u
s C� �2.r C C/� �r i V.�
�..,1:��t�c�j-��S�>�'k'r r— �� 6��' .� �U�- ;�'7C ��l �
❑ I am a sole prq�rietar,ge�erai e�tractor,or homeowier(�rcle o�e)and have hined the co�tois listed below who have
the following worlcas'compensation polices:
�r�:
�
dtv' nlrte�-
#
��:
�s:
t�1.7: ��•
Fa�r sec�e errera�e a�req�te�ed nder Sa1Ma 2SA�f MGL IS2 eu le�d b tYe t�p��[cr4�ia1 p�l�n�f a�e�b S1,SM.N aad/�r
eie ye�ts'ia�tir�mest as wU as dv�pe�aitla h t6c fi�eta 3T0!WORK OBDER and a Aae d316S.N a day asaio�t re. 1 ndnslud t6at a
c�py ef tih sfa�t my 6e forwarded 10 tse Omoe e[Im�as of tie DIA t�ro�wage verUlatlw.
/do beneb ' wrder tlie pslns sn/�f of pe�wry dYat tlie infonwaBoe provldsd arboae tr uxe awd onrnct
Signattu�e C O \�Ct� pate d �" � � '�SJ
Printname Diann _p F_ C1i�ran� Phone#
efficial ase onry ae eot wrke it c�is u+ea ca ne e�pleted Dr dty.r�wn.eadal
dty or tewn: P�/�oc�e# ����
❑e4eck if lmme�ah r�pe�ae b ral� �Sdeef�'s O�ee
�D�r�t
(��: P��' ❑�
�
1Vlarsh Page 1 of 3
MEMORANDUM OF INSURANCE DATE
23-Nov-2005
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
entity 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.6 See Additional Information Section
CVS Corporation &Its Subsidiaries and Affiliates 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
ONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MEMORANDUM 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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
CO TYPE OF POLICY NUMBER POLICY POLICY LIMITS
LT INSURANCE EFFECTIVE EXPIRATION LIMITS IN USD UNLESS :
DATE DATE OTHERWISE INDICATED
ENERA� B - 600-76-99 (Prem/Ops) 01-)an-2005 01-Jan-2006 GENERAL USD
LIABILITY B - 605-14-50 (Druggist) 01-]an-2005 01-Jan-2006 GGREGATE 10 000 000
COMMERCIAL PRODUCTS - INCLUDED
ENERAL UABILITY QMP OP AGG A80VE
CCURRENCE PERSONALAND USD
DV INJURY 4 000 000
EACH USD
CCURRENCE 4 000 000 '
FIRE DAMAGE
(ANY ONE
FIRE
MED EXP (ANY
NE PERSON
UTOMOBILE B - 204-62-22 (AOS) O1-Jan-2005 01-]an-2006 OMBINED USD
LIABILITY B - 204-62-23 (TX) 01-Jan-2005 OS-Jan-2006 SINGLE LIMIT 1 000 000
NY AUTO B - 204-62-24 (VA) O1-Jan-2005 O1-Jan-2006 BODILY INJURY '
HIRED AUTOS B - 204-62-25 (MA) 01-Jan-2005 01-]an-2006 pER PERSON
NON-OWNED BODILY INJURY
UTOS (PER
Self Insured - CCIDENT
Physical Damage PROPERTY
DAMAGE
EXCESS EACH
LIABILITY OCCURRENCE
GG REGATE
ARAGE UTO ONLY
LIABILITY (PER
CCIDENT
OTHER THAN AUTO ONLY:
EACH
ACCIDEN
AGGREGATE
ORKERS - 589-93-47 O1-Jan-2005 01-Jan-2006 ORKERS Statutory
OMPENSATION /(GA,HI,IL,IN,KS,KY,LA, 01-7an-2005 O1-Jan-2006 OMP LIMITS '
EMPLOYERS MD,MO,MS,OK,OR,PA,SC,TN) 01-Jan-2005 O1-Jan-2006 EL EACH USD
LIABILITY D - 589-93-48 (AL,AZ, O1-Jan-2005 O1-Jan-2006 CCIDENT 1 000 000
HE PROPRIETOR/ CO,DE,MI,NH,NV,TX,VT) EL DISEASE - USD
http://www.marsh.com/MarshPortaUPortalMain?PID=AppMoiPublic&acceptOrRej ect=a... 11/23/2005
�Marsh Page 2 of 3
PARTNERS/ E - 589-93-49 (CA Only) POLICY LIMIT 1 000�000
EXECUTIVE D - 589-93-50 (Retro EL DISEASE - USD
FFICERS ARE: MN,NY,WI) EACH 1,000,000
EXCLUDED EMPLOYEE
A PROPERTY 8754341 30-Ju1-2005 30-Ju1-2006 LL RISK OF USD
DIRECT 25,000,000
PHYSICAL LOSS
R DAMAGE
INCLUDING
FLOOD AND
EARTHQUAKE,
SUBJECT TO
POLICY TERMS
ND
ONDITIONS
EXCESS F- 375-75-67 01-Jan-2005 01-Jan-2006 C - EMPLOYER
ORKERS STATUTORY LIABILITY:
OMPENSATION USD 500 000
ORKERS F- 589-94-38 (OR only) 01-Jan-2005 01-Jan-2006 WC EMPLOYERS
COMPENSATION - STATUTORY LIABILITY-
DED USD
1 000 000
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any
modifcations hereto are not authorized.
MEMORANDUM OF INSURANCE DATE
23-Nov-2005
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
entity 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 INSURED
Marsh USA Inc. CVS Corporation &Its Subsidiaries and Affiliates
("Marsh")
ADDITIONAL INFORMATION
PROPERTY:
ADDITIONAL PARTICIPATING INSURERS
United States Fire Insurance Company #2441885022, Axis Reinsurance Insurance Company #RAF708478-05 and
Nutmeg Insurance Company #SX0000408.
ADDITIONAL INSURED, LOSS PAYEE, OR MORTGAGEE
Any party which the Named Insured is contractually required to include as an Additional Insured, Loss Payee, or
Mortgagee is granted such status under this policy as such interest may appear. Coverage under the policy applies
only to the extent of the coverage required by such contractual requirement and for the limits of liability specified in
such contractual requirement, 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, Additional Insured or other interests shall not serve to increase the limits
of liability of the policy.
PROPERTY COVERED
Real and Personal Property, Business Interruption, Extra Expense, Rents, Improvements and Betterments,
Structures in the Course of Construction, Newly Acquired Locations and as more fully described in the policy.
PROPERTY VALUATION
Replacement Cost except Stock and Time Element as more fully described in the policy.
GENERAL LIABILITY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION: �
http://www.marsh.com/MarshPortaUPortalMain?PID=AppMoiPublic&acceptOrRej ect=a... 11/23/2005
� �Marsh Page 3 of 3
COMPANIES AFFORDING COVERAGE:
B- American Home Assurance
C -American International South Insurance Company
D - New Hampshire Insurance Company
E - Commerce &Industry Insurance Company
F- National Union Insurance Company of Pittsburgh, PA
Terrorism coverage included on General Liability,Automobile Liability, Workers Compensation and Excess Workers
Compensation policies.
Liquor Liability is included on General Liability policy GL 605-14-50
$4,000,000 Aggregate �imit
$4,000,000 Each Common Cause Limit
' SELF-INSURED RETENTIONS:
General Liability - '
USD 500,000
USD 1,000,000 Druggist '
Automobile Liability- Massachusetts Only-
USD 500,000 Limit Excess of USD 500,000 Self Insured Retention
Excess Workers Compensation:
USD 500,000 - DC, MA, OH, RI
USD 1,000,000 - CT, NC, NJ,VA
USD 2,000,000 - FL
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any
modifications hereto are not authorized.
�
http://www.marsh.com/MarshPortaUPortalMain?PID=AppMoiPublic&acceptOrReject=a... 11/23/2005 '
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-028 FEE: $75.00
In accordance with reQulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�eneral Laws,a pemut is hereby granted to:
South Yarmouth CVS Inc., 97b Route 28, South Yarmouth, MA
Whose place of business is: CVS/Pharmacv#735
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2006 BOARD oF�,�,'rH: B ��5. o�osL,A�l.`?S., '
��� s�, �.�., v�e���
VARIANCE EFFECTIVE 08/15/02: /�o�wlr��. B�ux�utt, e�e�tl�z
Carpeting allowed in food aisles; n�/�e��
Tiles required around all cooler areas. . � fQftst(��ee�t, R./V.
January 2�.2006 ruce G.Murphy,MP , .,CHO
Director of Health
THE,C�MMONWEALTH OF MASSACHUSETTS
TOWN OF YARM�UTH
BOARD OF HEALTH
PERMIT NUMBER: #06-023 FEE: $25.00
This is to ce�tify that 3outh Yarmouth CVS Inc. d/b/a CVS/Pharmac�,#735
976 Route 28, South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBLJTION OF TOBACGO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REC'iULATION.
�s�er$it�ant�i���for��tv with Articlsu P�of the Satv�tarv Code of The Commonwealth of Massachusetts,and
e es er d e�s sooner ded or revo ed
J�,�2�.aoo6 Bo�oF��,�: B �. �oad.o,�,il19.�5., .
�i��s�, R.�v., v�e����
Rad�t�. B�, Gl�
A��l��s�t
�4��j , R.A!
ce .Murphy,MP . ,
Director of Health
�
��� i
o�`'YA�� ,,
�� ;� , o TO N F Y1� IZMOUTH �
E
��-_ �_, _ �'�,, 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 �
MATTACMEES Telephone (508) 398-2231,Ext. 241 — F� (508) 760- {� �1]j � ��y��,p I
� ��ADONAtt0�6�9� � � � ,� �<] 1�J l,`� 1=d �
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B V L'1 1! L o L' Il L' � L 1 11
,�9� �� '! L���5
To: Yarmouth Board ofHealth Permit Holders HEALTH D�PT.
From: David D. Flaherty Jr., RS. ;�D r
Health Inspector �
Town of Yarmouth '
Re: Federal Taac ID Number
Date: l�lazch 22,20O5
The Massachusetts Department of Revenue is now requiring that we furnish detailed information ';
to them regarding all permits and licenses that we issue. One of the details that they require we '
send to them is every establishment's Federal Employer ldentifieation Number(FEIN}otherwise
known as your"Tax ID Number". This is purely for administrative purposes only. '
Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the
case for your establishment, be assured that we will not allow this information to be public
record.
Please fill out the fields below and return this letter to
Yarmouth Health I?epartment
1146 Route 28
South Yarmouth,MA 02664
Tl�ank you for your anticipated compliance. If you have any questions regarding this matter,
please do not hesitate to cail. The of�ice hours are Monday to Fr�da.y, 8:30 a.m. to 4:3U p.m. The
telephone number is(508} 398-2231,e�. 24L
Establishment:�U S� `� ���EIN or SSN: �'
Location Address: `��,Q ��� � 4
� ���
Signature: .
3
{ ����� ��l, � Title: « �.,�/��.�
Print: ���Y�..�•�,,��
f ^;..
�r{'•
:
I �� 1�11
�m �
,� ` '; '
-� . ' ���sti�t
` }�°f:�R c TOWN OF YARMOUTH BOARD.�1F �I��� G'� �'`���'���
�: _,,� �• APPLICATION FOR LICF�NSl�/P�, ���,00� p E C 3 0 2004
•.. ..... � �� , �-
` * Please complete form and attach a11 necessary dpcumrents by Decembe 31�E2�Q�:H EPT.
Failure to do so will result in the return o�your application pack
NAME OF ESTABLISHMENT: � S TEL. # �j
LOCATICIN ADDRESS: �
MAILING ADDRESS 'C' �1 � "'
OWNER/CORPORATION NAME: `� S
MANA ER'S NAME: � �. TEL. #
MAILING ADDRESS:
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 minirnum of two emplo ees 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. T6e 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.
Yoa must provide new copies and maintain a fde at your estabtishment.
l. 2.
PERSON I���4RC�E: ___ __ _ ____ _ ___ __ .__- -— --_ _ __ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of opesration.
� \_
1�E'. � �\ C�C,� . ,2. �C�'�ln ���� L����
HEIlVILICH 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 fde at your place of business.
1. 2.
3. 4.
RESTALJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING-
LICENSE REQUIIZED FEE PBRMIT# LICENSE REQUIIZED FEE PERNIIT# LICENSE REQUIItED FEE PERMTf#
B&B $50 _CABIN $50 MOTEL $50
_INN $50 CAMP $50 _SWIlvIlVIIlJG POOL$75ea.
_LODGE $50 _TRAII,ER PARK $50 _WHIRI.POOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQiJiRED FEE PERMIT#
0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQiJIRED FEE PF_RMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIItED FEE PERNIIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $Z00 �VENDING-FOOD $20 ',
„ _ , �
���.; ���� . I��� � �o�-o.��- �
��� FROZEN DESSERT $35 ��
NAME CHANGE: $10 AMOUNT DUE _ $ loa.OO
'•*•"PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM"""'�"
: �►-�._
L , �
ADMINISTRATION
> � �f
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal r
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's �
Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR i
CERT. OF INSURANCE ATTACHED '
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES r/ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. �
€
i
SEASONALESTABLISHMENTS ARE TO CONTACT'TI�HEALTHDEPARTMENTFORIlVSPECTION?-10 `
DAYS PRIOR TO OPENING FOR THE SEASON. '
;
�
�
ALL RENQVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COMI��NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN.
_ i
E
1
I
i
ADDITIONAL REGULATIONS �
i
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.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, 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
C4NSUMER ADVIS�RY:
Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post '.
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the
required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be
ohtained at the Health Department. '
_ -��U�EN DL�SS�RTS: - _ - _ _ ___ -- - _
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 ha�e prior approval from the Board ofHealth.
