HomeMy WebLinkAboutApplication and WC � � �� TOWN OF YARMOUTH BOARD OF HEALTH ������ � �� ''�
� APPLICATION FOR LICENSF/�P�ERMIT -2014 i��.0 �I 91013 i
� � !_`h=�-4�-t Z577& �:��-� .
* Please complete form and attach all necess�y c�o�t�m nts by� ' e .
Failure to do so will result in the r�ti�in o�'�$��li�t' ` .
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ESTABLISHMENTNAME: n�s�m� �' � � �
LOCATION ADDRESS: ��' �cN �V2. �. o TEL.#: - �i -C'�a� �
MAILING ADDRESS: rvQ. ` � , ' 1 �" ,.? �- CL-�. ��i ' ;
E-MAIL ADDRESS: `�pA/V n►� .�t�M'1 a��w �' �S CA'1-'���irZ-�.>.tWM �
OWNER NAME: ['US Pharmacv� I11C. t{Qt_?7a�5�2 �x ��ot-652 -�o$ �
CORPORATION NAME (I PPLICAB E):
MANAGER'S NAME: ���h �C1��'c��i- TEL.#: O�`" ��" 1 t�`t1 �
MAILING ADDRESS: � [��vQ., C_V S O�l. M C i 1 t� �1.�C.�t��.l�� ,�L2 v3&'�S i
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. ,
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Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and j
Community Caxdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list t
the employees below and attach copies of their certifications to this form. The�-Iealth Department will not use past �
years' records. You must provide new copies and maintain a �le at your place of business. i
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l. 2. i
3. 4.
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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 i
copies of certification to this application. The Health Department will not use past years' records. You must ;
provide new copies and maintain a file at your establishment. i
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f
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC)on site during hours o�operation.
1. 2.
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ALLERGEN CERTIFICATIONS: '
All food service establishments are required to have at least one full-time employee who has�llergen certification,as
defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of ;
certification to this application. The Health Department will not use past years' records. You must provide new �
copies and maintain a file at your establishment.
;
1. 2. '
!
HEIMLICH CERTIFICATIONS: �
All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich �
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach i
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: TOTAL# i
OFFICE USE ONLY �
LODGING: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
B&B $55 CABIN $55 MOTEL $55 !
INN $55 —CAMP $55 SWIMMING POOL $80ea. I
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. �
I
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 ,
>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 '
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
<50 sq.ft. $50 >25,000 sq.ft. $225 NDING-FOOD $25
�<25,000 sq.ft. $80 �–0 3 _FROZEN DESSERT $40 TOBACCO $95 i
I
NAME CHANGE: �is AMOUNT DUE _ $ [�idSC�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION ` ,,
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of
any license or permit to operate a business if a person or company does nothave 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 10 j
OR '
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH f
Town of Yarmouth taa�es and liens must be paid prior to enewal or issuance of your permits. PLEASE CHECK �
APPROPRIATELY IF PAID: �
YES NO
;
4
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.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of
not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall �
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 i
POOL OPENING:Al�swimming,wading and whirlpools which have been closed for the season must be inspected by
the Health Departrrrent prior to opening. Contact the Health D�partment to schedule tfie inspEction three (3) days
prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and
opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a
State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of �
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening. '
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CATERING POLICY: ��
Anyone.who caters within the Town of Yarmouth must notify the Yarmouth Hea�th Department by filing the required ;
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ;
Heal.th Department, or from the Town's website at www.�armouth.ma.us under Health Department, Downloadable �
Forms.
i
FROZEN DESSERTS: �
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter; with sample results ;
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert �
Permit until the above terms have been met. �
OUTSIDE CAFES: I
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. �
- --_ _ _ _ _ -- — _— --_ I
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2013. i
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE PLAN.
DATE: `���;�� ►3 SIGNATURE:
PRINT NAME&TITLE: Joanne P. Amitrano
i nsmg oor is�a or
Rev. 10/08/13
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,
. . . . ��S/I�harmacY� ---- -- -- -.
