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Home My WebLink AboutApplication and WC� � GVS Of�g�M . �'q�� ;. � � C��7�� TOWN OF YARMOUTH BOARD OF HEALTH ,� � �;, � c� � �t�,�� APPLICATION FOR LICE ;S�E�VII'�' 2��3 - U I��!��7i�G � � � � rr�1�5�2�'� � � *,�ease complete form and attach a11 ne,e,��`�� t�r�ie�t��by ce ��t`7 ��P t : Failure to do so will result in the ur�i��ru�'�rp�'1"c�ti packet. '�CE � HEALTt-�D�PT. ESTABLISHMENT NAME: �S G�(M.�c, � �LI TAX ID: LOCATION ADDRESS: t?'� J�lv��'ln Ci�1.o�.+p�EL.#: o�(p MAILING ADDRESS: g R.. �M � �" 0 OWNER NAME: � CVS Pharmacy, nc. CORPORATION NAME APPLICABLE): MANAGER'S NAME: 'I��1-� �1AC�C'C< �1" TEL.#: ' � o�� ( MAILING ADDRESS: ' - 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. �, 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 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• i - ; ---Y-� . - � . . — :� 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 Establishn�ents, 105 CMR 590.000. � Please attach copies of certification to this application. The Health Department wilt not use past years'records. i You must provide new copies and maintain a �le at your establishment. � i 1. 2� � PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2• j i HEIMLICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWIMMING POOL $80ea. LODGfi $55 TRAILER PARK $105 _WHIRLPOOL $80ea. I — , FOOD SERVICE: � _—_--- - --- _ _—___ --- - _ __ _ _ � - - - - - _ ,�� _ ----� LICENSE REQUIRED FEE PERMIT# LICENSE REQCJIRED FEE PERMIT# LICENSE RE(�C11kED FEE Y�,KI�ITI'# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 ' RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 j �<25,000 sq.ft. $80 ��J —FROZEN DESSERT $40 �TOBACCO $95 l�i-O3� i NAME CHANGE: $15 AMOUNT DUE _ $ /?5• OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I i 4 ! � �r— ADMINISTRATION ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal it to o erate a business if a erson or com an does not have a Certificate of Worker's � o f an y l i c e n s e o r p e r m p p p y Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF 1NSURANCE ATTACHED / OR �j WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta��es and liens must be paid prior t �'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.Transient occu anc sha11 enerall refer to continuous occu ancy of not more than thirty(30)days,and P Y g Y p an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i ection three 3 da s by thc Hcalth Dcpartmcnt prior to opcnmg. Contact thc Hcalth)c�artmcnt t�sch�dulc thc nsp ( ) y prior to opening.FLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ' closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. - FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with saxnple results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment is prohibited. _ ---- - . . . - - � NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 COMMEN .EMENT. RENOVATIONS MAY UIRE A S E I�LAN. DATE: `2- L`� �L. SIGNATURE: ]oanne P. Amitrano PRINT NAME& TITLE: Rev. 10/09/1� � 7'he l�ummanwealth ofll�assuchaasetts �epartm�nt of Ind�a��rrial�c�ide�ats C�ffrce of l'nves�iga�ions 60�1 i�'ashir�gtnn Street ��ton,.tl�A 42d�'I wiv�.�as�gav/daa ��rkers' �o�np�ens�ti€►�n I�asu�ance�{imvit: �z��rai�3usin�s�s �4,�t��a�ant�nforn�ation P'lease�"rint L��ihlv CVS/Pharmacy # �� B�siness/Organization Name: Address: �-�'lU� 5�c�+ 10U� Sd�`��1�°`�I"tV�.G''�l� � CitylStatelZip�� V�`�l Phone#: ��=b�� Ar�you an eanpioyer?Gl��ck the agg�ra��afe boz: lBusi�aess'Type�rs�aired): l.(� I asm a employer with emp�layees{f�.ell and/ 5. �Retail or part-time).* C. ❑RestaurantlBar/�ating Establishment 2.Q I am a sole p�roprietar or partnership and have no 7. ❑f)ffice and/or Sai�s(irscl.real estate,euEc�,etc.) emplayees wori�ing for me in sny capacity. [No workers'comp.insurance required] $. ❑Non-prof�t 3.