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Home My WebLink AboutApplication and WC :, � TOWN OF YARMOUTS BOARD OF HEALT� �� O s �� APPLICATION FOR LTCENSE/PERMI'�-Zd�O *Pleas�complete form and attach all necessary',c�oc�ument�by;�e em��,+�X��I,9 a�lur o do so w�ll result m the return of yau�a,pp�icatto p� t 1 H u t"r�: A NAME OF ESTABLISHMENT: fJ TEL. #`��v�p -� �'� LOCATION ADDRESS: �.3 �. MAILING ADDRESS: !� � uo'r� � � � OWNER NAME: D E or • CORPORA.TION NAME APPLIC LE . - �'"�� MANAGER'S NAME: i� �fS TEL. # -' MAILING ADDRESS: d0 � � POOL CERTIFICATTONS: The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated Paol Operator(s) and attach a copy of the certification to this form. 1. 2. Paol operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Com�nunity Cardiopulmonary Resuscitation(CPR). Please list these employees belaw and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. �. a. 3. 4. FOOD PROTECTION�VIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishrnents, 105 CMR 590.000. Please attach copies of certificarion ta this application. The Health Department wiU not use past years'records. You mast provide new copies and 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. L 2. HEIMLICH CERTIFICATTONS: 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 rimes. 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 m�intain a file at yonr place of business. 1. 2. 3. 4. RESTAUR.A,NT SEATING: TOTAL# OFFIGE US� ONLY LODGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B$cB $55 �CABIN $55 �MOTEL $55 AV1+7_ . _ -�s�5 - ---, _ __ �CA.'1�IP � $55 _„_SWIMMiNGPOOL $80ea. : „_LODGE $55 � �TRALL,ERPA.RK $105 „_WHIRLPOOL $80ea. FOOD SERVICE: LICENS�REQUIRED FEE PERMIT# LICENSE REQUIRED �'�E PERMIT# LICENSE REQUIRED FEE P�RM1T# �0-100 SEATS $$5 _CONTINENI"AL $35 NON-PROFIT $30 >100 SEATS $160 _ �COMMON VIC. $60 rtWHOLESALE $80 , RETAII,SERVICE: �RESID.KITCAEN �80 ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. �50 >25,000 sq.ft. $225 VENDING-FOOD $25 �<25,000 sq.ft. $$0 0� �FROZEN DESSERT $40 �TOBACCO $55 -�[6-(�LZ— NAME CHANGE: $is AMOUNT DUE = S 135• (ZO i """**�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** , , ADNIINISTRATION .� . ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernciit:to operate a business if a person or compa.ny does not ha.ve a Certificate o£Worker's Gompensat'ron Insura�nce. THE ATTACH�D STA1'� WURKER'S COMPENSATION INSURANCE . ; AFFIDAVIT MUST BE COMPLEI'ED 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 tv renewal or issuance of your perimits. PLEASE CHECK APPROPRIATELY IF PAID: � YES NO �� MOTELS AND OTHER LQDGING ESTABLISHMEl�I'TS . _ TRANSIENT OCCUPANCY: For purpases of the limitations of Motel or Hatel use,Transierrt occupancy shall be limited to the temporary and short term occupancy, ord�naril�and customarily associated with motel and hotel use. Tra,nsient occupants must have and be able to demonstrate that they mairrtairn a principal place of residence eLsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirCy (30) days, and an ; aggregate of not more than ninety(90) days within any six(6)month period. Use of a�uest unit as a residence or ' dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defm.ed in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transieirt. I ( POOLS � POOL OPENING:A11 swimming,wading and whirlpools wluch have been closed for the season must be insp� � by the Health Department�prior to opening. Contact the Health Aepartme�t to schedule the inspection three(3)days � pnor to opening.PLEASE Nn'fE:People aze NOT allowed to sit m the paol area.until the pool has been inspected � and opened. � PUOL WATER 1'ESTTNG: The water must be tested for pseudamonas,total coliform and standard plate aount by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLO�ING: Every outdoor in ground swimmin�paol must be drained or covered within seven(7)d�ys of � closing. � I FOOD SERVICE f i � CATERING POLICY: � Anyone who caters within the Town of Yarmouth must notify the Yazmouth Healtlx Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FRO�EN DESSERTS: I Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health ` Department. Failure ta do so will result in the suspension or revocation of your Frazen Desse7t Pennit untit the above terms have been met. ' OUTSIDE CAFES: 4utside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromtheBoard ofHealth. OUTDOOR CQOKING: Outdoor cooking,pre�ation,or display of any food product by a retail or faod seivice establishmern is prohibited. NOTICE:Permits run annually from January 1 to Dec�mber 31. IT IS YOUR RESPONSIBII.ITY TO RE1'tJRN TI-�COMPLETED RENEWAL�PPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ' ALL REN4VATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOI. (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL � , DATE: �i`�-' SIGNATURE: PRINT NAME&TITLE: Dianne La�,�p,,� �icensir�g coordtnator 09/25/09 . . . . CVS/P�r�r� One CVS Drive �Woonsocket, RI 02895 G3�C��OM[�D DEC 0 4 i' �g HEAL I H t�tr� . December 1, 2009 Dear Sir/Madam: Enclosed please find completed application(s) and/or invoice(s) along with payment in the appropriate amount to cover the cost of the renewal for the CVS/pharmacy store(s) in your area. Please note any chan�es made on the application re�ardin�trade name and or mailin,�address, and include store numbers on invoices and permits - as indicated on the application to insure correct pavment to the proper store. - Please send the permit(s)/license(s) and any future renewal ; applications for this store, with the store number on it, to mv attention at: One CYS Drive, Licensin�Dept., Mail Drop 23062A, Woonsocket. RI 02895. After receiving the licenses, I will make the necessary copies for my files and forward the originals to the stores for posting. If you have any questions, please contact me at 401-770-5772 or by : fax 401-652-0608. Sincerely ,,;f.R F f��, Dianne L. Lackey Licensing Assistant Legal Department Marsh Page 1 of ' MEMORANDUM OF INSURANCE DATE 12-Mar-2009 This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rights upon any viewer of this Memorandum. This Memorandum does not amend, extend or alter the coverage described below. This Memorandum may only be copied, printed and distributed within an authorized viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an 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.B See Additional Information Section CVS Caremark Corporation &All Subsidiaries and Co.0 Affiliates, including without limitation CVS Pharmacy Inc, ` 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 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 ENERAL B - 6506290 (Prem/Ops) O1-Jan- 01-Jan-2010 GENERA� USD LIABILITY B - 6506291 (Druggist) 2009 O1-)an-2010 GGREGATE 24 000 000 COMMERCIAL B 6506303 (Liquor) O1-Jan- O1-Jan-2010 pRODUCTS - INCLUDED GENERAL LIABILITY 2009 COMP/OP ABOVE OCCURRENCE O1-Jan- GG , 2009 PERSONAL USD ND ADV 4,500,000 NJURY EACH USD 4.5M OCCURRENCE (PREM); 4M DRUG FIRE DAMAGE USD (ANY ONE 1,000,000 FIRE MED EXP (AN ONE ' PERSON UTOMOBILE B - 6506148 (AOS) O1-Jan- O1-)an-2010 COMBINED USD LIABILITY B - 6506149 (MA) 2009 O1-Jan-2010 SINGLE 2,000,000 4NY A!►T4 B - 5506150 (VA? Q1-J�n- 01-)an-2014 LIMIT HIRED AUTOS 2009 BODILY NON-OWNED O1-Jan- NJURY(PER UTOS 2009 PERSON Self Insured - BODILY Physical Damage IN]URY(PER CCIDENT PROPERTY DAMAGE EXCESS EACH LIABILITY OCCURRENCE GGREGATE ARAGE UTO ONLY LIABILITY (PER CCIDENT OTHER THAN AUTO ONLY: EACH ACCIDEN AGGREGATE WORKERS C - 3566698 (AR,GA,HI,IL,IN,KS,KY,LA, O1-Jan- 01-Jan-2010 WORKERS Statutory COMPENSATION /MD,MO,MS,NM,OK,PA,SC,SD,TN) 2009 01-Jan-2010 COMP LIMITS EMPLOYERS B - 3566699 (AL,AZ, 01-Jan- OS-Jan-2010 EL EACH USD LIABILITY CO,DE,ID,IA,ME,MI,NE,NH,NV,UT,VT,WV) 2009 O1-Jan-2010 CCIDENT 2 000 000 HE