OUTDOOR COOI�NG:
Outdoor cooking,preparation,or display of any food product by a retail or faod service establishment is prohibited. ,
I A . '
DATE: S GN TURE•
�
- ��� .�� �
PR1NT NAIV�& TITL � � S S'� !f �i5i�lof �C'.s's►:s�i't�
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10/22/04
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Workers'Com.pensafion Insurance Affidavit
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❑ I am a sofe proprietor and have no one working in any capacity �
1 am an employer prov�ding workers compensation for my employees worWng on this�ob.
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❑ 1 am asole proprietor,general contractor,or homeo�wn`e�le nne)and have hired the contr � �,n ��r��Mw��..Y�`t,
have actors listed below who
the follow�ng workers' compensation polices: �
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Faiiure to secure covernge as reqwred under Seccion 25A of l�1S2 cxn Iead 10 Ihe imposttion of c:iminaf penalties of A fine up to�2,iU0.�0 and/or�
one years'imprisonment as welk as civil�cnalties in tY�c form oT A STOP\�1'ORK ORDER and a fine af 5100.Q0 a day Against me. I understand that a
copy ot this statcment may be forwarded to the Otfice otinvestigations of the DlA for caverage verification.
I!!o hereby cerf��under ih�pains anr!penatti o cr u �!l:nt Yhe infornmtion rovided above is true and correct,
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Sienature � ^` j � " �
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Print name `lC��.� � �E"� r4
Phone# `1�:r f''��h C-�� � ,:�,J,—
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official use anly du not write in this arca to be completed by cify or town afGcial
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� cit}�or towa:
permit/iicense# (�f3uiFding fi3epartmeut
�? ❑check if immcdiate resuonse is required �Licensing Soard
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phunt�': ❑tieait6 Lepartmenf
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, /'I CO�Dm CERTIFICATE OF- LIABiLlTY,,INSURANCE � .�•, _ "- DATE(MMlDD/W)
..� .a�„ _.. ' 01/12/05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN: DENISE HART-HOUSTON HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
200 CLARENDON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON,MA 02116 COMPANI�S AFFQRDING COVERAGE_
__.__ 617-424�290__.., ._ _ _ ___ _._ _,. �.._._..,_..__ _ _..
_ .: . :.. , - . ' _ COMPANY , ` .
o.s,' ._. .:
S02908-ALL�(NES-09l06 � � • -- A AMERICAN HOME LfiSSURANCE o _
INSURED ..' . -: .� COMPANY , y�. �
= C�CORPORATION AND I�S'"SU�$IUTARIES �� '-�"-`' B AI SOUTHINSURANCE CO.��� `
_ _; ��'FFI�Ii4fiES __, . , _
__ .
OI�E CNS DRIVE "' �^, , , COMPANY io'-'
. _�. ;, •.
WOONSOCKET,RI 02895 '- C NEW HAMPSHIRE Il�$URANCE O� _ i
��*•�
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COMPANY
D COMMERCE&INDUSTRY INSURANCE CO.
��\\\ , y� ���� � � ��� o�� � �
CCF F�1GES �� ` T'his cecf��G�t��upers� es and,repl�„� �ty�r„evit�u�(y issu�d;cerbfilca#e���,,.,,.� . ,.,,�� ..� 1
......,. .... �u�z�x ,.. {# �-
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THIS IS TO CERTIFY THAT THE 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
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 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TypE OF INSURANCE POLICY NUMBER �UCY EFFECTIVE POLJCY EXPIRATION LJMITS
�� DATE(MM/DD/YY) DATE�MM/DDIYY�
GENERAL LIA&L1TY
GENERALAGGREGATE $ 10,000,000
X COMMERCIAL GENERAL LIABILIN PRODUCTS-COMP/OP AGG $ INCLUDED
A a�`;. CLAIMSMAOE �OCCUR 6��7699 01/01/05 01/01/06 PERSONALBADVINJURY $ 4��00��0�
OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
X FIRE DAMAGE(My one fire) $
X .I.R$1 MM-DRUGGIST ONL MED EXP
(/vry one person> $
AUTOMOBILE LIABILITY
COMBINED SINGLE L�MIT $ 'I,OOO,OOO
B X ANY AUTO 2046222(AOS) 01/01l05 01/01/06
ALLOWNED�AUTOS . " " PO4BZZ3(TX� 0�/0�/Or'J ��/��/06 ' BODILYINJURY $
S.f�lfDULEDAtffOS.:- 2O4BZ24(VA� 07/01/05 01/Ol/06 ;:(Perperson) _
X ... � -:- ' "., 20d6225�MA> '�' 01l01/05 .,01/01/06 : r--
HI}2LD AUfOS � -"" � � r GODILY iMJURY � �
..__ � $
X NON-0WNED AUTOS ��(�) LIMIT $500,000� (Per accidenq
� -X ELF-INSURED PHY.DMG. 'EXCESS OF" ,� �
��$SOO,OOOS.I.R.�� PROPERTYDAMAGE $
GARAGE LIABILIN AUTO ONLY-EA ACCIDENT $
�.
ANY AUTO OTHER THAN AUTO ONLY: � 3� =
r i..a,.......,�.�
EACH ACCIDENT $
AGGREGATE $
EXCESS LJA&tJTY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATiON AND p _ ,
B 5899347(SEE 2ND PAGE) - 01/Ot>05 01/01/O6 �C , TaRr�xa}� , � r� ,r :��_ ,
� ��oveRs u,��n _ ,
C 5899350(RETRO-MN,NY,WI) 01/01l05 01/01/06 EACHACCIDENT $ 7,000,000
p THEPROPRIETOR/ INCL 5899349(CAONLY) O'I/O'I/OS O'I/O1/OB DISEASE-POLICYLIMIT $ 1,000,000 �
PARTNERSJE)(ECUTNE 5899348 SEE 2ND PAGE DISEASE-EACH EMPLOYEE $ �,OOO,OOO
C OFFICERSARE: EXCL � � 01/01/05 01/07l06
E ER 5899438(OR ONLY) 01/01/05 01/01/06 SAME AS WC ABOVE
E EXCESS WORKERS'COMP. 3757567 01/01/05 01/01/06 USD 500,000-DC,MA,OH,RI
E 3757567 01/01/05 07/01/06 USD 1,000,000-CT,NC,NJ,VA
E 3757567 01/01/05 ,01/01/06 USD 2,000,000-FL
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
CERTIFICATE 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 LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.
VARIOUS LOCATIONS,STORE#161,735&944.
�EF27'} �, ; ��'�`�; . � �� � � �5 .��FIGEtL�I�tQN�"���� k ��_ � , � � ;(� ������,
��.�0\....����....u; �e�.� ..-f_ z== �....�\ � .._� �-_,,..,,,,,, ,��.~`,�.,�-:. ...,,,,, '�" .:..GacN.�^?��..��' .�'..��':._ :�s.-.�.� .... .... �.���+s. ,c. „.� ..Y� �,
U
SHOULD ANY OF THE A�VE DESCRIBED POlJC1ES �CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL '
THE TOWN OF YARMOUTH 3O DAYS WRITTEN NOl10E TO THE CERTtFlCATE HOLDER NAMED TO THE LEFT,
ATTN: BRUCE MURPHY
BOARD OF HEALTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLJGATiON OR LJABILITY OF
1146 ROUTE 28 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
SOUTH YARMOUTH,MA 02664 �zH��� M USAIN �T-/J '
Edward R Ford Td'�
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AC.O,�t}25 j1/95j.�_� '�.... '. ' �u��::,. �: ;�.... �,�, 'O�AGOR�GORR(3RATIt?N 19$�i
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AL��ITIONAL�INFO�RMATIE}N� �;�K , � �� �i���� oiii2io5�
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PRoouceR COMPANIES AFFORDING COVERAGE
MARSH USA INC. connPnrvv
ATTN: DENISE HART-HOUSTON
200 CLARENDON STREET E NATIONAL UNION FIRE INS.CO.OF PITTSBURGH,PA
BOSTON,MA 02116
617-421-0290
COMPANY
F
S 02 908-A L L-L I N E S-0 5/06
INSURED COMPANY
CVS CORPORATION AND ITS SUBSIDIARIES
AND AFFILIATES G
ONE CVS DRIVE I� '� � �� I] �n '? ��� .�
WOONSOCKET,RI 02895
C'OiMPANY �,(�� � g 200�
t�> ; '( �', I 3 ' ' � , ,
� ".aw,,,,,,.. ��',s- E `a,,,,.,... \\ �..,,,,:, f%��a.G �%„i,.„,: � a.�.�'�,h .�.\��\�0�.?Y,__ ,a,,,P�.�.,,. �\\\\.w• �sz�s„ �`x�..\.< ..�,v,s,'�S'�rso:._ �\�..\,.,, �
WORKERS COMPENSATION CON'T:
POLICY#5899347-(GA,HI,IL,IN,KS,KY,LA,MD,MO,MS,OK,OR,PA,SC,TN)
POLICY#5899348-(AL,AZ,CO,DE,MI,NH,NV,TX,VT)
i
G�I�T[FICPiTE HOLDE[� ' ;�� �
�a �� �1 �`.: .�"�.. ���:. � �
�... u. THE TOWN OF YARMOUTH,� . ..,.��:,,.... . ...... ..... ;� ....... ......., ... .� m... .. � �;
ATTN:BRUCE MURPHY
BOARD OF HEALTH
1146 ROUTE 28
SOUTH YARMOUTH,MA 02664
MARSH USA INC.BY I
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Edward R Ford ��,�u.nto���
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j TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: #OS-038 FEE: $75.00
In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pernut is hereby granted ta
South Yarmouth CVS Inc., 976 Route 28, South Yarmouth, MA
Whose place ofbusiness"is: CVS/Pharmacv#?35
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2005 BOARD oF HEALTH: B�rcfcrxiuk `.�5. �io�o�c,/N`�. '
A�M�s� v�e��
VARIANCE EFFECTIVE OSl15/02: Ro�J�� B�io�wt, �
Carpeting allowed in food aisles; o�eleit cs'�i, /�./V
Tiles required around all cooler areas. � fQsua�fie�e�t�s��rt, R./�.
Februacy 2.2005 ruce G.Murp , ,RS.,CHO
Director of H
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-032 FEE: $25.00
This is to Ce�tify that South Yarmouth GVS Tnc_ d/b/a CVS/Ph rm cv#735
976 Route 28. South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTR TTTON OF OBAC' O PRO ('T�
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
T7us�er�it i�e�t�i���for�itv with Article VI of the Sani�ta��Code of The Commonwealth of Massachusetts,and
exp es e�s sooner suspended or revo ,
February 2.2005 BOARD OF HEALTH: Best�tt�t�. �j�/y/.�., '
� P���� v�e��
Rad�t� B�, Gl�k
�S!� R.N.
�� , R./V.
.,.
Bruce G.Murphy , ,
Director of Health
��gr���
�. * . ���" `�aa�RBt .$7S s !� �. _ �c;�r����"
. � ,
_g�' 2�fr R o TOWN OF YARMOUTH BOA�(�� T ��` � � 200 °
sY' � �C APPLICATION FOR L�P"��I'�'=20 3
'` � .••'"�? � ' � ' � _ � � :� HEALT
�, �=' �; �° � :z -r� t H ����T.
* Please complete form and attach all nec � , d ti�y Decem r , .
Failure to do so will result in the ret ' ' of your application packet.
vs � �- D 3 s - -$s9�
C �-e o� `' t.c�I- o u, � < � '
MAILING ADDRESS: �►�Ce-v-�:'�v� De� � C�vc� CV� �- � df.'�o�✓s ac��F l��' u��y'�'
MANAGER'S NAME: G���`C,`c� ' ,'� TEL. #S�� –y� �9'�fi
DRESS: ._ ��
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s;�a.nd attach�copy o�the certifcation ta th�s form.
1. �qi�./�- 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 maintain a file at your place of business. '
1. .1/l� 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 file at your establishment.
1. , ��1/� 2.
_ _ _ _
___ _ ._ _ - __ _ _ __ -
PERSON IN CHARG�:-__ ______ _---- _ — -- ---- — ,
�
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. '
1. .,qi�/�- 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 premi.ses at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Heaith Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. r✓)� 2•
3. 4• ;
RFSTAURANT SEATING: TOTAL#�` '
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_BBcB �50 _CABIN S50 _MOTEL $50
INN S50 CAMP $50 _SWIMMING POOG$75ea.
_LODGE $50 `TRAILER PARK $SO _WHIItLPOOC. S75ea ,
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS �75 _CONTINENTAL $30 _NON-PROFIT S25
>100 SEATS $150 _COMMON VICT. SSO _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEG PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $2(Hl _VGNDING-FOOD $20
I <25,O00 sq.R. S75 ���� _Fk0"l.h:N DGSSfiR'I' S35 I TOBACCO S25 ����
NAMECHANGE: a�o AMOUNT DUE = S /00.06
**•**PGEASE TURIV OVER AND COMPLETE OTHER SIDE OF FORM"****
� � �
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i
of any license or permit to operate a business if a person or company does not have a Ceriificate of Worker's �
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATI4N INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED j
� �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ��
Town of Yarmouth taxes and lieris must be paid prior to renewal or issuance of your permits. PLEASE CHECK .
APPROPRIATEL�I�PAID: /�
YES �/ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'TLTRN i
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2Q03.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
1
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e.2 PAINTING, NEW
EQUIPMEN'F,ET�:), 1GIU�T BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO C�MMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ;
�
4
ADDITIONAL I�FGULATION,� �
�
s
POOLS
POOL OPEl�1ING:All swimming,wading and whirlpools which have been closed for the season must be inspected �
by the HeaIth Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard late count �
by a State certified lab,prior to opening, and quarterly thereafter. p
POOL CLOSING: Every outdoor in ground swimming paol must be drained or covered within seven(7)days of
closing.