❑ We are a corporation and its nfficers have,exeroised 9. ❑Entertainmen�t their rig�t of exempfiion per c. 152,§1(4)>anci we have ; i0,�Manufacturing : no employees.[No workers'comp.iasurance required]* �i.[��-Iealth Gare i 4.❑ We are a nan-profit argaxsization,staffed by volunteers, with no exnployees.[No workers'comp.insurance req.] 12.�Other *Aay applicant that checks box#i must atso fiti nut thc sxtion below showing their wrnksrs'comgensatian policy information. :aIf the corpotste afficers have exemptod themselves,burthe cor�xrration has oiher employees,a workecs'compensatioxz policy is rcquired and such>an orgazuza#ion shoutd chectc tsox#1. 1 am:un employer that is provitli�tg�e+arlrers'compensation insuranee fnr my e.�rployees. Belvw is the palicy in,form�ttion. Tnse�rance Company Name: New Hamshire Insurance Company I75 Water Street Insurer's Addrsss: New York, NY 10038 City/�catelZip: pQlicy#ar Self-ins.Lic.# 4 3 0 9 74 0 9 Expir.axion Date: O I/O 1/2 013 Aitac�a co�y of the workers'eompensat►4n palicy rlecta�rat�on page(show�ng the��icy number and ex�ir�tepm tl�te}. Failure to seeure covera.ge-as required:under Section 25A of MGL c, 1.52 can lead to tlie imposi#ion of criminal penalties of a fine up to�I,5�0.Of��d/ar�ne-year imprisanmen€,as well as civil psr_alties in th�form ofa STbP tWORK URDER and a�ne of ug to$250.t}0 a day again&t the violatar. He advised that a cc�py of this sta�ment,may be forwarded t�the Office of Investigations af the DIA fox insurance eoverage verifrcation. d do hereby ce ' ,under the piains a�ad enaliies of per,�ury that the i�fornaation pravided above is true and correct Sl a17.tTe: .. I1ate: -(`G t" p�Q��: 40 -770- 72 (Dfficiad use !y. Do not write ut this area,to be cont�rleted by eity or town a�cia� Ciky ar Town: �LNl�c7'i� I'exaatit!!�„ic��ase# Is' ' _ e oe��): .Bosrd af Heatth Z. uilding Depsrtu�ent 3.�ityiT'own�lerk 4.Lice�sing�c�ard S.�Select�en's�ffice �ont$c�r��soa: ��#: ,��3��2Z3��c I�Yr �.�.gfl�ia;$ :» COMMONWEALTH OF MASSACHUSETT5 DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF INSURANCE Self Insarer CVS/Caremark Corqorat.ian and its subsidiaries Reinsurer National Union Fire Insarance Companv of Pittsbureh.PA Contract Period from Ol/Ol/2012 to Ul/0112Q13 Contract is a � Caf.astrophe Policy XX Policy No XWC 119-24-'74 Aggregate Excess Self Insurer's Retention $540.000 Maatimum Liability:of Insurer Part t)ne: Statutorv Pa3rt Tvvo: 500.400 The contract contains the following conditions: 1) It is understood and agreed that any money received 6y the Self-Insurer under the , ' provisions of this contract shall be deposited in such bank, or with the Treasurer and , Receiver General of the Commonwealth, as the Department of Industrial Accidents may determine, and.any such maney shall be held in trust far the payment af any ' liabilities incurred by the Self-Insurer under Chapter 152, General Laws (Ter.Ed.) as amended, and no use or dispasition of any such money sha[t be made without the approval of said Department. It is further understood that no money shall be ass�gnable or subject to attachment or be liable in any way for the debt of the Self- Insarer nnless incarred ander said Chapter 152. 2) It is understood and agreed that if any party to this contract desires to cancel this contract, such cancellation shall not become effective far a period af at least thirty days following notece to the�Department of Industrial Accidents of the Commonwealth of Massachusetts,by registered raael,of such cancellation. 3) No commutatian of any liabil�ty 3ncarred by the Self-Insurer under said Chapter 152, during the period this contract Is in effect shall be made without the approval of the Department pf industrial Acc�dentss of the Commanwealth of Massachusetts. Sclf Insurer CVS/Carerttark Corporation and its subsidiaries By Reinsurer National Union Fire I surance Com an of Pittsbur h PA. , sy Jaseph A vide, hief Underwriting Otficer