PROPRIETOR/ B - 3566700 (CA Only) O1-Jan- EL�DISEASE - USD ittp://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrRej ect=accept&printable=tr... 3/12/20( r Marsh , Page 2 of . PARTNERS/ B - 3566701 (Retro MN,NY,ND-EL ONLY, 2009 POLICY LIMIT 2 000 000 EXECUTIVE WI) 01-)an- EL DISEASE - USD OFFICERS ARE: 2009 EACH 2,000,000 EXCLUDED EMPLOYEE A PROPERTY 8757386 30-Ju1- 30-)u1-2009 LL RISK OF USD 2008 DIRECT 50,000,000 PHYSICAL LOSS OR DAMAGE INCLUDING , FLOOD AND ' EARTHQUAKE, SUBJECT TO PO LICY ERMS AND CONDITIONS EXCESS E - 4780447 O1-)an- O1-Jan-2010 WC - EMPLOYERS ORKERS 2009 STATUTORY LIABILITY: COMPENSATION USD (CT, DC, MA, NC, 500,000 N7 ON RI VA ORKERS D - 3566702 (OR only) 01-Jan- O1-Jan-2010 C - EMPLOYERS OMPENSATION 2009 STATUTORY LIABILITY: USD 2 000 000 The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any modifications hereto are not authorized. MEMORANDUM OF INSURANCE DATE 12-Mar-Z009 This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and ,r_ _ 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 Caremark Corporation &All Subsidiaries and ' ("Marsh") A�liates, including without limitation CVS Pharmacy Inc. ADDITIONAL INFORMATION ; PROPERTY: ADDITIONAL PARTICIPATING INSURERS: Axis Surplus Insurance Company Policy # EAF 728076-0$, Lloyd's of London Policy #DP658108 ADDITIONAL INSURED, LOSS PAYEE, OR MORTGAGEE Any party which the Named Insured is contractuaily 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 contractuai 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: "All Risk" of direct physical loss or damage including Earthquake, Flood, and Wind, subject to policy terms and conditions. PROPERTY COVERED Real and Personai Property, Extra Expense, 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 fuily described in the policy. Boiler& Machinery coverage is excluded. http://www.marsh.com/MarshPortal/PortalMain?PID=AppMoiPublic&acceptOrRej ect=accept&printable=tr... 3/12/20( r Marsh � Page 3 of , Terrorism Coverage is excluded. GENERAL LIABILITY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION: COMPANIES AFFORDING COVERAGE: B - New Hampshire Insurance Company C - American International South Insurance Company D - Insurance Company of the State of Pennsylvania E - National Union Insurance Company of Pittsburgh, PA TEXAS WORKERS COMPENSATION DEDUCTIBLE POLICY: Policy # 3566703 (via New Hampshire Ins. Co.). Effective January 1, 2009 - January 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM FLORIDA WORKERS COMPENSATION DEDUCTIBLE POLICY: Policy # 3566718 (via New Hampshire Ins. Co.). Effective January 1, 2009 - January 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM WORKERS COMPENSATION POLICIES - LONGS DRUGS STORES ONLY Policy # WC 3566746 Ins. Co.: New Hampshire Ins. Co. States Covered: CA Effective January 1, 2009 - )anuary 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM Policy # WC 3566747 Ins. Co.: Ins. Co. of the State of PA States Covered: OR Effective January 1, 2009 - January 1, 2010 : Limits: WC - Statutory/ Employers Liability $2MM Policy # WC 3566748 Ins. Co.: New Hampshire Ins. Co. States Covered: TX Effective January 1, 2009 - January 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM , Policy # WC 3566749 Ins. Co.: New Hampshire Ins. Co. States Covered: AZ, CO, HI, KS, MI, NV, PA, UT, VA Effective January 1, 2009 - January 1, 2010 Limits: WC - Statutory/ Employers Liability $2MM Terrorism coverage included on General Liability, Automobile Liability, Workers Compensation and Excess Workers Compensation policies. Virginia Garage Liability coverage is included on Generai Liabiiity policy 6506290 SELF-INSURED RETENTIONS: General Liability - USD 500,000 Prem/Ops USD 1,000,000 Druggist Excess Workers Compensation: USD 500,000 - DC, MA, OH, RI USD 1,000,000 - CT, NC, N), VA 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&acceptOrRej ect=accept&printable=tr... 3/12/20(