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Home My WebLink AboutApplication and WC p n r. 1 �. . ' ; Gf��}2�1, ��1��} °' r TOWN OF YARMOUTH BOARD O�H,�ALTH 5 " R!''� � f^ r n.,, � � � APPLICATION FOR LICENSE/PERMIT-20ll ��W � �� .�it� �tl :�� '' � �� * Please complete form and attach all necessa`ry documents by Dec "�15.��0�� Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: c� � TAX ID: LOCATION ADDRESS: .�� TEL.#• -D MAILING ADDRESS: �'�p�*�r�• OWNER NAME: " CORPORATION NAME (IF APPLICABLE): � .Z MANAGER'S NAME: � SS � TEL.#: -' �S/�U MAILING ADDRESS: 11A/C� (�/'.� �,��'j �7 3Q��J�- //�Gr�,r/�1�,� f�..,� d�-"� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Eo��Qperaror(s) aiid attach a copy of the�ei-ti�icaticn to ±his form. 1. 2, Pool operators must list a muiimum of two employees cun ently certified in basic water safety,standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies ofemployee 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. F�OD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined ui the State Sa.iutaiy Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The HeRlth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. � S JU�il/� 2. PERSON 1N CHARGE: ' Each fooci establislunent must Iiave at Ieast one Person In Charge (PIC) on site durulg hours of operation. ' 1. -�5,�-� �r>�/r�� ' HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trauled in anti-choking procedures below and attach copies of em�loyee certifications to this foini. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. 2 3. q.. RESTAURANT SEATING: TOTAL # _ � ! OFFICE USE Ol�'LY LODGI\G: LICENSE REQUIRED FEE PERMIT?# LICENSE REQUIRED FEE PERiVIII'� LICENSE REQUIRED FEE PERI�IIT� _B&B S�5 CABIN S55 MOTEL S55 _INN S55 _CAMP S55 'S`�%LV11l�IlNGPOOL S80ea. _LODGE S�5 ,�TRAILERPARK 5105 ��?4'HIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER�IIT# LICENSE REQUIRED FEE PERibIIT.# _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 _>100 SEATS S160 _CO'_VIlVION VIC. S60 �'�'HOLESALE S80 RETAII.SER�'ICE: —RESID.KIICHEN S80 LICENSE REQUIRED FEE PER'�IIr� LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER'�1IT* _<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S35 �4�,000 sq.ft. S80 �JL�� _FROZEN DESSERT 540 �TOBACCO S�5 ��1�-v Z$ �a�7E c��cE: sis AMOUNT DUE _ $ ( 35. 00 *""�*PLEASE I'i;R\'OVER A�iD CO�TPLETE OTHER SIDE OF FOR�T�'**** -i_�� ADMINISTRATION � I Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 i F CERT. OF 1NSURANCE ATTACHED ; OR � WORKER'S COMI'. 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 � � 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 ofresidence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not rnore than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. , POOLS � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m 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 ins�ected 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 Yannouth must notify the Yarmouth Health Depaitment by filing the required Temporary Food Service Ap lication form?2 hours prior to the catered event. These forms can be obtained at the a Health Department,or from t e Town's website at www.varmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results ' submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen ' Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: I 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 RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQ IRE A SITE PLAN. DATE: � D SIGNATURE: ,�j PRINTNAME&TITLE: Dianne Lackey Licensing Coordinat�r 10�06�10 I �r�ll��7f/Mharmacy� E.. R ._�° �_�_.