HomeMy WebLinkAboutApplications, WC and Licensesi �A !��f•. � � r
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�, � � TOWN OF YARMOUTH BOARD OF H�A�, � � � �� � � � �
� APPLICATION FOR LICENSE��YIiT�.� `
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Please complete form and attach all necessar�cu�ents y Dece er I S 2008.
Fa11ure to do so will result in the return of your application p c ,��_-�,� ��pT.
NAME OF ESTABLISHMENT: S � TEL. #�,-�39da�d���
LOCATION ADDRESS: ,� � Oal�
MAILING ADDRESS: E� .�— .t/ c .�` O �
OWNER NAME: TAX D F IN or SN : �
COR.RORATION NAME ( APPLIC�LE): �' s S �? �C..��
MANAGER'S NAME: �� �'�/' TEL. #� � �790�
MAILING ADDRESS: G S �
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the cei�tification to this form.
1. 2,
Pool operators must list a minunum 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 ofemployee
certifications to this form. The Health Department �vill not use past years' recards. 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 establishme�ts are requued to have at least one full-time employee who is certified as a Food
Protection Mana�er, 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.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours 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 empioyees trained in anti-cliokmg procedures below and '
attach copies of employee certifications to this foi�n. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place af business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGIti G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S55 _CABIN $55 MOTEL S55
TINN S55 _CAMP $55 _S�'VIMMING POOL S80ea.
_LODGE S55 _TRAILERPARK $105 WHIRLPOOL $80ea.
_ FOOD SERVICE: ,
—_ _ � __ _ ______ __ __.�_ _ , _: _ _ -_.__ __ __ i
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS �85 _CONTINENTAL S35 NON-PROFIT �30
_>100 SEATS 5160 _COMMON VIC. �60 _WHOLESALE �80
RETAIL SERVICE: —RESID.KITCHEN �80 ;
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERIvIIT#
_<�0 sq.n. �50 _>25,000 sq.ft. $22S VENDING-FOOD $25
�<25,000 sq.ft. �80 �0�'D�J`f _FROZEN DESSERT �40 / TOBAGCO �55 �� ! ;
�Ta��cxa:vcE: �lo AMOUNT DUE _ $ / 35. Oo '
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*****PLEASE TUR�OVER AND COVIPLETE OTHER 5IDE OF FORNI**•** �
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� �,�, ��, �
ADMINISTRATION _ � �
Under Chapter 15�; �ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal !
of any license or pemut 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
Town of Yarmouth taa�es and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT UCCUPANCY: 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 s�(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.
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_ POOLS .
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(S�days
pnor to opening.PLEASE NOTE:People are NOT allowed to srt 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, 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.
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FOOD SERVICE '_
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CATERING POLICY: t
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme�t by filing the required !
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the i
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 sea.ting with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING: `
;
Outdoor cooking,preparation,or displaq of any food product by a retail or food service establishmern is prohibited.
� I
� NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN '
,
' TF�COMPL�TED RENEWAL APPLICATION(S) AND REQUIRED 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 TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA
DATE: ��- ' l�_� SIGNATURE:
PRINT NANIE&TITLE: [�annP LaCk2y �icensina Coordinator
io�2i�os
� ��.� �
CVS/pharma�Y� � .�� ' :�
�F �
. . , � �r 4 �.`> �.
One CVS Drive �Woonsocket, RI 02895 �"'� �'�'�Y�' � � �
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'�`:� � 1 2008
1�r��� •r
December 4, 2008 `""�- f� DEP7-.
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 application re�arding trade name and or
mailin�address, and include store numbers on invoices and nermits
as indicated on the apnlication to insure correct navment to the :
proper store. !