�
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�
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FOOD SERVICE `
CONSUMER AI)VISORY• �
Each food establislunent which serves or selis ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CAT�Ri_NG POLI Y•
Anyone who caters within the Town of Yarmouth must notify the Yatmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
�
_ �����1����E�P ; -- . __ _ _ _ -_ _-- __ �
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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.
OUTSID� CAFF:S: i
Outside cafes(i.e.,outdoor seating with waiterJwaitress service),�have prior approvai from the Board of Health. �
�TDOOR COO iNG:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited.
�
i
DATE: 2- :� ,
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PRINT NAME& TITLE:��� �e���' �o,' �� � .�,,,s��. � `
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10/22/03
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- ----__� The Commonwealth ofMassachusetts
'��. v-� _-� Department of Industrial Accidents
':� .=- -= Office oflnvestigatioAs
_ 600 Washington Street
- � .��,K'0�� Boston,Mass. 021I1
� Workers'Compensation lnsurance Affidavit
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name: � \I � ��i'�A��✓ � ` / �� ^_ _...�. __ _._ _
location: � ]�j� �'�'� C�� __
citv ��c,1�h ,�'0.r mo��-h i� d o�c[�� y ahone# ��� �9� ���
� I am a homeowner pe ormmg all work myself.
❑ 1 am a sole proprietor and have no one working in any capacity
I am an employer prov�dmg workers' compensation for my employees workmg on this�ob
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comoanv name ��,j�-�'�+ �+�{""�Y'�'�C' �F�'�Y"'�.0 � s����v>=�-x...� °f �`"'
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❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices: •
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com an name �� r,, ��~
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address �' ���,�
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Failure to secure coverage as required under Section 2SA of MGL 152 cHn lead to the imposition oTc�iminal penalties ota fine up to$1,500.00 and/or
one years'imprisonment as well as ciyil penalties in the form of a STOP V!'ORK ORDER and a fine of S100.00 a day against mc I understand that a
copy of this sfatement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and pennttie of perjury that the information provided above is true and correcG
.. '
Signature Date `� 2—`�—f�3•
Print name_ �lC,���Cg �j� Phone# `"}��`��1(�-',,��3 � �'
ofiicial use only do not write in this arca to be completed by city or town official
city or town: permit/license#_ flBuilding Department
❑Licensing Board
% ❑check if immediate response is required ❑Selectmen's O�ce
j ❑Health Department
contact persort: p6one#; I'10t6er
f:;: ; , � � � � � � � � �,,.,�...;,:..
A CORD � �� � � ����� ��? � ���� �� �� DATE(MM/DD/YY)
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� '� 12/30/03
i T�IIS CERTIFICATE IS IS�� ' ������ �
PRoouceR ' SUED AS A MATTER OF INFORMATION
MARSH USA INC. � ` LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN:DENISE HART � ':! � � � ��} H LDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
r � 200CLARENDON�TREET . A TER THE COVERAGE AFFORDED BY
; , BOS7'ON, �MA>_02116 � , � COMPANIES AFFORDING
; � �" �' '� �
, cs1��a,2�.-o2so : � F=���L.�..�? �� � �_.
� COMPANY �. , ,
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i S02908-PlLL-EtIVES-04/05 �_.;+':,. .. r_,�:.-,"? ;;,;',.;;,A UNITED STATES Flb:8�GUARAN >> > �� ��j��. --
:INSURED� ... .. ;�; ,z, . , ` ,�OMPANY : '
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..;� ...._ -
'. �' a� Ct/S CORPORATION AND IT�Sl1BSiDM�cF�IES_-; , ,.;;,,:.-;B DISCOVEI2 PROPERTY�CASUAL"�Y_I1��1�(��EPT.
ONE CVS DRIVE
�__._ WOONSOCKET,RI-02895 _ . connPnNr _: , . ,.
_ _ . __C _ _ _.__
COMPANY
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,:� �E,v<„ � .?a� f� � ,."�i$. _ ;( .. ����11CI�8}�CC�d&�[f�f,[�S%1�t�1S'�ll�ClC1B4��� im;.. �' �'��" a,���i; �
,:: , ,,.., ,, :�;
THIS IS TO CERTIFY THAT THE 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
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 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIOk LIMtTS
LTR DATE(MM/DDIYY) DATE(MM/DDIYY)
GENERALLIABILITY GENERALAGGREGATE $ 8,000,000
X COMMERCIAIGENERALLIABIIITY PRODUCTS-COMP/OPAGG $ INCIUDED
B � RN, CLAIMSMADE �OCCUR DOOIQOOO77 ���01�� Ol/Ol/OS PERSONALBADVINJURY $ 4,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
x FIRE DAMAGE(My one fire) $
X .I.R$1 MM-A/O INCL.LIQUO MeD exP(Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 'I,OOO,OOO
B X °arSrAUTo'";� � ;� fy ' ' :' DOQ1A00171.(AOS) 01;/01/04�._: � A,1/01l05 , ;
_ , _ _ . :
. .
-f `=". ai.L Own�ED AUTOS . _ _ DOO1 VOOO12(MA) Ol/O1/04 - Ol/Ol/05 BODILY INJURY $
' -' D001 A00170(lX) 01/01/04== 01701/D5 :
"" � "SCHEDUCfD AUTOS (Per Perso�) _ _ _
X HIR�D�4UTOS ., -' BODILY INJURY $
X NON-OWNEDAUTO$.; ��(MA) LIMIT $500,000� __ (Per,accident) . _. -
X ELF-INSURED PHY.DMG. "EXCESS OF"
PROPERTY DAMAGE' $ -
"$500,000 S.I.R."
GARACE LIABILITY
AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY.
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELLA FORM _ __ $
__--
WORKER$COMPENSATION AND - 3� � ;-?
A D001W00213(HIDEb) 01/01/04 01/01/05 X TORYLIMITS ER ,.� -�.: :;
EMPLOYERS'LIABILITY ,a. �'
q D001W00211 (OR,NV RETRO) 01l01/04 01/01/05 EACHACCIDENT $ �� 7,000,000
A THEPROPRIETOR/ INCL D001W00212(AOS) O'I/O'I/O4 O'I/O'I/O5 DISEASE-POLICYLIMIT $ 'I,OOO,OOO
PARTNERS/EXECUTNE
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 1,000,000
TXER Limits: WC/EL/SIR
g EXCESS WORKER'S COMP. D001X00047(DC,FL,MA,OH,RI) 01/01/04 01/01/05 Statutory/$500,000/$500,000
B EXCESS WORKER'S COMP. D001X00046(CT,VA,NC,NJ) 01/01/04 01/01/05 Statutory/$100,000/$1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESISPECIAL ITEMS
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE IEASED PREMISES,BUT
ONLY TO THE EXTENT REQUIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.
VARIOUS LOCATIONS,STORE#161,735 8�944.
v W�i �S+"1zn v ,t� ��....":K A f ,�kl �dk . � � 4+�1' .. �,� .,� .. }€ � ,� :.: £ "::- 5
., . ...b� �,�...�.a� .,� ✓a,��.. ...�.��.a.� �x��.a...II"",�.� .��,.���,�:s �. .m, s.,.�.Y�. � _.,?�.fS3��z �k�:�,¢�'W..," '�� � �`a�'�'�' a ����. .., , u� . �,,,�'„� ,..w � .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
THE TOWN OF YARMOUTH 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
ATTN:BRUCE MURPHY
BOARD OF HEALTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
1146 ROUTE 28 ANY KIND UPON TNE COAAPANY, ITS AGENTS OR REPRESENTATIVES.
SOUTH YARMOUTH,MA 02664
xrxM��aeseNmwaxe� M USA IN���
Edward R Ford �C.�
�1�t31�:�5;("���} :� �� � `�, `��� ��P� �{'#�''��8'
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TQ OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #04-045 FEE: 75.00
In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter
11 I,S�tion 5 of the al Laws,a peimrt is hereby granted to:
CVS Phaumacy, Inc., 976 Route 28, South Yarmouth, MA
' Whose place of business is: CVS Pharmacv#0735
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Toum of Yarmouth
Pernut expires: December 31, 2004 BOARD oF HEAI.TH: Be��irc `�. C�'�»d� �l._`?S. '
A�il�l��«�1`, v�(���
VARIANCE EFFECTIVE 08/15/02: Ro��Bhow�, G�
Carpeting allowed in food aisles; e+�e� es'�i, Q./�.
Tiles required around all cooler areas.
February 6.2004 ruce G.Murphy �H, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BUARU OF HEALTH
PERMIT NUMBER: #04-030 FEE: $25.00
This is to Certify that CVS Pharmacv,Inc. d/b/a CVS Pharmacv#0735
976 Route 28 South Yannouth MA
IS HEREBY GRANTED A LICENSE
For � i.E DISTRTF3ITTION OF TOBACCO PRODUCTS
AS FER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This�er�it is ant�i�c��for��it�with Article VI of the Sani�tar�r Code of The Commonwealth of Massachusetts,and
exp es sooner suspended or revo
Feb , 6,2004 BOARD OF HEALTH: B�t f�'.�rts�t�. ��,/��., '
a��r�.� v:�e��
a�t�. a�, et�
a� �r,� a.�v.
ce .MiuP Y, ,R .
Director of Health
[� I� (c a - �,��
harma � � � ��o�_
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i-����_��; ���-r.
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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(s)of the renewal for the CVS/pharmacy
store(s) in your area.
Please send the per"m�s)/licens�(��a►rcfffif a�rv fatiure�newat auAfi�ations #'or-- - - -
this store to mv attention at the address below. After I 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, contact me at 401-770-3315
Sincerely,
�-
Anabela Sa
Licensing Assistant
Licensing Department
� � I
i
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
i
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`�� ' _ ' �`� CVS�` ��35
���f;�R.� TOWN OF YARMOUTH BOARD OF HEAL � ` ,� � , , ; �
o , � � � _, , , r
�� APPLICATION FOR LICENSE/PERMIT��' 0 '-� �` � �`� ' ^ � �� � J
. � �, .� '
� Y�,�f? j�, �. t,e� � � { ��:
* Please complete form and attach all necessary docum ` mber 31 2002. �
Failure to do so will result in the return of your a���ation packet. �-;�.�' v �5+, ;
T I M 3 � 5 - �!- S�'9(o
DDRE 'l� S.' �!o(o
�' s� � / Cv v�'✓ 9s
WN R/ N E• �L-
MANAGER'S NAME• �r��� !QJ,YnGta� ��ote, Y�� TEL # �(�-��v''.�3/S
1VLAi�ING ADDRES S• L►c n o��i nc�p pfi 1 GVS �1�v� �;l���c�YLSc.�cic�.t- �l ��`�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Poo�Operator(s) a�attac_h_a copy o_f the certification to this form.
I. l.
Pool operators rnust list a min' um of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopu onary Resuscitation (CPR). Please list these employees below and attach copies of
employee certification o this form. The Health Department will not use past years' records. You must
provide new copies d maintain a file at your place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: �1/�A' ;
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 file at your establishment.
1. 2.
___-�£��€33'� f3�E�-�-�vE:- - _-__ _ ___._ _ _-_ __—,_ '
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. I���s�'n I�rr�.� . S�� m�_ 2.
HEIML.ICH CERTIFICATIONS• /V�-
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 a�td maintain a file at your place of business.
L . 2•
3, 4.
RF.STAURANT SEATING: TOTAL#� '
OFFICE USE ONLY
L,ODGING:
• LICENSE R�QUIRED FEE PERMIT# LICENSE RI;QUIRGD FCG PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CRBIN $SC _Z10TEL $50
_INN $SO _CAMP $50 _SWIMMING POOL$75ea
LODGE $50 TftAILER PARK $50 _WHIRLPOOI, $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICEN5E REQUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-]00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE RBQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,
_<50 sq.ft. S45 _>25,OOOsq.ft. $200 _VENDING-FOOD $20
/ <25,000 sq.ft. S75 �03��8 _FRO"LEN DGSSt;R7' $35 /TOBACCO $25 ���=-�7a-
NAME CHANGE: S10 AMOUNT DUE _ $ /D�.GO '
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** '
�-3►�3
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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 Certificate of Warker'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 ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID:
YES�_ NO
NOTIt'F:Permits run annually from January 1 to December 31. I'I'IS YOUR RESPONSIBILITY TO R�TURN
THE COMPLETED APPLICATION(S) AND 12EQUIRED FEE(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL REN4VATIONS TO ANY FOOD ESTABLISHMENT, 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 SITE PLAN.
��DITIONAL REGULATIONS
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.
POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,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
('ONSLIMER Ai�VISORY:
Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products are required to post
Consumer Advisories.
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. Thses forms can be
obtained at the Health Department.
��QZ-�N--H�-C��C� --- -
- _ _ _ _ --
-- - — - - _- - ---
Frozen desserts must be tested on a monthly basis by a State certified lab. T'est results must be sent 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 witl�waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING•
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
- ��� �19/�a ����'T'[�R�• � '
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.. . — -----�
a ,��a �'�"�i�:
•� . � . Shirley McCartin
Licensing Coordinator
10/18/02
�
;
" ` 2�'ie Common�weal't�i of�Vlassachusetts �
1�epar�ment of IndustriaC.,�ccid�ents
, 600 �NasFiington Street �
V
Boston, �I� 02111 .
Workers' Compensation Insurance�ffidavit
APPlicant informarion: ,
Name: �jUS �r?Q.�t'1'ZQC�-1 � ..��' -- '
Location: �f�(,� �� �"� - �
�
. �j
_City: � ��►��N.C� Phone# t�d g' ��'/' O��
� I am a homeow}�er performiag all work myself.