One CVS Drive � Woonsocket, RI 02895
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�`�E� 19 Z�13
H�ALTH pFFT
�al► ��►3
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 chanqes made on the application reqardinq trade name
and or mailinq address, and include stare number on invoiees and
permits as indicated on the application to insure correct payment to the
proper siores.
Pleuse send the permit(s)license(s1 and anV future renewa/apptications
for this store, with the store number on it, to mv attention at: One CVS
Drive Licensing Dept Mait Drop 23062A, Waonsocket, RI 02895.
After receiving the license, I will make the necessary copies for my files and
forward the originals to the stores for posting.
If you have any questions, P{ease contact me at 401-770-5772 or by
fax 401-652-0608
Sincerely
��t�+u�ve�u�"t°�
laanne P. Amitrano
Sr. Licensing Coordinator
One CVS Drive/Mail Drop 23062A
Woonsocket, RI 02895
�� ?'he�or�nrv�z�eadtla of 1t2'assaclzusetts �;; ��r�nt Forrr� °
� �'?ep�r�ttt vf fndustrial A�cir�en�s
� G�,�`fice vf Ir�u+est%�a�i�ns
�- ` t 1 �'ongres�Str�ee�Suite Il1tl '
. �ast�v�, R�41f2�14-�a�7
` � ww�v.r�ass.gvv,�dia
'VVa�kers' �ormpe�asatiom Ins�ra�ace Af�idavit:�e�eral�u�sz�esses
A lic�nt��fo�m�tivn Please Print L '� ,
Bii5�18SS/di',g��ti€1LlN�ne: CVS/Pharmacy #00944
�����5. 465 Station Avenue
' ���f�t������p: South Yarmouth. MA 02664 ��Q��#i 508-398-0926
Are you a�t em��c�yer?C6eck the�p�r€�priatc box: Bnsiness Type(r�q�ired):
2.� I am a employer with employees(fu�l anrU 5. [,�Retail
or part-ti�me).* 6. ❑Restaui�antlBar/Eating Establishment
2.❑ I am a sole proprietor ar partnership attd have no 7. �Offtee andlor Sales(incl.real es2ate,auto,etc.)
emp�oyees working for me in auy capacity.
�ia workers'comp.insurance required� S. Q Nan-prcafit
3,0 We are a corporatian and its off'zcers bave exercised 9. ❑Entertai.nment
their right of exemption per c. 152,§I(4),and we have 10.[]Manufaci:urizag
no employees.[I�Fo u�orkers'comp.insura�ce required]* I 1_C]H�al�Care
4.❑ We are a�aon-prafit organization,st��#'ed by volunte�rrs,
wittr no�mplayees. [Na warkers''comp.ins�uance req.] 12.� Othez
�`Any�pgtic�ut€bat checks box#i must slso:�Tl aut''ttte section belaw shawua�the�warkers'ccympcnsatana palioq infor�nation.
»�L the corparate o�icars have exerngted thea�lv�s,bnt t�te-curparariaa hss othcr emgioyees,a workexs'caa�ret�sation paiicy is rcquired and such an
' tion;shautd cheok box#1.
I am an empdoyer t&at�S pravfdtitg war�'ers'cvttrper�satiEtn i�surance for my e»iployees Be�riw u the polacy inf'vrmativaa.
��c�����y���: New Hampshire Insurance Company
175 Water Street
Insuxer's Adciress:
City/StatelZip: New York, NY 10038 '
POlic #OT Self-ins.Lic.# 019358776 � O1/O1/2014 '
Y xpiration-Date:
Attach a copy of the r�4rkers'co�pens�tion poliey declaratiaa p�ge(sh+�wing#he ptrlicy number antd expiratia�n date).
Failure to secure covera�e'as required under Sectian 25A of TvIGL c, 152 can lead to tiae unpnsitian of crim.'vaal peraal#ies of a
�ne up ta$1,500.40 a�d/or o�ae-year imprisonment,as welI as civi]penalties in the forn�of a S'�'OP WURT�ORDER and a fine
ofup ta$250.OU a daY aSainst the violator. Be advised that a copy of th'rs statemeni may t�e forwarded to fh�(a�ce of
Investigations c�f the DiA for insurance eov�rage�verification.