Please send the permit(s)/license(s) and any future renewal
applications for this store, with the store number on dt, to mv
attention at: One CYS Drive. Licensin�Dent., 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
_
r ;>s��f; ' �`��,
Dianne L. Lackey
Licensing Assistant
Legal Department
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• � �'he Con�nz�nwealtlz vf Mnssat?huse�s I
�epartment of Induslrial Accirlents
Office vf�'nve��stc�afions�
6D� T�ashingt�an�treet � �
, Bo,rtvn,M:� p�1I1 � �
y T4�F1�i1�tlTldSS�OV�ltl[I. �
�arkers' Campec�sa�'ron �sur.anc� �'ic�avi�: ��n�r.a��usiat�ss�
�4, lica�4:�a�'orma#�on I
]P'fe��e Print Y,e�ib���
Business/Organization Name: cvslDha�,,�, �
AdclI'ess: One CVS Drive, I�5ai1 Drop 2306?A ' I
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�1�IS'�.��IZl�:_S�7orn�cnrkPr_ RT . fl R45 '
r. .�h� #: ��arn������,� �. , �. .� .. .� . .�
Are yvu an empl�yer? Chec�the apprapriate box: Business•Typ�e.�re��r.edj � I
1.0 I am a emplayer with__G�emp.loyees(fv11 anti/ 5. O..Reiaii �
2.❑ ar part-time).* 6. ❑ Resfaura�tBar/Eai�ng Es{�bi' hment
I am a sole praprietor or partnership and hawe no I
employees working for me in any capacity. �. D O�frce andlor Sa}es{in�l.jreal.estate, auta,etc.)
jNo workers' comp.imsuranee required] 8• ❑Nan-�rrofit �
3.❑ We are a eorporation and.its affi�ers have exercise:d Q: �En#ertainment ,
their ri�ht of exemption per c. 152, §1(4),,anc}`we have
no cm la ees. I0.(�I�iSa:nu�'acturin:o �
P Y [�1`l0�vorkers' conzp_insurance requii-e ; , i
4.❑ We are a ncan-profit organizarion,.:sfaffed b3�vole�nteers, 'll..[]Health C-are ;
wiih no e�ployees. j�1a workers' cornp:.insura�xee.r�q,] 1`2.[� Other ' �
WAny app}icantthai chc¢ks box#1 mustalsafrll out(�esectioahcinwshowingtJaetrwoikefs+:compeny�auonpolicy infor�iiatia l:
r"`If'the corporace o�cers have exempted tbcroselvrs;bttt:the co�oration has ofher eruPia3'cc��.a workcrs`compensatiompQ3ic�is�uirec3:and such an
or(�anization skould check boa#L
� �
.�am ara e�rpdo�=er thal is�roria'i�g wor�e.*s'cQm�ensr.tii�n uzsur�rce for rny en�lavees. L'etox,rs�lte p�iliey irzfi�:rnat.�rz.
Insurartce Company Name: Ar�rican H u e I
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Insurer's Acidress: 70 Pir�e St e�t ; �
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Ciry(State/Zip: tv w ' ��Y i . � ' '
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PoIicy� or Self-ins.Lic.# 5Z�>-39-C� I I
Expiration.I).ate: Op.l(11VC'q
Attach a�opy of�he workeFs'compensa�ion po�icy de�aratian paae(�ho�ina th�pc���ey;n�mbe :;an exgirafa�n�ate).
Failure to secure coverabe as required.under Section 2SA of 1vfGL c. 1�2 can Iead.to the imposition ot'cr' ' i Fenaities of a
fine up to �1,500.00 and/or one-y�ar imprison�nent;a.s well as avil pez�alties in tlie�orrn of a STOP'�(} C�RUER and a fine
of up to $250.00 a day a�ainst the violatar. Be advised that a co�ry af t�is,statcment ffia3�.I�e f�I.R,��}��t� e Q�ree of
Investigatians of the DIA for insurdnce coverage verification.
I do hereby certif}>,i er tlre pai s an a[r�es P er u.:t �
.fP .I �1 tlzui-Ylae infornirztiart.pravtdea`ubove is� ue and:correeL
Si�natvre: DEC Q t� �OQ
Date:
Phosre#: ���'��.5� p �
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G�ffccial use Qnl��. I�o not►Yrite in lhis arc�n,:r�be.eonzplet�b}}city ur toivrr.a � '
fficircL i �
�ity or Tc�v�n: ;
PesinitlLi�ense# i i
�.s.suiug Authority(circle t�ne): �
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1.Baard of Hea2th 2. �uilding Ilep�rttn�nt 3.�tvfTown Cierk 4.Lizensing Buard 5.Sete�tme:n's CD�ce
6. Oth�ea�
; :
�untact Persou: �
Phone#: i
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www.mass.gov/dia i
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-034 FEE: S80.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
11 l,Section 5 of tbe General Laws,a permit is hereby granted to:
Massachusetts CVS Pharmacv, LLC, 453 Station Avenue, South Yarmouth, MA
Whose place of business is: CVS/Pharmacv#944
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yannouth
Pernut expires: December 31, 2009 BOARD OF HEALTH: .i�¢tR SI��, �JZ..JV., C�.fl�avYrnan
Cf�aur�ee .�E. 9'Ce�!'iRr�t `l�ice C'f�avrncac�t
J`�.t+�e�ct !�. J�acown, e�
��r�J2..t1r.