, � I am a sole proprietor and have no one working in any capacity. - ,
I�I am an employer providing workers'compensation for my emgloyees worldng on this job.
Company Name: ��V�
K.I�a��iS '
Address: � G(/,S �.�l U'� City:j�tk?f 15�C'.k4� Phone# �i�)-7 7`0 5— /`,3�U
Insurax�ce Co: �(S F�G-� Policy# �U I l��C�rJO
�I am a sole proprietor,geaeial contractor,or homeowner(circle one)and have]ured the con�actors listed below
who have the followiug workers'compensation policies: '
Company Name:
Addmss: City: Phone#
Insurancc Co: Policy#
Comlpaay Name:
Address: City: Phone#
Insurance Co: Policy#
ATTACH ADDITIONAL SHEET IF NECESSARY
Fallure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposit�an of criminal
pEnatties of a fine up to$1,500.00 and/or one years'imprisonment as weil as civil penalties in the form of a STOP
WORK ORDER and a fine ef 5100.00 per day against me. I understand that a copy of this statement may be !
forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certi er the pa' ti o p 'ury that the info»nation pmvided abo is irue and correct.
Signature: � Date: �/� �
Print Name:S��'rJEc,{ �G�Ca,('�,iyt Phone#: �IU 1-�7?lU-��1�
Official Use Only: '
('�nr Tnvm• Pnrmit/T iranor�t Tl�h "
Cl Check if immediate msponse is required.
Qi i!= `!ya ��_ I� '�'/� �=� L�
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harma � ���=� H�-�. �.,.:��-�
p �y �_��:.�.���w-� �
November 2002
Dear Sir/Madam:
Enclosed please find completed application and/or invoice along with payment in the
appropriate amount to cover the cost of the renewal for the CVS/pharmacy store in
your area.
Please send the permit/license and/or any further renewal applications for this store
to my attention at the address below. When the licenses are issued, please send '
them to mv attention at the address below. After making the necessary copies
for my files, I will forward the originals to the stores for posting.
If you have any questions, feel free to contact me at 401-770-3315.
Sincerely,
�%'l,�t �C CCd�j�
�
Shirley McCartin '
Licensing Coordinator
Licensing Department
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
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PRoouc� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN:DENISE HART HOLDEH. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
200 CLARENDON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON, MA 02116
(617)421-0290 COMPANIES AFFORDING COVERAGE
COMPANY
S02908-ALL-LINES-03/04 p UNITED STATES FID 8�GUARANTY '
IN3URED COMPANY
ONE CVS DR VE ON AND ITS SUBSIDIARIES B � � �
WOONSOCKET,RI 02895 COMPANY
� 0 9 00
COMPANY
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THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIFiEMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFlCATE 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 POLJCIES.AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCEQ BY PAID CLAIMS.
CO 'rypE OF INSURANCE POIJCY NUMBER �UCY EFFECTIVE POUCY EXPIRATION LIMITS
LTR DATE(MM/DDIY`� DATE(MM/DD1Y1�
�ENERAL LIABi1JTY OENERAL AO(iREORATE $ 8,000,000
A X COAAMERCIAL OENERAL 11ABILITY PRODUCT3-COMP/0P AOO $ INCLUDED '
CLAIM3MADE�X OCCUR D001(]0011 01/01/03 01Po1b4 PER90NAL&ADMIWURY $ 4,000,000
.� OWNEFi'3 8,CONTRACTOR'3 PROT EACH OCCURRENCE $ 4,000,000 �
X S.I.R.$250,000 PREMSbPS FIRE DAMAOE(My one fire) $ ;
X S.I.R$1 MM-AfOINCLLIQUOR MED DCP(My ane peraon) $
AUTOMOBILE LIABILITY COMBINED3INOLE LIMIT $ 1,000,000
A X ANYAUTO D001A00087(AOS) 01l01/03 01l01b4
ALLOWNEDAUT03 D001V00010(MA) 01l01/03 01�1Ib4 BODILYINJURY $
9CHEDULEDAUT03 D001A00088(TX) Ot/01/03 01/Olro4 fPerperson)
X HIREDAUT08
BODIIY INJURY $
X NON-OWNEDAUTOS "(ARA) UMff $500,000' (PeracadenA
X 3ELF-INSURED PHY.qNO. "EXCESS OF'
"$500,000 S.I.R." PROPERTY DAMAOE $
f3ARA�E LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY: i'���,�},�,�?'r,,,,v� ,��� �;��
EACH ACCIDENT $
AOQREOATE $
EXCESS LIABWTY EACH OCCURRENCE $
UMBRELLA FORM AQ�REDATE $
OTHER THAN UMBRELLA FORM
A WORI�RS COMPENSATION AND D001 W00129 HI DED.) 01ro1/03 01/01/04 WC 3TATU- ' � �
� X ' ���,��„... 1�Ku,�:.r,
A EMPLOYERS'LIABIUTY ��W�12� OR�NV RETRO 01/01l03 01/01/04 TORYLIMIT9 ER , �.�...r��,: ,�r�''�'.'�,..s� : __$
� ) EACHACCIDENT $ 1,000,000
q THEPROPRIETOR/ INCL ��W�128�AOS) 01/01/03 01/O7/04 DI3EA9E-POUCYLIMIT
PARTNER3JEXECUTIVE $ �����
OfFiCER3 ARE: IXa 013EA3E-EACH EMPLCYEE $ �ppp ppp
OTHER UMITS: S.I.R.DED.
A IXCE33WORKER'3COMP. D001X00030(DC,FL,MA,OH,RI) Ol/Ol/03 01/01/04 $500,000 - $500,OOOSIR
A IXCE3sWORKER'3COMP. D001X00029(CT,NJ,NC,VA) 01�1/03 01/01b4 $100,000 - $1,000,OOOSIR
DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLE&ISPECIAL ITEMS
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE
EXTENT REQUIREO UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIWS LOCATIONS,STORE#161,735
&944.
._...__ . - - - -
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�"' ". : • ` ___�� � ' ' ' " � '_,�`' ` �: : r-�'t,,�;y��i� '_''r'� ,y .
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.. ... ..�:,:�__ _ + n. �..�'..::3�•.y-.�.`�.�:^-_s'S5 ... .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIE8 HEREIN BE CANCEILED BEFORE THE
THE TOWN OF YARMOUTH exa�raanoN�aTe rHeaeoF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
ATTN:BRUCE MURPHY 30 DAYS WRITTEN NOTICE TO THE CERTIFlCATE HOLDER NAMED TO TME LEFT,
BOARD OF HEALTH BUT FAIWRE TO MAIL SUCH NOTICE SHALL IMPOSE NO 08LIOATION OR LIA81L1TY OF ANY
1146 ROUTE 28
SOUTH YARMOUTH,MA 02664 IOND UPON THE INSURER AFFORaNO COVERAOE,ITS AOENTB OR REPRESENTATIVEB.
MARSH USA INC
Edward R Fad �R���
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-01 S FEE: $75.00
In accordance with re�uiations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 ofthe�eneral Laws,a permit is hereby granted to:
South Yarmouth CVS, Inc., 976 Route 28, South Yarmouth, MA
Whose place of business is: CVS Pharmacy#'735
Type of business: Retail Food Service less than 25.000 syuare feet
To operate a food establislunent in: Town of Yarmouth
Pernut e��res:December 31, 2003 soA1t�oF xE.�,�: �a�rlea� ��, �zaraac
_ __ __ _ __ _
_ _ _ _ _ __ __ _ -
__�tu fa.�cr,�c D:C�:�l:�:, `I/ie;c
VARIANCE EFFECTIVE O8/15/02: _ �d�ozt`j�.���, elark _ a_,
Carpeting allowed in food aisles; �a�tiek��ot'�
Tiles required azound all cooler azeas. 's�elea$�c. �'h
December 17 ,2002 _ ruce G.Murphy, , .,CHO
Director of Health
THE COMMONWEALTH.OF MASSACHUSETTS - ----- -
TOW�T-A�`YARMOUTH :;�_ ,
�
BOARD OF HEALTH ` ,,
PERMIT NUMBER: #03-012 _, FEE: $25.00 ;
` This is to Certify that South Yarmouth CV�:Inc. d/b/a CVS Phartnacy#?35 . '
� � 976 Route 28, South Yarmouth, MA� � �� �
'Ty`' IS HEREB�GRANT�D A LICENSE
�- ; �
For SALE AND DISTRIBUTION O�,TOBACCO PRQDLTCTSe F�� , : ; , . , .. � ;`_ * � �3. �. ,
,, - t � AS PER THE YARMOUTH BOARD O�,.HEALTH TOBACCO REGULATION. .
This�er�it is�ant�i���for�'t�+with Article VI o the S�ter�+Code of The Commonwealth of Massachusetts,and ;
exp es ece er e s sooner suspend�or re� e . ,
December 17 ;2002 BOARD OF HEALTH: (�� �eP�, �ucvuxct�c
_ . $'e.�.xti�c�. G�alo.�, 'JK D., `l/lee'
�o�art�, t�aoaa,c, �,(.ar� -
�a�tfc�'�Dor�cot�
r��c S�ak. �'fl.
ruce .MwP Y� • •,
Director of Heal
,
' ; .. `� CV S -�73S
� �* . T YARMOUTH BOARD OF HEALTH
ION FOR LICENSE/PERMIT-2002 � ��' ��3�
�a?�o i7a� C',�i9d. a-�+J �,:, � _:
* Please complete form and attach all necessary documents by December 31, 2001. F�ai�u�re�o�idc5��wi11 result in
the return of your application packet.
NAME OF ESTABLISHMENT• (';fJti YYk�Gf•i ���l TEL. #5`U�- 39�-��`'S�
LOCATION AI�DRESS• q,�t Q., `Z vU�2 dSs
MAILING ADDRESS: r ° �n t L Cus �.� �,�5vc?�i. 1 �'S
OWNER/CORPORATION NAME• ,����l�C� o�muv`� US I n� __
MANAGER'S NAME�,K►'�S-I-i n "i�Ct�.� TEL. #5�f- �3�NS�'(�
MAILING ADDRESS•�..i c��-�s i r�� �Qo� �'`� (' U S .1.�. -i I.UvC�nSv�'.�t.�, �K-'-1 U�9�
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 minim o o employees currently certified in basic water safety, standard First Aid
and Community Cardiopulm n citation(CPR). Please list these employees below and attach copies of
employee certifications to . T e Health Department will not_use past years' records. You must
provide new copies and m i a file at your place of business.
l. 2•
3. 4.
FOOD PR TECTION NA ER - CERTIFICATIONS:
All food service establishments ar re uired to have at least one full-time employee who is certified as a Food
Protection Manager, as define i te Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certifica s application. The Health Department will not use past years' records.
You must provide new copi n maintain a file at your establishment.
1. 2•
PERSON IN CHARGE: _ --- ------ - -- ------------- _ - -
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. I�.�'i S�h r`�k�t�, ��tt�, i'n�f . 2.
HFIMLICH CERTIFICATIONS•
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises t times. Please list your employees trained in anti-cholcing procedures below and
attach copies of employee i i tions to this form. The Health Department will not use past years' records.
You must provide n w o i a d maintain a file at�your place of business.
1. 2.
3, 4.
RESTAURANT SEATING: TOTAL#
4FFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B '$50 ' _CABIN $50 _MOTEL $50
INN $50 _CAMP $50 _SWIMMING POOL$SOea
LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SE�R.TS $150 COMMON VICT. $50 _WHOLESALE $75
R�TAIL SERVI�:.
LICENSE REQUIRED f�E PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 `�� �<25,000 sq.ft. $75 �O�-a�.a I TOBACCO $20 �Qc�"Oc7-�
_<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ 95.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�����
� �
5 �
M
.,.; �.� �Q ;.� i, _ .
, � �,,,. �,� �' - '
ADMINISTRATION ' ���Z� =�A� 1� � � �
I
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 Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
V4TORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001.
SEASONAL ESTABLISIIlVIENTS ARE TO CONTACT'TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
E
�
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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 SITE PLAN. ;
i
�
ADDITIONAL REGULATIONS �
POOLS ___-- -______ .---__----____` E
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected '
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �
by a State certified lab,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
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
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. Thses forms can be �
obtained at the Health Department. :
—_ ------ ------_---------------- --- - --
- -—------_�.—_ --------_ _
FROZEN DESSERTS: ' '
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 COOKING: j
Outdoor cooking,preparation,or display of any food pr c a retail or food service establishment is prohibited.
� .
DATE: �rY[o(vi SIGNATURE:
PRiNT NAME& TITL : a�l�� ��G�f� "T
09/11/O1
; `
�
` � ' . �
, The Commonwealth of Massachusetts
� � Department ojlndustrial.-�ccidents
o Of/Ice oJ/�s1lOs�is
600 Washington S�reet
' �� Boston, Mass. 02111
�'" °�y V4'orkers' Compensation insurance Affidavit
Annlicant intormation: P'Iease i1�7'T�.'i,�e
namr l:V � �lQ'}�VV��� ��'J`�
Locati�n: ��� ` Tv� a�
�it� �, �''� 1/yj�R/�.. NITI phone# �� '?J�l�'"C�Ij`�,(�
� t am a homeowner pzrtorming all work myself.
� f am a sole proprieror�-,', ha�e no one ��orkin� in am� capacit�•
�am an empio�er pro�.�din�workers' campensation for my employ�ees w•orkine on this job.