I dv h�reby t�fy,ur�der the ains pena[ties ofP�ury that the infvrma�on pravaded u6vve is tru�+and carrec�
__.__
S� ��' 12/12/2013
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te:
Ph e#; 40 -770- 72
�.1�.fr�iat use dnty. Uo nnt write i�x this area,to be compteted;by c�t�r tvwn o,�`'iciat
City or Town: YR�M�UT1� , Pcr��i�tlLfcense#
�'ss carete ane}:
.Board ofHeai�h .Buiidiag lle�artanen# 3.City/Town Clerk 4.Licen�ing Board 5.Selectmen's O#�ice ;
Co�tac#F`erso�: Phuaae#; SD8��98;��/ X/Z�� �
wPrw.mass.gov/aia
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SEP-24-2013 TUE 06�33 AM CUS RISK MGMT FRX N0. 401 770 6989 P, 03
C�;R7IFfCAT'E OF�XCESS IHSURANCE
STA7E OF TNtA
To;De�i t Af lndustria{Accidertts
On� Con�rbss Straef
10«'�"foorSuite �40
aoston,NiA Q2114
I�ATE:�„_
Slr/Mad�rns:
'fhls certlll�a lhal a Workore Comprsnsatlon Excess Irtsuranc�,Pollcy hes been Issued qrxi deliVered tb the emp(oyat nerrled below,and
th�t by G�sunnca AnrJ d�rlivery af�a[d policy and tha fifing o(fhl�cartfflcalo vf insurance,It Is adrn�NQd thet said eycce�s pollcy Waa e(fectfva
�r+lhe dat�i�taled balow and thei q�a cav��aBe provldod therofn ia epplicable to beneflte under the Workors CompensaU�n Act o(tho st�te
, ��..,..,`1�A.._., av�d thal s�ld poHcy shall ramafn fn tuA forc�and ef►ect unl1l 90 days af(or recefpt by lhe dlvlelon af iabor of natica o(
l:s c�ncellstlon or explratfon and/or non-renewbL
; • Namu of�rnptayer Insured ��t,S��ramc�rk Corar�� ,
Addr�as 1 CVS pR,WOONSbCY.�7,f�i D28g5-8195 ��� ;
Nama ot Inaurer _NA.TC�NAI.Uf�ioN FIftE INS Co .
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Addreae �.Z$..�!(fi1��5`_s_Tl��L�E. YORK•� � ,
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. pnllcy Nurnb�r....4���77,�__,.__, � ''
Ftf4eflva Dal��j[f�1�,;,p�� .�___._ '
, �xpkatl0il Date�j¢g�oia �
�ORM aF COVERA(3� •
•lipc�olffc Exces� 'Ag9rngate�xcass ,
hoNcy Limlt$S7A'fUT012Y Fopcy Lfm{t$���` '
, (I'raroccurrenco) ��~^ --
i.oes�und f'srcentage `
_ 3pecfilc Retentton�6�tT.�O TM,�,,��� ..
(Per occurrenca? MInlmum Lo�s Fund a_N/A , _ •
Pollcy T'erm,_��Q___,___` ` _. Estlrrwled Loas Fund$,N/A �
..—. �.,.�,�_ ,
� Policy Tarrp�q �
}f more tAap dne Insurer la provlding covuraga,you m�st pravidb seperete certiftoates tor e2ch insurer. •
tNlN CGRTI�"ICAT� C7F INSURANCE N�I7NER A�FIRMA71VElY NOR NEDATIVELY AMENbs, EX7ENPS OR ALT�RS TH�
CUVERAi�f:(5)A��rURUEi)py•�HE Po�14YpCS}L1ST�D O�!THIS CERTiFICA7�, '
. NATIONAL UNf4N INS CO
, t rance Company '
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Autharizad A�ent � �
' 175 Water S1r'eet Naw York,NY 50038 �
c�a���aa � ,
.
Ac'a� CERTIFICATE OF LIABILITY INSURANCE °"�,M�°°""""'
�,,,,.-� 12/26/2()13
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATIYE OR PRODUCER,AND THE CERTIFICATE HOLDER.
iMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsemen� A statement on this certificate does not confer ryghts to the
certificate hoider in lieu of such endorsemen s).