December 31.2008 B ce G.Murphy,MI' , .5.,CHO
Directar of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #09-024 FEE: 555.00
This is to Certif}�that Massachusetts CVS Ph�rmac,y, i.i.C' ci/h/a C'�I /ph rmac,y#944
453 Station Avenue South Yarmouth MA
IS HEREBY GRANTED A LICEl�'SE
For � I. . AND DL T iB TTION OF TOBA O PROD 1(`T
_ AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO RE ULATION
Thp.�er�it is ant��i i��CB�forn}itv��-ith Article VI of the San'ta •Code of The Conunon���ealth of Massachusetts>and
ex i es ecei�i�ier_ i un e5s sooner suspended or re�•o�e�.
December 31_?008 BOARD OF HEALTH: .`��UZ $�� �„lV., (�lftRlt
C'�ia�tPeo .�. 9Ge1�e�c, `Uice C"��carrnaa
Jta��ct 3.53�r.awn, e�ex� ,
Qtut C�eeerr.�auern, ✓2..N.
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ce . urp y;MPH,
Director of Health
i � � �'9 y7
J`'Y"k TOWN OF YARMOUTH BOARD OF = o
r, -�� �L`�'H �,�, G3C� C� C� dMGD
� � ' APPLICATION FOR LICENSE/PERMf1' '20 �� ``
Y��',2' _:. �'
..�,. �� DEC 0 5 2007
* Please complete form and attach all necessary documents by Decemb r 31, 2007.
Failure to do so will result in the return of your application pac .HEALTH DEPT.
NAME OF ESTABLISHMENT: fyI 9 � TEL. # o�
LOCATION ADDRESS: �-�J /pharmacy a
MAILING ADDRESS: one cvs Dr Ma;l Drop 23o62A
OWN�R NAM�: woonsocket,RI o2895 D IN r N -
CORPOR.ATION NAME (IF APPLICABLE):
� /' —Massachusetts CVS Pharmacy,LLC
MANAGER S NAME: �/,/���J/ � ��/��' TEL. # • -�
MAILING ADDRESS: Cvs/pharmacy ' —
One CVS Dr Mail Drop 23062A
POOL CERTIFICATIONS: �'�'oonsocket,iu o2895
The pool supervisor must 6e 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 minimuxn of two employees currently certified in basic water safety,standard First Aia and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
eertifieatians to this form. T�te I�ealt6 Depert�ent will not use past yea�s' records. Yo� t�t�st previde new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD 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 in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Flease afitach copies of certification to this applieation. The Health Department�viH�at use past years'recards.
You must provide new copies and maintain a rle at your establishment.
l. 2.
_P�RS9I�T.IN��R{`iE: _. -- - _ _._
-—- � —.� _, --- _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 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 premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employ�e certifications to tbis form. The Health Department will not use past years' reeords.
You must provide new copies and maintain a file at your place of business.'
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE Ol�LY
LODGING:
LICENSE REQUIRED FE� PER'vIIT# LICENSE REQL?IRED FEE PER'tiIIT� LICENSE REQLTIRED FEE PERYSIT=
_B&B S50 _CABIN SSO _MOTEL SS0
INN 550 CA11�IP S50 SWI:�IING POOL S75ea. –
LODGE �SQ TR4ILERPARK S100 VVHIRLPQOL S75ea.
FOOD SERVICE:
LICENS£REQUiRED FEE PERMIT� LICENS£REQLTIItED FEE PER1411T* LICENSE REQL;IItED FEE PER'b11T=
_0-100 SEATS 575 _CONTINENTAL S30 NON-PROFIT S2�
>100 SEATS SI50 CO�ION VIC. S50 VV"HOLESALE S75
RETAII.SERVICE: —RESID.KITCHEN S75
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERv1IT*� LICENSE REQLTIRED FEE PER'�iIT�
_<50 sq.i�. S45 >25,000 sq.8. S200 _�'ENDING-FOOD S?0
�<25,000 sq.ft. �a75 ��,�� _FROZEN DESSERT S35 �TOBACCO SSO #o8-a�
�:va:�cxa�vcE: sio AMOUl�T DUE _ $_/2�.00
•**•*PLEASE TL'R.\OVER 2���CO�IPLETE OTHER SIDE OF FOR�Z**"�**
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Anlvmvis�TTON
�
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Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pemut 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 �
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 us�. E
Transient occupants must have and be able to demonstrate thax they maintain a principal place ofresidence etsewhere.