_ _ _ _ - - __ ,_ -..__ - _ - � ---- __
_ __ _ . __ _ ---— ---_—
comnan�� name: C,U S �h����.�il ��3��
address ���a � ��
sitt': �.. ���rnG�;L�� phone tf• �U�''��y�`�7��
insurance co. �.S �� oolicy# I)�����73U/
� I am a sole proprietor. Qeneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follo�cin_ ��orkzr� :ompensation polices:
sompanv name•
address•
titv• ohone tt•
insur�ncc co. policv# ,
S2�^Y name:
address•
slly: nhone il:
insurance co. eoiiev 1f
t
Failure to secure cover�ge as required uoder Secnoo 25A of MGL 1S2 a�iead to tbe iopoeifioa of uioi�tl ptedtla o(a O�e ap to Sl¢00.00 a�d/or
one years'imprisonment as w•ell a�eivil penaltie�in the fo�m of a STOP WORK ORDER aad a Aoe of 5100.00 a day apinst ma [a�detsta�d t6at a
eopy of tAy statement may be for.varded to the Ofiiee of Inveati��tion�of tbe DIA for eoven=e verifiudo�.
I do hrreby cerrij}•un er tbe porrts and penalties of per,�ury tkat!bt injornration providtd obovt ts true and conect
Signature �._. ' ll �r3-f��r)�
Print name ��.�1` )�7 l-P.vl l�''I� IL.U"`f b'�-- Phonel! �7d/-��U' ��J/�
.. o(Ticial use only do not Mrite in this area to be completed by eiry or town o111eia1
city or town: YA��IIT$ _ permitAicense M nBuildiog Dcpartmeat
OLieensiog Board
�cheek if immcdiate response is required 261 QSelectmen'�OlTice
�Healt6 Depanmeet
con�act person: ' - - phontN:_ �508) 398�Z231 e�t. nOther
„ :: �:_ .. ,,::: „ � e�l '.; 5.;p'* :: t � �
s �
a�:��i.��� ����`������ ��.���������
; .,. , ;. . , � , �E .,��. .., ,,.._ -�- �-, , __ �..,�.
` DATE(MM/DD/YY �
r: ,, . �
v..: � � r ... ,._ r , 1/04/02 �
��.
PRoouceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN:DENISE HART HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR '
200 CLARENDON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON, MA 02116 COMPANIES AFFORDIµ�a COVERAGE
(617J 421-0290
_ _ _ __
___ _
�, -= COMPANY
� � ' -A UNITED STATES FID&GUARANTY
S02908-ALL-LINES-02/03 ,
INSURED ;;.. . _ :.COMPANY _ ._ '
:.
CVS CORPORATION AND ITS SUBSIDIARI�S � ` B ' , ' - � _ '
ONE CVS DRIVE '
WOONSOCKET,RI 02895 _ coMPnNv
_. _
C
COMPANY
D
�����A��s °',;,, Tt�is cert�t���i�ei�ed�s and r�p��ar�r;��a���d.�rti�ate. � . .:.,,
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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFECTIVE POUCY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYY) DATE(MM/DD/YY) LIMITS
CaENERALLIABILITY GENERALAGGREGATE $ H2OOO,OOO
A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ INCLUDED .
CLAIMSMADE � OCCUR D001Q00005 01/01/02 01/01/03 PERSONAL&ADVINJURY $ 4,���,000
ONMER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
X S.I.R.$250,000 PREMS/OPS FIRE DAMAGE(Any one fire) $ ,
X S.I.R$1 MM-A/O INCL.LIQU MED EXP(My one person) $
AUTOMOBILE CIABILITY
COMBINED SINGLE LIMIT $ 'I,OOO,OOO
A . X ANY AUTo ' D001 A00024(AOS) 01/01/02 01/01/03
ALLQWNEDAUTO$ D001V00005(�� Q�/Q�/QQ O'I/O'I/O3 -- BODILYINJURY. $
SCHEDULEDAUTOS D001A00025(TX) Q1/01/02 �7/0�/03 (Perparson)' '
x HIRED AUTOS _ BODILY INJURY . . $
X NON-OWNEDAUTOS �(MA) LIMIT $500,000 (Peraccident) . -.- - -.
X SELF-INSURED PHY.DMG. 'EXCESS OF PROPeRrr oAnnnce $
'$500,000 S.I.R.'
GARAGE IJABILITY
AUTOONLY-EAACCIDENT $
�
ANY AUTO OTHER THAN AUTO ONLY.
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELL4 FORM $
A WORKERS COMPENSATIdIi AND DOO'I WOOOS'I OR `
EMPLOYERS'LIABILITY � � O'I/O'I/OZ O'I/O'I/O3 X STATUTORYLIMITS
A D001W00050(DED) 01/01/02 01/01/03 EACHACCIDENT $ 1,000,000
A THEPROPRIETOR/ INCL D001W00052(HI) 01/01/02 01/01l03 DISEASE-POLICYLIMIT $ �,���,���
A Pa,RTNERS�XECurlve p1/Ol/02 01/01/03
OFFICERSARE: EXCL D001X00011 S.I.R.$SOOOOO DISEASE-EACHEMPLOYEE $ �,OOO,OOO
OTHER
DESCRIPiION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL 17EMS LIMITS MAY HAVE BEEN REDUCED BY PAID CLAIMS AND MAY NAVE DEDUCTIBLES OR RETENTIONS.
ERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT
NLY TO THE EXTENT REQUIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.STORE
161,735 8�944.
��'�i�'���"�����: lti�rG�E�4{���b1 ',: , C���L�,� ,� �� _ � �;..:
��
:.� .. � . ,.,,�. , . �- � a .
� _.;: _
� . _.....� � .. , �� s
SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
THE TOWN OF YARMOUTH EXPIRATION DATE THEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
BOARD OF HEALTH 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
ATTN:BRUCE MURPHY BUT FAILURE TO MAII SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
1146 ROUTE 28
SOUTH YARMOUTH,MA OZBB4 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
xrxH�oxa�c�aessNmioaa� H USA 1! .���/J
Edward R Ford Ta'���
�k..-? ,..,, �, � � � ,� ;�� ���. .
�G�fIRf?���5 �t$�,�� ,.�, �. ._ �'�� , y :.
� �`� i�E3Ft�'!=��1�F1}t�'"fI At I
�_ � y���
� � ?
harma �
p cY
November 27, 2001
Dear Sir/Madam:
Enclosed please#ind completed application and/or invoice along with payment in the
appro�riate amount to cover the cost of the renewal for the CVS/pharmacy store in
your area.
Please send the permit/license and/or any further renewal applications for this store .
to my attention at the address below. After making a copy of the permit/license for
my files, I will send the original to the store.
If you have any questions, feel free to contact me at 401-770-3315.
Sincerely, ��
, �
�'br,�c �c C��,;t. �� o�
� '� , �.d �,��
Shirley McCartin Q�� J ��5� P
Licensing Assistant � �� ��o����
O.�` N\
Licensing Department �4`�',�P�
'���p��
5
�"� � � ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
���- ' ;
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-030 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
South Ya�rmouth CVS, Inc_�976 Main StreetlRoute 28, South Yarmouth, MA
Whose place of business is: CVS/Pharmacy#735
Type of business: Retail Food Service less than 25.000 sc�uare feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31.2002 BOARD OF HEALTH: ��s� ��, elcav�,rak
�e.ifa.xu�D. G�ia�calaa. �11.D.. 2/�ce
VARIANCE EFFECTIVE 08/15/02: ��zt� S'�tou�, (�
Carpeting allowed in food aisles; �a.�tick��atiAwt�
Tiles required around all cooler areas. �feee.a $�, ��
August 15 ,2402 ruce G. urphy ,R.S.,CHO
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-024 FEE: $20.00
This is to Certify that South Yarmouth CVS,Inc. d/b/a CVS/Pharmacy#735
976 Route 28. South Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 3 l.2002 unless sooner suspended or revoked.
April 17 ,2002 BOARD OF HEALTH: �rled's� i�dlikez, ��ia�
�iie.�ajao�ruc D. G�a7da.r. 'I1�?�., 2/iee
Z'o�it? �zoawc, �
�i��itek'��xo�
'�fileoc .$i�, ,�72
. u y, . .,
Director of Health
.� .s ` ,_-� r��v5 vH�9�2MAc �'.Z
. ;� �� �s:� t � 9� ' - i���' �' `r�)
� E� � �
TOWN OF YARMOUTH BO � � c#����i��' p�� 0 5 Z���
APPLICATION FOR LICENSE/PERMIT-200 q��
C��'' �� "�i`�� HEALTH DEPT.
* Please complete form and attach all necessary documents by December 31, 2000.�ail o o so will result in
the return of your application packet.
---------------------------------------------------------------------------------------------------------------------------------------------
�1�ME OF ESTAB�I$HMENT: C,U S,� ��"�' .(MG7 r�r� ?�� �,� •�,#..���21r�- ��G'�
� �i , --�--
. i =�. S _ _g �
OWNER/CORPORATION�; ,���n�r��u��,w, �at�y )n� ,
�
c t Cfl r' u '
-------------------------------------------------------------------•-------------------------------------------------------------------------
POOL CERTIFICAT.�ONS: n1�0�'
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s�and attach a copy of the certification to tlus form.
l. 2.
Pool operators must list a minimum of two emplayees 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 Deparlment will not use past years' records. You must
provide new copies and maintain a file at your place of business.
L 2.
3. 4. �
HEIMLICH CERTIFI�;ATIONS: nl��
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.
RESTAURANT SEATING�OTAL# NON-SM�KING SEATS: TOTAL#
--------------------------------------------------------------------------------------------------------------------------------------------
_ - - _ _- __--- -------- --_
------ ---——__ __--- -- - _--- __ __ _ _
_ ___ _ _ _
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED , FBE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&s $so c��r $so
_INN $50 TCAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
�'001��'RVICE: �
NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for
food protection manager certificallon is October 1,2001. �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 _WHOLESALE $75
�TAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 �TOBACCO $20 #D( - c�
/ �5,000 sq.ft. $75 �+'��'1`��Q' ____FROZEN DESSERT �35
_>25,000 sq.ft. $200
NAME CHAN�� $10
AMOUNT DUE _ $ gS•00
**�'**PLEASE 3'URN OVER AND�MPLETE OTHER SIDE OF FOKM'���"�* — :
�
,.� s
, �
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 Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth ta��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE�OMPI,ETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLISH1VbII�T1TS ARE TO CONTACT THE HEALTH DEPAR'TMENT FOR lNSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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 SITE PLAN. :
ADDITIONAL REGULATIONS
POOLS '
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State
certified lab,prior to opemng,and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing. . ,
FOOD SERVICE
N W,.�TATE SANI�Y CODE FOR FOOD ESTABLISHMENTS�
�
The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR
590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection
manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As sta.ted in 105 CMR 590.000(K),enforcement
of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which s�ll
or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories.
��RiNG POLICY•
Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Department by filing the
required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be
obtained at the Health Departrnent. `
_ -- --- _ _ _ - - - --- _
-__ ._ _ _
_ i
F1_�OZN DESSERT5: ;
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failuxe to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
QUTSIDE CAFES; '
Outside cafes(i.e.,outdoor searing with waiter/waitress service),must have prior approval from the Board of Health. i
i
OUTDOOR COOKING: j
Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prohibited. ,
DATE: j I �?�c%l C1c.� SIGNATURE: P �� '
PRINT NAME&TITLE: 5hirley McCartin
Licensing Assistant
11/16/00 �
: .-
�
' ' �
_ The Commonwealth ojMassachusetts
: W Department ojlndustria!�ccidents
� o Olf/ceof/�resU�s�liis
� 600 Washington Slreet
� �.� Boston,Mass. OZlll
�'" " Workers' Compensation Insurance Affidavit
A.Rniicant information: PfeasePlilP1'Ti�'bit� ���
namr� �'i1�i I ��Q,11 VYIC,IL���3 J
L
1�,s:,icon: q�J�� 1'�Qr_� �
�� J• �Q/ti VY)(/Z,i� Ahone# �U� 3��'����o
� I am a homeowner pertorming all work myself.
� I am a sole proprietor��� ha�e no one���orking in am•capaciry
[�I�am an employer pro�iding workers' compensation for my employ�ees working on this job.
com�an�• name� W� -- .
�ddress• I ��S �CJY�U� _
�X� L�/[.)�/✓�SU C��- �,� ���7'-� �hone q• `7C/�- ��OS�/��
�
insur�nce co (.�-SM4�-� (?�L-� ��-� ���L2,�'1 vP �v policy# u� ?J`-7 7'"Q �J'�J
� I am a sole proprietor. _eneral contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below� „ho ha�e �
the follo��in���orker' �ompensation polices:
com a�nv oame• ,
^u�ress• �,
S�' p hone#•
insur�nce co �,►licy#
i
_ _______ _companv namr
addrets• --
ciri. ohone 1�•
insuran�co ' p9�Y M
Failure to secure coverage as required under Sectioo 25A of MGL 1S2 as lad to tbe iopaitioo of erioi�al ptaalda of a 6�e op to Sl¢00.00 a�d/or
oae yean'imprisonment a�w•clt as eivil penaldes io the form ot a STOP WORK ORDER and a Aee of 5100.00 a day apiost ma I a�dersta�d t6at a
copy of thH satement may bc forwarded to the ORee of Investigatioa�otthe DIA tor eovenge veriliutio�.