PRODUCER CONTAC
MARSH USA,INC. NAME:
99 HIGH STREET PHONE AI�C No:
BOSTON,MA 02110 E-MA��
Atln:CVSCaremark.CertRequest@marsh I Fau:212•948-5338 ADD e :
..�.. - .._, iNSURER S APFORDINCa COVERAGE NAIC#
S02406ALL-GAW-t415 iNSURert a:New Hampshire Insurance Co. 23841
iNsuRe� Nadonal Union Fire Ins Co Pittsburgh PA 19445
CVS CAREMARK CORPORATION AND ITS INSURER B:
SUBSIDIARIES AND AFFILIATES �� O 6 2O�4 INSURER C:
ONE CVS DRIVE INSURER D:
WOONSOCKET,RI 02895 HEALTH DEPT: INSURER E:
INSURER P:
COVERAGES CERTIFICATE NUMBER: NYc-oosos52sa2o REVISION NUMBER:�
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATEO. N0TIMTHSTANDING 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.
��� TYPE OF INSURANCE DL U ppuCY NUMBER MM DDYlYYYY MM/DD� LIMtT3
A GENERAL LIABILITY GL 6819521 01/0112014 �1/01/2015 EqCH OCCURRENCE $ 4,5�,0�
X COMMERCIAL GENERAL LIABILITY AMA T RENTE ��Q�
PREMISES Ea occurrence $
CLAIMS-AMDE a OCCUR MED EXP(My one person) $
X SIR: $SOO,OOO PERSONAL&ADV INJURY $ 4����
X LIQUOR UABILITY INCLUDED GENERAL AGGREGATE $ 28���� '
GEN'l AGGREGATE LIMIT APPLtES PER: PRODUCTS-COMP/OP AGG S INCLUDED
X POLICY PR� LOC $
B AUTOMO&LE LIABILITY CA 7062798(AOS) 01101/2014 01/01/2015 _ _ COMBINED SINGLE LIMIT .�
__ _ acci� __ _ ,
B X ANY AUTO CA 706Z799(VAj 01/01/2014 O1/U1IZO1b BODILY INJURY(Per person) $
B ALL OWNED SCHEDULED CA 7Q62800(NIA) 01/01/2014 O1/�1I2015 BODILY INJURY(Per accideM) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accideM
SELF-INSURED PHY.DMG. g
UMBRELLA LWB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
q WORKERS COMPENSATION See Page Two for Pdicy Numbers 01/01/2014 01/0112015 X WC STATU- OTH-
AND EMPLOYERS'LIABIUTY 2��
ANY PROPRIETOR/PARTNERlEXECUTIVE Y�N E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED7 � N/A
�Mandatory in NH) E.L.DISEASE-EA EMPLOYE' $ 2����
If yes,describe under 2,UOO,OUO
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Addf6onai Remarks Schedule,if more space fs required)
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.