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an �
aggre�ate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as�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�enerally be considered T"ransient. �
�
* NOTE: En��osed Motel Census must be completed and returned with t�is app�ication. �
POOLS
PUOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' ected j
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�S days
pnor to openuig.
POUI.WATER TESTI_NG: The_water must be tested for pseudomonas,total coliform and standard plate count ;
- by��ate 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 F
closing. ;
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FOOD SERVICE �
�
CATERING POLICY: :: €
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required i
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be abtained 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 Pennit urrtil 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:
' , eparatiatt,ordisplay of�nyfnodprociue�by . . es�bfishment-isprohi6ited. __ I
N4TICE:Permits run annually from 7anuary 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 ESTABLIS��ViViEEN'f, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RE:VOVATIONS MAY REQUiRE A SITE PL .
�
DATE: 3 O SIGNATURE: f
ARINT NAME&TITLE: �ianne LaCk@y �icensing Coordinator 4
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ia;n o� �
<,- ��"` �- i
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' ` Marsh Page 1 of 3
MEMORAIVDUM 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 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
COVERAGES
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 PO�ICY POLICY �IMITS
LT INSURANCE EFFECTIVE EXPIRATION LIMITS IN USD UNLESS
DATE DATE OTHERWISE INDICATED
ENERAL B - 583-59-69(Prem/Ops) O1-Jan- 01-Jan-2008 GENERAL USI
LIABILITY B - 583-59-70(Druggist) 2007 O1-Jan-2008 GGREGATE 15 000 00(
COMMERCIAL 01-Jan- PRODUCTS - INCLUDEI
GENERAL LIABILITY 2007 COMP/OP ABOVE
OCCURRENCE GG
PERSONAL USI
ND ADV 4,000,00C
INJURY
EACH USD 4.51
OCCURRENCE (PREM); 4t
DRUG'
FIRE DAMAGE '
(ANY ONE
FI RE
MED EXP (AN
ONE
PERSON
UTOMOBILE B - 583-67-33 (AOS) 01-Jan- O1-Jan-2008 COMBINED USI
LIABILITY B - 583-67-34 (MA) 2007 O1-Jan-2008 SINGLE 1,000,00C
NY AUTO B- 583-67-35 (VA) O1-]an- O1-Jan-2008 LIMIT '
HIRED AUTOS 2007 BODIIY
NON-C�WNED O1-Jan- INJURY(PER
UTOS 2007 PERSON
Self Insured - BODILY
Physicai Damage INJURY(PER
CCIDENT
PROPERTY
DAMAGE
EXCE�S EACH
LIABILITY CCURRENCE
GGREGATE
GARAGE UTO ONLY
LIABILITY (PER
CCIDENT
OTHER THAN AUTO ONLY:
EACH
ACCIDEN
AGGREGATE
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I
' ' Marsh Page 2 of 3
ORKERS C - 292-08-02 O1-Jan- 01-Jan-2008 ORKERS Statutory
OMPENSATION /(AR,GA,HI,IL,IN,KS,KY,LA, 2007 OS-Jan-2008 COMP LIMITS
EMPLQYERS MD,MO,MS,OK,PA,SC,SD,TN) O1-)an- O1-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) 01-Jan- EL DISEASE - USI
PARTNERS/ B - 292-08-04 (CA Only) 2007 ppLICY LIMIT 2 000 OOC
EXECUTIVE D - 292-08-05 (Retro MN,NY,ND-EL O1-Jan- EL DISEASE - USI
OFFICERS ARE: ONLY, WI) 2007 EACH 2,000,00(
EXCLUDED EMPLOYEE
A PROPERTY 8756280 30-Ju1- 30-)u1-2008 LL RISK OF USI
2007 DIRECT 50,00O,OOC
PHYSICAL
LOSS OR
DAMAGE
INCLUDING
FLOOD AND
EARTHQUAKE,
SUBJECT TO
POLICY
ERMS AND '
CONDITIONS
EXCESS E - 375-80-57 01-Jan- O1-Jan-2008 WC - EMPLOYER:
ORICERS 2007 STATUTORY LIABILITY
COMPENSATION U51 ;
500 OOC '
ORKERS F - 292-08-06 (OR only) 01-)an- 01-Jan-2008 C - EMPLOYER '
COMPENSATION 2007 STATUTORY LIABILITY
USI
2 000 00C
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
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 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;//wwve.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.