/do hrreby certijy�under rhe pains d penalties ojpery'ury thar!he injornwtion provided abovt is true apd conect
Signamrc eu
�,/�fa�
Print name )�l6 I�Lf r'"l� ��VI Phone�t �/G/��7�- �3/S�
.. olTicial use only do not w rite in this aref to be completed by tiry or town oltitial
city or town• Y��DTQ _ permiNicense# nBuilding Departmeet
OLicensiog Board
�check if immediate respoese is required 261 ❑Selectmen's OfTiee
�Hralt6 Departmeet
contact person: phont#;_ �508} 398t2231 ext. nOther
Irevised i;95 PJA1 �'
u .: :" . \ :. S . . � .. yf, ..�' , ,..:;
�
�11:/11:11� ��z �T?�� � �� �. .., � ���.�� � �: � � �� � oi�o9ioi ►
s
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,
�
�. _ ����� � � _.., _� � �_ , , A ,..__r� ,., ,x ..�_
Y
PRODUCER THIS CERTIFICATE IS 13SUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN:DENISE HART HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
200 CLARENDON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON, MA 02716 COMPANIES AFFORDING COVERAGE
(617)421-0290
; _ , ' COMPANY
315000-ALL-LINES-00/01 °' - A UNITED STATES FID&GUARANTY
INSUR�Q.. � _ _v COMPANY ,,`
CVS CORPORATION AND ITS SUBSIDIARIES =� ' {' :� ' ` �
ONE CVSDRIVE__:;�. _- _ __ , '
WOQN$G�CK�T,RI 02895 < ,• `coMPiwv , ; .. '
w,. .
, ��... � _„ . , .. .�� _ _ -
. ...._� COMPANY . . ....
. _ _ _.
_.
p _ __. __. _ _ .__.
.�.
'�� � �� ���' �� � ��i�t� ,� �' :,�`�� �� '�
r ���
,..,,., , .:. . .:.. , .- ��.-,:,, . _ , ,:, , .. ���,. .. � . „r_....<,_.,. .�;:a�o..✓,:,,... .,.n�'r,,.,
u.:� �_..s...,_,_ . .... .... ���._.,, �� �,... ... ._,. „ .,�;:. , '!'.
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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POUCY EFfECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MIA/DD/YY)
GENERAL LIABILITY
GENERALAGGREGATE $ S,OOO,OOO
A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ INCLUDED
;.�.�,-;::, CLAIMSMADE � OCCUR DRE5247401 01/�1/01 Ol/01/02 PERSONAL&ADVINJURY $ 1,750,00�
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,750,000
X S.I.R.-$250,000 FIRE DAMAGE(My orre fire) $
MED EXP(My one person) $
AUTOMOBILE 11ABIUTY
A_,., .X ,��Tp , DRE5247707 (AOS) 01/01/Oa. 01/01/02 conneiNeosiNG�EUMiT - $ - --- 1,000,000
' ALl.OY�EDAUTOS DRE5Z4�6O'I (MA� O'I/O'I/O'I . _O'I/O'I/OZ BODILYINJURY
`,, , . . ,. ,,_ _ �Per person) _ _. . _ .$ _ __
SCHEDULEDAUTOS' DRE5247501 (TX) 01/01/01 01/01/02
X HIREDAUTOS __ - ' _ BODILYINJURY __ $ _
X NON-OWNEDAUTOS (MA� LIMIT $7�JO,OOO (Peraccident), , _ _
X SEIF-INSURED PHY.DMG. EXCESS OF PROPERn,oa�nA�E $
$250,000 S.I.R. '
GARAGE LIABIUTY AUTO ONIY-EA ACCI�ENT $
� iri r ������<
ANY AUTO OTHER THAN AUTO ONLY i,��,i, ;.;
EACH ACCIDENT $
AGGREGATE �
EXCESS LIABIUTY
EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
---- ---- -- OTHERTHANUMBRE44°�FORM-----_ __�_ - —_ _. . _ .�- --- - -- -- --- _ $- . _ ___
WORKERS COMPENSATION AND X STATUTORY LIMITS ' `
EMPLOYERS'LIABILITY
q DRE5247101 (OR) 01/01/01 O'I/O'I/OZ EqCHACCIDENT $ 1,000,000
A THEPROPRIETOR/ INCL ORE5247201 O�/Ol/Ol O1/O1/OZ DISEASE-POLICYLIMIT $ 1,000,000 '
A PARTNERS/EXECUTIVE 01/01/01 01/01/02
oFFiCeRs aRe: exc� DRE5247301 S.I.R.$SOO OOO DISEASE-EACH EMPLOYEE $ �,OOO,OOO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESISPECIAL ITEMS UMITS MAY HAVE BEEN REDUCED BY PAID CU►IMS AND MAY HAVE DEDUCTIBLES OR RETENTIONS.
ERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMiSES,BUT
NLY TO THE EXTENT REQUIRED UNDER THE IEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.STORE
161,735&944.
����N� �� '3��S,c,4������������ '���� ��'� m.. T.t��+����� 3 �� � �:.�':r �'. � �' Y x• .
n.:�� �...� x•,. ��? z �, ���,�� �..,:�.. , s� ,�,.,,.r r,;�����.�,��� u� �, �..�� ,���I ��,�:a� x.. 'r.�e"
SHOULD ANY OF TNE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
THE TOWN OF YARMOUTH EXPIRATION DATE TNEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
BOARD OF HEALTH HO DAYS WRITTEN NOTICE TO THE CER7IFICATE HOLDER NAMED TO THE LEFT,
ATTN:BRUCE MURPHY BUT FAILURE TO MAIL SUCN NOTICE SHALL IMPOSE NO OBUGATION OR LIABILITY OF
1146 ROUTE 28
SOUTH YARMOUTH,MA 02664 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
�rzM��o�aeseNmaaa� H USA I! ��
,:: �..���.,. � �� � � � � �� Etl x �� , �>
ward Ford .
�ill������� ��,a ` �4�m���u,�. r,�3 ���� rs� r,E �a �..��s i � �R���t��iC�Fi;���'
� �� r� � ,,� ��� � � �. y���$�, �� DATE MM/DD/YY
�/1//'r'/m � � �c���� �' a������ ��,��� n,� �;a � �ai��� ( )
�-_ �:..�. _..>e __. „ �., . _ ,�.�.. ���.e���.aq.� _. _ �F � ����' ���,�.,, ���� O1/09/O1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ATTN:DENISE HART HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
200 CLARENDON STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON, MA 02116
(617)421-0290 COMPANIES AFFORDING COVERAGE
COMPANY
, _
31500b-ALL-LINES-00/01� " ' '' A UNITED STATES FID&,GUARANTY
INSURE'D; .. CQMPANY
cvs c�aPo�ari��v A��irs suBsio�;aRiEs ���� ,�::� =. � .B � ��� ���- G�3 C��f� a;_�I �-� , . _ _ �
ONE CVS"I3RIVE' : -, -. . :
u110QN$Q�T,RI 02895 t ; connP,vNv ` ' 1�Q� � � '
„ � ,r , _,.._ , .. _. ,,„ - _ . _
_ ,. _�
ZOQ1 ,..
,. _
.., .. _: _. _ __ _ _. _._ _ COMPANY _ _ _ HE�L 1,�,DEPT..
_ D
,� � �� , � � � �,��, � , � � � ,
y���{ ��y, },�
..�:��; ,..�,.,..:.u. �; :�>. . ......,,�:� :t,,�,['r'�,.,�,���`!l,.,��1` . , .`�,.,� .:;. .. �§� 5�?!,,, .. . �'� .� . �.�,,,,�i.�,/'�F..;.`�§��r����!.�,�g� . . 5sk.�,4s�;�r,
- �.> ,- 4s:.
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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFECTIVE POLICY EXPIRATION
L7R TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDDlYY) LIMITS
GENERAL LIABWTY
GENERALAGGREGATE $ 5,000,000
A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ INCLUDED
CIAIMSMADE �OCCUR DRE5247407 07/01/01 O'I/01/02 PERSONAL8ADVINJURY $ 1,75�,�0�
OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $ �,7SO,OOO
X S.I.R.-$250,000 __ FIRE DAMAGE(My one fire) $
MED EXP(My one person) $
AUTOMOBILE LIABILITY -
COMBINED SINGLE LIMIT
A � X ntv�Au7o<„; - ,. DRE5247701 (AOS) 01/07/0+1' 01/01/02 $ 1,000,000
, > �.` aioWntE�nuros DRE5247601 (MA) O'I/O°I/O'I - -O'I/OUOZ - -- BODIIYINJURY__
,, , ,�,; , . , _.,. - $ __ __
„ �CHeDu[EisauTos" � ``� DRE5247501 (TX) 01/01(QT 01/07/02 �P��fSOf�
X HIRED AUTOS . .: _ _ BODILY INJURY $_ _
, X ;,; (Per accident) , _ _
NON-OWNED AUTOS (MA) LIMIT $750,000
X SELF-INSURED PHY.DMG. EXCESS OF PRoaeRrr�a�nnace $
$250 000 S.I.R.
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT $
��A�Sa S y z�' �' .
ANY AUTO OTHER THAN AUTO ONLY '� �•�y ,�c„��� :
_ �, ,
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
QTHER THAH UMBRELI4 FORM_- �
- - -- -- ----- ---- _ _ _ _ __ __ ,
WORKERS COMPENSATION AND g ; ;�: J
EMPLOYERS'LIA61lJTY X STATUTORY LIMITS !
,a,.
A DRE5247101 (OR) 01/01/01 01/01/02 EqCHACCIDENT $ � 1,000,0004
A THEPROPRIETOR/ INCL DRE5247201 O1/Ol/Ol Ol/O1/OZ DISEASE-POLICYLIMIT $ 'I,OOO,OOO
A PARTNERS/EXECUTIVE O'I/O'I/O'I O'I/O'I/OZ
oFFiceRs�e: exc� DRE5247301 S.I.R.$5OO OOO DISEASE-EACH EMPLOYEE $ 7,OOO,OOO
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS LIMITS MAY HAVE BEEN REDUCED BY PAID CLAIMS AND MAY NAVE DEDUCTIBLES OR RETENTIONS. :
ERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT
NLY TO THE EXTENT REQUIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT.
ARIOUS LOCATIONS,STORE#161,735&944.
iM �,�, �d� 2�� . � , „k�i�� �C�� . „ ��5�� � ����. -bwm'�`T � . ..���F� �e�� '�� £k`s,�� � �35� �
e..,..�n .,,.,.<.z�,.. '+� .,� . 1C .f: �s'+ � �� .
, . �_... .... _. ���.,._, . _ �H .. _ � 6;__ ��� � ��. � . a�ts€.��, �
SNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE�CANCELLED BEFORE THE
THE TOWN OF YARMOUTH EXPIRATION DATE THEREOF,TNE INSURANCE COMPANY WILL ENDEAVOR TO MAIL
ATTN:BRUCE MURPHY 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BOARD OF HEALTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Of
1146 ROUTE 28
SOUTH YARMOUTH,MA OZB64 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
<:, X�
.
Edwar�d�R�F�� H USA 1 �p
� < � �.� � ���� r,�� d�� �� 1�� ���
sE �� F � � � � � �
�
�s�.>= _ .„. � `
�}��."��m'�`,$ x,rr.�. . , ��5� �..,�..� �.- �.. . � � ,r:�� _ � K' ^ ��
� .. . -.
- - ��,� ,A.`� .o:� a: � .
` TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #O1-029 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
�rn�th Y rmo � h VS, inc", 976 Main StrPe /Ro � 8, 40 �th Y rmo � h, 1��A
Whose place of business is: CVS/Pharmacv#735
Type of business: Retail Food Service less than 25 000 square feet
To operate a food establishment in: Tawn of Yarmouth
Permit expires: December 31.2001 BOARD OF HEALTH: �d� �e�ed, �iavrarra,�
�lia�ea s� �a�. `�/ice ��nas�
ttEs'i'RtcTTorrs r�atvY: Prepackaged foods only- �o��, t',��tou�, ��
Chips,candy,chewing gum,soda. �tQ� d �.�
e.r 'tfao�iot D. ��. � .
. i
Februarv 13 .2001 Bruce G.Murphy,MPH,R .,C
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #O 1-024 FEE: $20.00
This is to Certify that South Yarmouth CVS, Inc d/b/a CVS/Pharmacv#7�S
_ 976 Route 28 outh Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTIZi3UTION OF TOBA ('(�PRC) CTS
AS PER TH�Y�RM(�UTH BOA OF i TN'rOBA �'O F TULATION
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
Februarv 13 ,2001 BOARD OF HEALTH: �� ���q., (��
�ra� s'�. i�e��� `l/ice Llravr�uaoi
�o�rt�. �;'noau�c, ��
I1l'�cl�ael 0 �.L�a�;��i
�' a�,ci�c D. , 7�
��
Dir ctor of Health � �
- ���3a 6�� CUS � �7��
�
� ' � ���"� � [E � I� DMC� L�
', � TOWN OF YARMOU �R��OF.$EALTH
> ' APPLICATION F���1"E�tMIT-Z000NOV 1 '7��'(� 1 1999
,,. � � �
� ...y' q �,.:.'
'- � LTH PT.
* Please complete form and attach al1 necessary doc��ients by December 31, 1999. Fail n
the return of your application packet.
------------�E-------------------------------------- --f-----------�----------- --------------------------#----------------------_.
L A I
L D
N
MANAG�R'��NAME: , TEL: -
MAII.ING ADDRESS: �i6,r o,,,,�.a,.Q- l T,�T�vuz�'ai!�--���,.v l.�'�,�_c ta c�r����' c�tcr4'j
POOL CERTIFICATIONS:.
The poot supervisor must be certified as a Pool Operator, as required by new State law, Please list the
desi�nated Pool Operator(sJ-arizl attach a copy of the certificati�n to tl�is form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Comrnunity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Hea,tth Department will not use past years' records. You must provide
new capies and maintain a file at your place of business.
1. 2.
3. 4.
HEIMLICH CERTIFICATIQNS:
All food service establishments with 25 seats or more must have at least ane employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list yt�ur 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.