�-�. °�One CVS Drive�Woonsocket, R102895 � � � Q�� 20�0 �, 4��LTN C�EF�T. December 3, 2010 ' Dear 5ir/Madam: �, �n�las�d p�eas� �irid com�Ieted applicarion(s} andlor invoice(s) aiong �vit�p��t€�t��i�ap�r4priat� amaunt to cc�ver the cost of�he � r�n�� f't�r t�i��`�lp�.�`i�ta�y stc�re{s} in your�.re�. 1°�l�euse itot`e anv ��` ��ti� _ r� "az�_. `� „ ' i�,� `rt r ardx� .i�t�ad�,�a��t�d or , imt��'` --i�' : = it� ��c ;��st r��u�rber��a ir�v�%c�►s a�n�d' ermits .� it��'i�� : � J�� . . ��tz�r�ta ins�z��ca�rre�t _ ei�t ta the ��_ �l't�l�i��l?� . ; ' . �:Pl�t�s�.s+��f�i�,�.�iit��lic�ns,e(s,� and ar�y�ture re�ewal ` �c i� � �r t� � �� vit ;�thi�s��rre.nur�rlr�r r�r� i to Yn �, :a�� ` ��•.�� '�`�i�t�i�e Lii��.sir� �e �t; .M�ril l�r� .23(�62A � �` l�`�g��1��..�:�� A�e��r��iv�ng t�ie licenses,I will make the £ .� .�.,.�..r� _ .; �` � '��sa�cc��i��fi�ir�� fil�s ar�ci f+��ward tli� cirigirials to the stores �: fc��p��rig� , _ �f yca�t ha�re any questions, please contact me at 401-770-5772 or by .�� fa� 40�-652=4b08. �`°� � �incerely ,�� fl l: l' � �i i� If<Y�1"r^`�f�'✓��i�� , # S!fr�� . s<�,'. � Dianne L. Lackey ' ° Licensing Assistant ' ' Legal Department � �-\ � - Depa�tment of Industrial Accidents Office of Investigations d 600 Washington Street � Boston, Iv1A 02I11 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Appiicant Informaiion Please Print LeQibl�� Business/Organization Name: CVS/pharmacy# �� ` , § ` �'- ^ Address: One CVS Dr,t�iail Drop 23062A �- City/State/Zip: WOONSOCKET,RI 02895 phone #: 401-765-1 S00 Are you an employer? Check the appropriate box: Business Type (required}: l. X❑ I am a employer with�C'�employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � pffice 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. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No worlcers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, sta.ffed by volunteers, with no employees. [No worke:s' comp. insurance req.] � ??•❑ Other � *Any appiicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporarion has other empioyees,a workers'compensation policy is required and such an organization should checkbox#1. I am�n employer that is providing workers;comper��atiorc insurance for my emgleyees. Below is the peli�y in.f'ormation. I1?Sur3Z1�?COT�:pan;,?�raz::e: NEW HAMPSHIRE INSURANCE COMPANY Insurer's Address: �0 PINE STREET � City/State/Zip: NEW YORK,NY 10270 Policy #or Self-ins. Lic. # 6506290 Expiration Date: O1/O1/2011 Attach a eopy of the workers' coanpensation poiicy 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 OR.DER 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 nisurance coverage verification. I do hereby certify�.�under•the pains nd penalties of perjury that the informaiion provided above is truc and correct Si lature: - �� Date: � rJ J � � � Phone #• .��i''r� ' ,�`r-�� ' - Official`use only. Do not write in thas area, to be completed by cit��or town officiaL . City or Ti own: �ermit/I..icense# - Issuing Authority (circie 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.eov/dia � J ,: ��'�� CERTIFICATE OF LIABILITY INSURANCE � � , DATE(MMIDD/YYY � �� THIS CERTtFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH� CERTIFICATE DOES NOT AFFIRMAtIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORD�D BY THE P041CIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUINE4-•HrBklRER(^�,-AUT.kiO�lZ� REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the � certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: 99 HIGH STREEf PtiONE FAX BOSTON,MA O21'I O E�A�� ac No: � ADDRE : 'f Attn:boston.certrequest@marsh.com 1 Fax:212-948-4377 ppo�ucea SO2406-AL�-GAW-��-�2 INSURER S AFFORDING COVERAGE NAIC i INSURED � INSURER A:NBYJ HBffIPShlf2 IOSUf80C2 C0. 