CERTIFICATE HOLDER CANCELLATION
THE TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:BRUCE MURPHY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28
SOUTH YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina ��sn;�ta.. !72[.z�^f��rs�n�
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
i
� ' AGENCY CUSTOMER ID: S02406
� LOC#: Boston
�^�� �
ACC�RD ADDITIONAL REMARKS SCHEDULE Page 2 of s
AGENCY NAMEOINSURED
MARSH USA,INC. CVS CAREMARK CORPORATION AND ITS
SUBSIDIARIES AND AfFILIATES
POIJCY NUINBER ONE CVS DRIVE
WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Cert�cate of Liability Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2014 TO JAN 1,2015
Ins.Co. Policy# States Covered
A WC 043409054 MN
A WC 043409055 ND,WA,WI,WY
A WC 043409056 FL
A WC 043409057 CA
A WC 043409058 IL,KY,NH,UT,VT
A WC 043409059 AZ,GA
A WC 043409060 AL,AR,CO3 DE,HI,IA,IN,KS,LA,MD,MI,M0,MS,MT,NE,NM,NV,NY,OK OR,SC,SD,TN,
TX,WV
A WC 043409061 PA
A WC 043409062 ME
_ . _ _ __ _ _ _ _ _ __ _ _ _
_
EXCESS WORKERS COMPENSATION PROGRAM ,
POLICY DATES:JAN 1,2014 TO JAN 1,2015
B WC 6636255
Excess Workers Compensation Self-Insured RetenGonx
DC,MA,OH,RI: �500,000
CT,NC,NJ,VA: $1,000,000
COVERAGE A:Workers Compensation:Sfatubry
COVERAGE 8:Employers Liability Limits:$500,000/$500,000/$500,000
COMMON POLICY CONDITIONS
A.Ca�eNation
2.We[Carcierj may caocel this policy by mailing a dedvery to the first Nart�ed Insured written notice of canceHatron at least �
a.10 days before the eifective date of cancellation if we can�l fw non payment of prerrwum
1)General Liability Additional Insured-Where Required Under Contract or qgreertient language per endorsement 61712(12I06):
SECTION II-WHO IS AN INSURED,is amended to include as an addi6on�insured:
My person or organizatan to whom you become obligat�to include as an addiUonal insured under this policy,as a result of any conUact or agreement you enter into which requires you to fumish insurance to ihat
person or organization of the type provided by this pol�y,but only with respect to Ii�iGty arising out of your operatans o�premises owned by or rented to you. However,the insurance provzled will not exceed the lesser
oE
•The coverage anlor lirr�ts of fhis policy,or
•The coverage and/or limi�required by said contract or agreerr�nt.
2)Gener�LiabVity Earfier Notice of Cancellatiai Provided By Us language per er�dorsement CG 02 2410 93:
Number of Days'Notice 90
�
ACORD 101 (2008/01) �2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
1
' AGENCY CUSTOMER ID: S02406
� LOC#: Boston
A��� ADDITIONAL REMARKS SCHEDULE Page 3 of 3
�-�
AGENCY NAMEDINSURED
MARSH USA,INC. CVS CAREMARK CORPORATION AND ITS
SUBSIDIARIES AND AFFILIATES
POIICY NUMBER ONE CVS DRIVE
WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFPECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability insurance
For any statutorily permitted reason other than nonpayrr�nt of premium,ihe number of days required for no6ce of cancellation,as prov�ed in paragraph 2.of either the CANCELLATION Common Policy Condition or as
amended by an appGcable state canceHaUon endorsement,is increased to the number of days shown in ihe Schedule above.
3)General Liability Advance of CancellaUon to En6ties OGier The Narr�d Insured Limited to E-Mail Notificatan per Chartis Manuscript endorsement:
In ihe event that the Insurer cancels this policy for any�eason ofher than non payment of p�mium,and
t. The cancellation effective date is prior to th�s policy's expiration date;
2. The First Named Insured is under an existing contractual obligation to notify a certificate holder whe�this pol�y is cancelied(hereinafter,the"certificate Hokler(s)");and has provided to the Insurer,either directly or
through its broker of record,the ema�address of the contact at such enGty,
and the Insurer receive�i this informatan after the First Named Insured received notice of cancellation of this policy and prior�ihis policys cancellation effeclive date,via an electronic spreadsheet thffi is xceptable lo
the Insurer,
the Insurer will provide advice of cancella6on(the'Advice°)via e-mail W such Certificale Fbiders.
Proof of the Insurer emailing the Advice,using ihe information provided under this policy by fhe First Named Insur�i,will serve as proof ihat the Insurer has fully satisfied its obligations under this endorsement
This endorsement dces not affect,in any way,coverage provided under this policy or the cancellaCwn of this policy or the effective date thereof,nor shall M�s endorsement invest any rights in any eMity rrot insured under
this policy. .
The folbwing Definitions apply to ihis endorsement:
1.First Named Insured means fhe Named Insured shown on fhe Declarations Page of this policy.
2.Insurer means the insurarice crompany shown in ihe header on the Dedar�ions Page of this policy.
All other terms,c�nditions and exclusions shall remain lhe same.
ACORD 101(2008/01 j O 2008 ACORD CORPORATION. All rights reserved.
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