_�TAi�I���'-��A�'1Nfr: T4�-# — -----�TOAi-�BI�-���4TS:TE��4t,#- -__----- - _. _
-----------_��-----------------------------------------------------------------�_..----------------------------------------------------_-----•
QFFICE U5E(?��
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQULRED FEE PERMIT#
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SWINIMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 I TOBACCO $20 �o_.�2L-1 I
I <25,000 sq.ft. $75 �5- �y2�C-I,3 FROZEN DESSERT $35 �
_>25,000 sq.ft. $200
rIAME CHANGE: $10
AMOUNT DUE = $ G�'J—
� - *'"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""'""
; '
�.r..._ ...,._ _ . _} ,
` � ADMINIST'RATION t
�
L�NDER CHAPTER 15� SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED -
P��O �QI,D I$S�T„�� �,�T�F OR RENEWAL OF ANY LICENSE QR PERNIIT TO OPERATE A BUSINESS TF A�
;°���@1�-0�-�Efl��NY DOES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSATION �
f
INSUR�NCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT `
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�'
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID►PRIOR TO RENEWAL OR ISSUANCE t�F
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES NO
NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FE�(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPEI�tING FOR THE SEASON.
ALL RENOVATIONS TO ANY F(30D ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW t
EQUIPMENT,ETC.),MUST BE ItEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO ;
CONIlV�NCEMENT. RENOVATIONS M�YY REQUIRE A SITE PLAN.
AL��ITIONAL REGULATI(,�NS
i
POOLS �
POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLUSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND T�3E WATER TESTED FOR
PSEUDOMONAS, TQTAL COLIF4RM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAS,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING:EVERY OUTDOOR IN GROUND SVVIIVINIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE �
CATERING PQLICY: '
ANYONE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NO'TIFY TF�YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM ?2
HOURS PRIOR TO TI-� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH
DEPAR.TMENT.
FROZEN DE SS ERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI-�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI-�
SUSPENSI�N OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,TI-�ABOVE TERMS HAVE i
BEEN MET.
_---
- _ _ _ . ,
QUTSIDE CAFES:
OIJTSIDE CAFES(i,e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLT5T HAVE PRIOR
APPROVAL FRQM TI�BOARU OF HEALTH.
(?UTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD
SERVICE ESTABLISHMENT IS PRUHIBITED.
i
DATE:� �- � ��j 9 SIGNATURE: '
PR1NT NAME 8L TITLE: Maria A. Charland
Licensing Clerk .
11/12/99 • �
,
r
,` �' �
' The Commonwealth of MassQc/tusetts
.
� � Departmen[ojlndustrial.-�ccidents
' T o OflJceol/er�stJostliis
� 600 Washington Street
' �` Boston,Mass. 02111
�N �•y V4'orkers' Compensation Insurance Affidavit
�Rnlicant information: P►ess�pRil'�TTe�.'i�r
n�m�� ,�','
� � a
�it� _ �07 l � ll l.�/(4�► a/VIO't t..�C �J^� l'3�( o( D � ohone�
� I am a homeow�ner pert�rming all work myself. ^
� I am a sole proprieror�r.,', ha�e no one aorkin_ in am•capacin�
� I am an emplo�er pro>idin_wnrkers' compensation for rn��employe�s uorkine on this job.
comoan�• name• ,� Q � .--.f p,l JIQ�J a a �� l " �` ��(.vl,L
address
��t�" nhone N•
i�surance co. policy t!
� I am a sole proprietor. :eneral contractor. or homeowner(circle oneJ and ha�•e hired the contracton listed below ��ho ha�e
the follu��in_ ��orkzr� �ompensation polices:
s4m[�anv name:
address•
���" ohone#•
insurancc co. oolicv!!
com�2ny name• —-- ----------
�d d ress•
�'� ohoee If•
insuranc�so. �(�n+*
t
Faiiure to secure covera;e as required unde�Seenoo 2SA o(MGL 152 n�lad to t0e iepaidoe of trivi�fi pt�dtla of a O�e op to 51�00.00 a�d/or
oae yean'imprisonment��w•eil a�civil pendtla io the form of a STOP WORK ORDER aed�tiee of SI00.00 t dar q�iott ma I a�dtrsta�d t5at a
copy of tAa statement may be fonwrded to the Of(iee of Invatig�tioo�of the DIA(�eoven�e veritkaeio�.
I do hrreby cenif}�under e 'ns vnd p�nal�ies of perjury tkot Nre injormation provrd�d abovt is trtte and eorreet
t
Signature � T_���=�'�
Mana . ar an
Print name Lice�sing Clerk Phone# T� I' �7(�� ���y
.. o(Ticial use onlv do not..►ite in this area to be completed by citv or towa otfleial
ciry or town: Y�M�IIT$ _ permitAicense N nBuiidiog Departmeat
�Lieeosiog Board
�check i(immediate respoese i�required 261 �Stieetmen'�Otfice
(508� 398-2231 �t. OHea1tA Depanment
contact person: phone N:_ ____, _ nOther
... .��. .< .I��, .
!
TOWN OF YARMOUTH
' BOARD OF HEALTH
' ' PERMIT TO OPERATE A FOOD ESTABLISHMENT
,i
I PERMIT NUMBER: Y2K-13 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
_ So � h Y rm� �th (:V�,,,j�, 976 RoLte 28, ��Lth YarmoLth, MA
Whose place of business is: CVS/Pharma�#735
Type of business: Retail Food Service less than 25.000 sauare feet
To operate a food establishment in: Town of Yannouth
Permit expires: December 31, 2000 BOARD OF HEALTH:�d�/. �Bf,��, C'��r.��
�oan� �ullivan, �I'/., Vice �hairma
RESTRtCTIotvs IF At�1Y: Prepackaged foods only- �od erE� �rou,ry �ler�
Chips,candy,chewing gum,soda. adriet�e�a�oGa�iy-../�toopea
ic� oCou �lin
December 7 , 19�9 ruce G. Murphy,MPH, .S., O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-11 FEE: $20.00
Tt►is is to Certit'y that South Yannouth CVS. Inc. d/b/a CVS/Phannacv#735
976 Route 28. South Yarmouth,MA
IS HEREBY GRANTED A LICENSE
For SALE AN�DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE Y�RI�OUTH BO�R� OF HEALTH TOBACCO REGULATION.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonweaith of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
December 7 , 19� BOARD OF HEALTH: �c�� ��ttee, C�iairman
�oan� �ulLivan, K.//., Vice l.�ivman
�obert.}. 9�rown� C,[e�h
�a�rielle�a�oG����ooPes
�L o 'rc
ruce . urp y, . .,
Director of Health
� _ 9 U���S3�� ��v� � �35
" - TOWN OF YARMOUTH BOARD OF H�ALTH � � � � � � � D
�
e APPLICATION FOR LICENSE/PERMIT- 1�9�9 �AN O 6 �999 �
* Please complete form and attach all necessary documents by December 31, 1998. Failure t
the return of your application packet.
-------------------T�------------------- ----------- ------------------ ----�----------------------------# ---.-9y���o
A I D S•
2 �
N �
ER' rn� L # 05�- �7- b
�G ADDRES S� �lo I ,t� aX
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as rec�,uired by new State law. Please listi the
designated Pool Operator(s) and attach a copy of the certification to tivs form.
-
. _ __ _ __ _
1. _ _ 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and ,
Commwuty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to ttus form. The Health Department will not use past years' records. You must provide new
copies and maintain a fde at your place of business.
L 2.
3. 4.
�
HEIlVILICH 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 a11 times. Please list your employees trained in anti-choking procedures below and
atta.ch copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fite at your place of business.
.
l. 2.
3. 4.
RESTAITRANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
------------------------------------ - _ __ _
_ _ f3I�FICE �SE Q�TLY __ ___----------------,- --_ _ _
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $SQ SV'�]NaVIVIMING POOL $SOea.
`WHIRI.POOL $25ea.
FOOD SERVICE: '
LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NUN-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAIL SE�tVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. �45 � TOBACCO $20 _9Q-�?
�<25,000 sq.ft. $75 �Q'�p FROZEN DESSERT $25
>25,000 sq.ft. $200
�tAME CHANGE: $10
AMOUNT DUE _ $ Q v --
R�!R R#pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""`•" .
�
�
. •
�
� � ADMINISTRATION ,
` UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,'THE TOWN OF YARMOUTH IS NOW REQUIRED ` �
TO HOI.D ISSUA�TCE OR RENEWAL OF ANY LICENSE OR PERMIT TQ OPERATE A BUSINESS IF A �
PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'5 COMPENSATION �
INSURANCE. THE ATTACHED STA'Y'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT �
MUST BE COMPLETED AND SiGNED, OR
CERT. OF INSURANCE ATTACHED
�
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
NOTICE: PERNIITS RUN ANNtJALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN 'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998. '
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i
TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I
i
t
C
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SVVIlVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
'THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND THE WATER TESTED FOR
� PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY'THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMIVIING POOL MUST BE DRAINED OR COVERED ;
WITHIN SEVEN(7)DAYS OF CLOSING.
�
FOOD SERVICE �
�
CATERIl*TG PO II=� ;
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPARTMENT BY FILING TF� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE
HEALTH DEPARTMEIVT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SE1�TT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN
THE SUSPEN5ION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS j
_ —HA��E�N IG��-_ _ __
_ __ __ ___ _ _ -- - . _ __ __ _ . __ __ _ _ f
(,�UTSIDE CAFFS:
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 RETAII,OR FOOD
SERVICE ESTABLISF�VVIEENT IS PROHIBITED.
, ,
DATE:/ o� -o��/''� SIGNAT
' Maria A. Charland
PRINT NAME& TITLE: Licensing Clerk ���
i I
_
. �
�
" � The Co►nmoawealth ojMassachusetts
� � W Department ojlndustrial,-1 ccidents �
' ; Ofllce ol/erestlos�is
� 600 Washington St�eet
„•� Boston, Mass 02!11
�� W'orkers' Compensation Insurance Affidavit
A��licant informaHon: P'IeesePR�'TTe�t�
namc: [ i V� {�1�Q.(��.I'�� 1 ��. J
locati�n: -{ �1.� t UI�K.(JIIJ
�it� �e f�. ��� phone#�'XJ�� J�`1 ' d� /(L/
� I am a homeowner pertorming all work my�self.
� I am a sole proprietor�r,� ha�e no one��orking in am•capaciri�
I am an employer pro�idin�w�orkers' compensation or mr�employees working on this job.
_ - � - -- ____ __
m a
address
cit}•: phone k•
insurance co. Aolicy#
� I am a sole proprietor. _eneral contractor, or homeowner(circle one/ and ha�•e hired the contractors listed below� ��ho ha�e
the follo�cin� ��orker�� �ompensation polices:
companv name• '
address• '
cisy: nhone!!•
insur�ncc co. policr•#
som�an,y name•
_ ---
_ address: _ _ _ _ __ . _
ci�' y: Rhoee M•
insurance ca ,�y M
Failure to seeure coverage as required under Seedon ISA of MGL 1S2 ea�lad to the iopaidoo of erisi�tl pe�altla of a A�e op to 51,500.00 a�d/or
one yean'imprisonment as w�ell as civil peaaldea io tAe form of a STOP WORK ORDER aad a flae otS100.00 a day apistt se. I a�denta�d t�at a
copy of thy statement may bc fonvarded to the 011ice of Invatigations ottbe DIA for eovengt veriSatio�.
I do hrreby cerrijj�unde�the poi and penalties oj ry'ury thar�l�e injo�nwtion providtd above ts tn�e and eontct
Signaturc . ��' � /�
Print name Mana A. Chazland Phone� ����- ��D��-'���
.. otTicial use onl� do not write in this area to be completed byciN or town o(}Itial
city or town: Y�MDIITfI _ permitAieense N nBuilding Department
�Licensiog Board
�eheck if immediate response is required 261 �Sdectmen's OtYitt
(508) 398�2231 eat. �Hea1tA Department
contact person: phone M;_ _ _ nOtAer
Im�ised i,95 P1A1 �.
TOWN OF YARMOUTH
. BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: 99-46 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
Sc�Lth Yarmnuth ('V�„ Tns„� 976 R� � 8, SoLth Yarmo �th, 1��A
Whose place of business is: CVS Pharmacy#0735
Type of business: Retail Food Service less than 25,�000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 1999 BOARD OF HEALTH:���/. �et�,, C'�tr�,�
�oan (�. �utlivan� /C.�� Vice (,�irmarc
ttEs�c�otvs iF arn: Prepackaged foods only- l�odert.c�. �rouin� C�eriz
Ch1ps,candy,chewing gum,soda. a�Pielle�a�iol��Zr�-./�ooPee
��Ic e Odou �[in
�
Februarv I 1 . 19 99 Bruce G. Murphy,MP ,RS. HO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: 99-37 FEE: $20.00
This is to cerafy that South Yannouth CVS, Inc d/b/a CVS Ph�rmacv#0735
976 Route 28, South Yarmouth,MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBIJTION OF TOBA O PRODU TS
AS PER THE YARMOLITH BOARD OF HEALTH TOBA O RE Ti ATION
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires Deceinber 31. 1999 unless sooner suspended or revoked.
Febmarv 11 , 19 99 BOARD OF HEALTH: Gd� �ette�, �`irir'a�.,usa
�oaic� �ulfivan,K.�/•, Vice l.�irman
�o�art J'. 4�rowic� l�ierh
�abrialle�a�ol�h�-J�toof►e� �
� /�iB� ' OK 'LHL -
Director of H�ealth �
,
" - x ID : RPR 14 '98 10 �23 No .006 P .02
, � �:���c�r��rr � G�3�[� , � M I��
.1 -. T��vN-OF YARMaUTH_II�A��) . ). APR 2 �+ 1998
APPLIGATIUN �'OR LICENSE / r .: , � �, , :r �
� � '" ,�� ��''' °' �' HEA�TH DEPT.
t Plcasc Complete form and attach aU necessary documattts t�y Deccmbcr 3l, 1997. Failure to do � ���3�� �
so will resuit ui the return of your applieation packet. .