23841 � � CVS CAREMARK CORPORATION AND ITS Chartis Casualty Company 40258 SUBSIDIARIES AND AFFILIATES INSURER B: ONE CVS DRNE wsuReR C:�nsurance Company Of The State Of PA 19429 WOONSOCKET,RI 02895 National Unan Fire Ins Co Pittsbu h PA 19445 INSURER D: � INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-004283461-12 REVISION NUMBER:1 THIS IS TO CERTIFY THAT THE POUCIES OFINSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 SUB.IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER M/DD/Yl/YY MM/DD ��TS GENERAL LtABILITY EACH OCCURRENCE $ 4�� A X COMMERCIAL GENERAL LIABILITY GL4406199(P�ErtIIS2S10p2f8600S) 01/01/2011 01/01/2012 DAMAGE T REN E PREMI ES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(M one person) $ X SIR: $500,000 PERSONAL&ADV INJURY $, 4�� X LIQUOR LIABILITY INCLUDED GENERAL A��REGATE $ 28�� GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ INCLUDED POLICY PRO- LOC $ A auroMo��e uaeiurr CA 430936G(AOS} 01/011201 i 0110112Q12 COMBINED SINGLE tlMtfi $ 2�� A X ANY AUTO CA 43�362(MA) 01/01/2011 01/01/2012 (Ea accident) A CA 4309361(VA) 01/01/2011 01/01/2012 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ X SELf-INSURED PHY.DMG. g UMBRELUI LIAB OCCUR EACH OCCURRENCE $ ��AB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A �MORKERS COMPENSATION See Page Tvuo for Policy Numbers 01/01I2011 01/01/2012 X WC STATU- OTH- B AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE� N�A E.L.EACHACCIDENT $ 2�� OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYE $ 2�� p Ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2+�� DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ff more space is 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 8 944. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN:BRUCE MURPHY ACCORDANCE WITH THE POLICY PROVISIONS. BOARD OF HEALTH 1146 ROUTE 2S AUTMORIZED REPRESENTATIVE SOUTH YARMOUTH,MA 02664 of Marsh USA Inc. Edward R Ford �s[.c�Jatsa..oC_�. ,T'-"�e,.t.� �1988-2009 ACORD CORPORATION. Afl rights reserved. ACORD 25(2009/09) The ACORD name andiogo are registered marks of ACORD � , ADDITIONAL INFORMATION NY��s,_,2 °"�`M""°°""'' 12I23/2010 PRODUCER MARSH USA,WC. 99 HIGH STREET BOSTON,MA 02110 Attn:boston.certrequest@marsh.com/Fax:212-948-4377 S0240frALL-GAW-11-12 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER G: CVS CAREMARK CORPORATION AND ITS — ----- SUBSIDIARIES AND AFFILIATES �NSURER H: ONE CVS DWVE it�suRER e WOONSOCKET,RI 02895 INSURER J: TEXT WORKERS COMPENSATION DEDUCTIBLE PROGRAM: POLICY DATES:JAN 1,ZQi 1 TO JAN 1,2012 Ins.Co. Policy# States Covered B WC 061967163 AR,GA,HI,IL,IN,KS,KY,LA,MD,N�,MS,NM,OK,PA,SC,SD,TN A WC 061967167 AL,AZ,CO3 DE,ID,IA,ME,MI,MT,NE,NH,NV,UT,VT,VW A WC 061967162 CA A WC 061967160 MN C WC 0619fi7165 OR A WC 061967161 TX A WC 061967164 FL A WC061967166 ND,NY,OH,WA,WI,WY EXCESS WORKERS CAMPENSATION PROGRAM D XWC 488�05-63 CT,DC,MA,NC,NJ,OH,RI,VA Excess Workers Compensation Self-Insured Retentions DC�MA.OH�RI: 5500,000 CT,NC,NJ,VA: a1,�00.000 COVERAGERiWorkersCompcxssationc3tatutory __ _ __ ___ __ _ COVERAGE B:Empbyers LiabUity Limi4s:5500,OW!$500,OOOl$500,000 CfRTIFICATE HOLDER THE TOWN OF YARMOUTH ATTN:BRUCE MURPHY BOARD OF HEALTH 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664 nurrior�zEu a�vre�rnrne of Marsh USA Inc. Edward R Ford �� ac zz-i- �; .�'� , �� y3,-:- � :� #.?.t , �.� 'a�; ,�r�r�"� � .. � s :��`�. �:{ ... �r �h ..��. .._��, � ' a.�� .r...,,, `�r��.�.....:�.�u�,�.�"� �a=._.��d� _.��'��r�;�x�F,'��._ ��.a.�€. 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