-------�______...'--------------------;--CVS/pharmacy #735�.--------------"�_-�1'f:I. #y508-394-8596
Route . , Sout Yarmouth, MA'02664 ;
, � Licensing Dept. , One CVS Driv,e, Woonsocket, RI 02895 ,
Q�Lt;QRPORA�I�IC� �� South Yarmouth CVS, Inc. n _ ,
�►aeUer.Rrz'CNAMF• aro Rus 1'�,L,.ft_508-420-6110
�e;t tA1C eT1T1k�QC� Licensing Dept.; One CVS Drive, Woonsocket, RI 02895
' � � 1'IO
1'00l Oper�tors must list u minitnum of two employces currentiy certified in basic water safcty,
stttndard first aid and Corrnnunity Gardiopulmon�uy Resuscitatlon(CPR),I'leasc list these
cmployeeti bel�w and att�tch copies of emplayr.�certiticetions t�this form. 'l'hc Health �
DepArtment will not u�e pa�t years records. You c»ast pirovlde new co�Ies and maintajn � ,
filc at your placc af busineas.
1...� �,...�, 2•� - ,
3. ....._, �• - -
;
�-t1?IMI.i li CFR'1'IF1C'A'1'IONS: ':
Al!fbad servicc esEablishments with 25 seals�r m�re must h�ve a� least one em�loyee trained in :
th� Hcunlich Mancuver on thc premiseg�t all timcs. Ptet��e list your emnlnyees lydinc:d in anti-
chokin�proc�clures bciow and att�ch copics of empl�yee eertlfication5 la this lorm. 'l'he�lealth !:
llepartment witl not uRe paxt ycars recorcfs. Yuu must pn►vldc ncw eu�ies and maintain s '
file�t your placc af buainess. �
I
1, --- 2. .. i
3. 4•� -- --
RFSAIJRANT SF,AT[NCi: '1`07',A[..# � NnN SMUKIN(i SEATS: TOTAL#..�.
.�.r•�.__..__�_��.���������������������������o�...�rr__��_�..��o.o.�.'�.....�.•--�.�..��..y.�oo�o�«��...ti..�__����������� ..
OFFI F. �C N ,Y
LC)�?�1NG:
I.IC. RL(?UIkNi) FEL 1'F�RMIT�! L1C. REQUIKLU FEE Yl��RMIT# `
,�„w.i38cH $50 .�C:E1131N �SO _
�INN $50 _ _ �CAMP $SO �
i
,!„I.(�1�tiF $SO �.�1'12AII.FR PARK �►50 ,__�___�.�.. i
;
.�M4T�I. �Sfl-- � —SW1M {'OE1�. $S��a.- �
i
�WHIRLYUOL �2Sea. � t
!
FOOD S�;RVICE: i
LYC. 1tEQL1JRFll 1��E PERMI"1'# T.IG.RL:QUIRFn i�L:L PERMIT�i �
;
_�-100 S�A'rS $7S � .,..._.GON'TINEN7'AL $30 ;
,.�>100SCATS $15U �._.NON-PRUI�IT $25 � i
COM. VIC'T. $SA ..,...�. ._...,. �OI�FSALE $75 �
: �'A1�1� _ - - � ,,
SE8Y1�� _ ___ ;
LIC. RFQ«1Rf;ll I�F,F, PERMI'I`# L1C. REQUIRE;ll FF,F PL'sKM1T#
_„_<SO sq. ft. $45 X'!'0�3ACC0 $2U �
��5,000 sq. ft. $75 ��...�p�, ,....^.FRUZ. ULSSh;K'1' $35
._>25.000 sq• li. �Z00
AMOUNT DUE s ` ` �� ,
` - ID � APR 14 '98 10 �24 No .006 P .03
, #735-RELOCATION
�� . ', ` ADMINISTRATION
�` ' ' UND�It C�'I'ER 152, SFCTION 25C,SLJBSEC'TION b,T13�?TOWN O�YARMAt)TH IS
NOW RLQUIRED TO I�30LD ISS�ANC�OR REN�WAL(3F ANY LIC�NSE OR PERMIT
TO OPERATL A BUSINESS lr A PERSON OR COMPAI�TY DOES NOT HAVE A '
CE?R7'1�'ICATE OF WORKEIt`S COMP�NSA?ION Y1�TSURANCE. THE ATTACHED
STATE WORKEIt'S COMPEN�SATI�DN INSURANC�A�FIAA,V�T MUST��
COMPLFT�U ANA SIGN�D. '
TOWN OF YARMOUTH TA3�S�NA LIENS MUST I3�:PAI�P1tIQR T4 RFN�WAI.,U�t
ISSUANCF OF XQi.TR AERMiTS, PI,EASE CHBCK APPROYKIA'1 ELY IF PAI�:
y�� xx �p
NU7'10E: Y�RNII'1`S�UN ANNUAI.,T1Y FROM JA13iJARY 1 TO DEC�M��R 31. iT lS
Yt�UR RESPONSIBILITY �'O lt�,'FURN THF C4Ma'LETED AFPLICATYON(S)AND
RFQUIREA FFF.,(S)BY DLCLMDL�R 31, 1997
S��3qNAL�?ST�Y.IS��N1'S ARF,Tp CdNTACT'I'F�HEt�I..TH DEYAItTN1�NT FOR
IT?SP��TIQN 7-14 DAYS��IOIt�'O OPENII�TG FOR THE SEA50N.
ALL R�NOVATIONS Tn ANY Foqb�ST�+�B�.13HMLNT,M01'EI,OR PO►OL(i.e. ,
PAINTI�IC�,Nr:W kQU1PN�NT,FTC.),M'UST BE RLPUR'1`�;1)'1'O A�VI�API?ROVI3D BY
THfi B4AKD OF HFAT.TH PRinR Tp COM1V�?NC�NdCNT. It�N4VATION5 MAY
RLQUIRE A SITE PLAN. �
„�DDITi��[y�$LGULATIONS
Ap0�.5
A(K)L OPEMNG:ALL SWIMMJN(�,WADINO AND WH1ItLPOOIaS VVI�TCN HAVE HEEN
CLOSEA�'OR THE SEASUN MUST B�J1VSP�CTED�Y T�H�1�LTI�DEPARTMFN'�',
AND THF WATF.R'1'ESTED FOR I3ACTERIA BY A STA�'E GERTII�I�:ll�,A13,PRIOR TO
OPEr1YNG.
�'OOL C�,OSYNG: FVERY OUTDOO�IN GTtOUNI)SWIMMINa POOL MU3T BL
DRAYNED Uk COVERF�WITHIN SEVEN ('l�DAYS OF CI.OSING.
FAA� S�ItYIC�
_ c�•r���a PS?�t.c�r,
ANYON�:WI�IO CATERS VVITHIN r�IC TOWN OF YARMbUTH MUST NOTIFY THE
YAI7MOUTH HEALTH DEPA.RTMFNT BY TILING't'I��E RFQIARED TLMPU�AYt"Y
FbUb SI"sItVICE APALICATION 1�ORM 72 Hp�II�4 PRIOR TO 773E CAT�REll�V�NT.
TH�SE�ORM5 C:AN BF QATAINEl)A7'''I'H'E HFA�.TH D�PARTMENT.
; •
FRUz�?N D�SSFRTS�MUST l��1'�STF.A ON A 1v10NTt��Y�ASI$BY A STATF
CFRTIFIEI)LAH. TF.ST RE5ULTS MUST BE SEN'I'T�D�'HE HEAI.TH DEPAR'T'MENT. '
FATLiJRE TO DO SO VVII��,RESULT 1N THF SiJSAkl�15�ON OR R.F,VpCAT10N OF YOi.3R
FROZEN DESSER'�'PLItM�T'[7NTI1.1`H�A�30VE TERlv�S HAV�;IIE�N MF'�'. ;
OUT��I?�,�1�1F�� '
4UTSIDE CA�S(i.c. ,�UTDbOK SLA'CING W!'�7�WAITER/WATTRESS S�RVICE),
�,'��AVE PR1OR APPROVAL FROM rH��3�ARI)QF HEAL1"�i.
OUTDOOR COOKING;
OUTD04R COOICll�(�,PR�PARATI�N,OR AISPLAY OF ANY FOQD PR011UCT BY A
RETAIL OR FOOD SERVICE ESTAAL�SHM�NT IS PROHYBITLD.
____D,e►�: . �r o23 �8 _ , --_ $IONAT ' C" `c�
.
tep en- . r ur�s g __._
PRiNT NANt�&TlTL�: Licensing Coordinator
10/97
page 2 af 2
.
___ __ _ _ _ __ _ ..�_.__ --_ __
• .#735—RELOCATION ID � APR 14 '98 10 �25 No .006 P .04
. . ` �
rv � �, ' The Co�rnonweatth of Macrsuchasetts
� : De�arrtment ojlndustrlalAccfdents
.
o �/'Ik/N/Irl:tl/��f/Il
; 60U Wcshington Sr«<r
' Bosron,Mass. 0,�111
1i�'orkcrs' Compensatioa lnsursnce Atfld�vit
A��a�info�m�tions PI�pA'�P1!Te��c
�
� �, South Yarmouth CVS, Inc. dba CVS/pharmacy #735
� i;�n. 976 Route 28
���, � South Yarmouth RherteM 508-394-8596
[] 1 am a homeowner prrtorming all work myself.
p I �m a sole pron�ie�or��d ha�e no onc uorkinc in am�capaciry
[x� ! nm an employer pro�,ding workers' compensation fo�my emplo�ees working on this job.
c�JlAA�a'�p�ne: Self In�u��� thru C'VS� Inc.
aJ:iress: _,_ Licensi� Dept. , One CVS Drive __
�b,, Woonsocket, RI 02895 ��e�! . 401-765-1500
�ess�r�u►ss sQ. � nnliex M
p 1 am a sole proprietor, 2eneral coatractor,o�homeowner(e(rcle one/nnd hare hired the contractors listed below ��ho hare
tha foilu�►�ins���o►kers' ,ompensation po[ices:
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ClSY' -- -�hoee M�
insur�nc�eo yelicy!1
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eoe ye�r�'in�prisoament�t•►•eN��eivil pea�ItM ia t�e tore�of a 37'O!WOR1C ORDER�u��lf�e ollf�0.9��d�K�IeN�e. t a/f�ud tlst a
eopy of Ihi�it�ttmeat at�r be foiwa�ded to the OfBce of Invad��t�t 4[t6e DG fir ceven�e ve�illeade�.
1 do.hraby c��r�y undrr r6r paint axd ptnalrira oj erfury tbal fht lxjprinallon provided abovt tt f�Me�d���
Signaturo �, c. ��2 3�q�
Printnamc Stephen E. Murphy, Licensing Coordinator p�,�� 401-765-1500
oflteia!use only ao not y rile in Ihi:sre�t0 be conlpletM by elty or 1ow11 otMfei�)
eity or tawa: y� __ �eraftntces.e M r'+SuildloR Dep�rtmc�t
OLireede��rd
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(508y 398-•�723I Rx�, ONeal��Dep�rtaaat
cont�ct ptrlon: pAoae M;_ ,,,,.._ _ - �Other
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-' APR 2 4 1998
HEALTH DEPT.
CVS/pharmacy
Apri123, 1998
Town of Yarmouth
Health Department
1146 Route 28
South Yarmouth, MA 02664
Attn.: Mr. Brtice Murphy
RE: Retail Food Establishment Application
South Yarmouth CVS, Inc.
dba CVS/pharmacy#735
1100 State Street
South Yarmouth,MA 02664
Dear Mr. Murphy,
Enclosed please find completed application and payment of$95.00 to cover the
cost of a Retail Food License for the above -referenced store. This store is scheduled to
relocate to 976 Route 28, South Yarmouth,MA 02664 on approximately, July, 5, 1998. ;
Mr. Dan Wentworth, District Store Manager,will contact your office to schedule
a pre-opening inspection. If you have any questions, or require further information
concerning this relocating store please contact Mr. Wentworth at 401-765-1500,
extension 9074 or myself at 4440.
. �.. _ , _, _ _ _ . __
After making the necessary copies for my files, I will forward the original to the store for
posting. Thank you for your cooperation in this matter. '
S' cerely, '
��� E
Ste hen .�
P �P Y
Licensing Coordinator-Lega1
cc. Mr. Dan Wentworth, DSM
ONE CVS DRIVE•WOONSOCKET,RHODE ISLAND 02895•(401)765-1500
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: 98-63 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 395A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
S�uth Yarmouth (:VS� inc., 976 RoLte 28,SoLth Yarm�uth, MA
Whose place of business is: CVS/Pharma�v#735
Type of business: Retail Food Service less than 25}000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31�1998 BOARD OF HEALTH:�d�/. �et��, C'�tr.,�►�
�oan � �ullivan�/C.//.� Vice (��irman
RESTRICTIONS IF ANY: PI'ePaClcaged fOOds oIIly- Ko�ert�}. p�rown� (..[er�
Clups,candy,chewing gum,soda. a�rielle�a�iola�rc�-✓dooPe�
ic�el oCou �Lin
�
Apri127 , 19 98 Bruce G. Murphy,MPH,R.S., HO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERIVIIT NLJMBER: 98-50 FEE: $20.00
This is to cerafy that South Yarmouth CVS,. Inc. d/b/a CVS/Pharmacy#735
__ 976 Route 28 South Yarmouth, MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS ,
AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31. 1998 unless sooner suspended or revoked.
Apri127 , 19 98 BOARD OF HEALTH: �c`� .}ef,�e�� ��iai�ma�
�oan� �ullivan� K.//., Vice (��irman.
l`Co�erE J. O�rouin� l�lerh
�a�rielle�a�ro[,1�icf-J�tooPee
' �el O� u��[in.
D ector of Healt�ti �