PRODUCEft INSURED
Marsh USA Inc. CVS Caremark Corporation &All Subsidiaries and
("Marsh") Affiliates, including without limitation CVS Pharmacy Inc.
ADDITIONAL INFORMATION
PROPERTY:
ADDITIONAL PARTICIPATING INSURERS: Axis Surplus Insurance Company Policy # EAF 728076-07, Lloyd'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 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.
PERILS: "All Risk" of direct physical loss or damage including Earthquake, Flood, and Wind, subject to policy terms
and conditions. '
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' °Marsh Page 3 of 3
PROPERTY COVERED
Real and Personal Property, Extra Expense, Rents, Improvements and Betterments, Structures in the Course of
Constructien, 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.
Boiler& Machinery coverage is excluded.
Terrorism Coverage is excluded.
GENERAL LIABILITY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION:
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, PA
F- Insurance Company of the State of Pennsylvania
Terrorism coverage included on General Liability, Automobile Liability,-Workers Compensation and Excess Workers
Compensati9n poHeies.
Liquor Liability is included on General Liability policy GL 583-59-69
$4,000,000 Aggregate Limit
$4,000,000 Each Common Cause Limit
Virginia Garage Liability coverage is included on General Liability policy GL 583-5969
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, 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.
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' •
TOV�N OF YARMOUTH
BOARD OF HEALTFI
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLTMBER: #08-024 FEE: $75.00
In accordance with re�ations promulgated under authority of Ghapter 94,Secrion 305A and Chapter
111,Secrion 5 of the neral Laws,a permit is her�by granted to_
Massachusetts CVS Pharmacy, LLC,453 Starion Avenue, Sauth Yarmouth, MA
Whose place of business is: CVS/Pharmacy#944
Type of business: Retail Footl Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2008 BOARD oF HEALTH: 3fePen SRtaR�, J2.,.N�., (�ai�t�tur�
CFEac�c�ea 3E�£e�eac `tJice C!I�aixnutn
�'�act 3.J`3�u�ct�L, C!�
c���, �..N.
December 12.2007 Bruce G.1Vlurphy, H,RS.,CHO
Director of Heal
THE COMMONWEALTIi OF MASSACHUSETTS
TOWN OF 3�ARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #09-020 FEE: $50.00
This is to Certify that Massachusetts CVS Pharmacy, LLC d/b/a CVS/Pharmacy#944
453 Sta#ion Avenue South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For_ SALE AND DISTRIBUT70N OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATIQN.
This�r.�it ie�ant��i��g�or�iri with Article VI of the San�tar�Code of The Commonwealth of Massachusetts,and
exp es ec er ��s sooner suspended or revo e .
December 12.2007 BOARD OF HEALTH: `.��¢�t S�� �..lv.� ���I�Y/t�p�LL
('.�iavr�'ee .�. �fi�'�if�ex, `tlice C'Peav�crruuz
� �i��ct s.J3�tur�, e�ex�
(I,�irc l�ceerr.�cuun, J`�..9r.
Bruce G.Murphy,MP , . ., H
Director of Health
. o�,,yqR � � ��G, �� � �l� l� ID
2 ,. � TOWN OF YARMOUTH BOARD OF HE T�
" o�.` - � APPLICATION FOR LICEN���- Q'T '; AUG 1 3 2007
� , .;s � ..
�R ��:� '�
* Please complete form and attach all neces dc�cy� �"becem �-DEPT.
Failure to do so will result in the ret r�t of your application packet. '
NAME OF ESTABLISFIlVIENT:_CVSI hQ,rmA[ �' Q4� TEL. # ' � q -�1O1o9 '
LOCATION ADDRESS:_y�j3 g�0.�C��r, AUt, Sou�h VQ�mt�1.l�!-h., I,daA Odcalay
MAILING ADDRESS: (�r1f_ CU.S .l�nve��,p a���aA, t�,snc x.s�F,'}�..� Cs�45
OWNER NAME:_Y`(1pS�QChuSe�-+-s CV'S �ho�nnnnw, L..I,.C. T�X ID(FEIN or SST�('�-�
CORPORATION NAME{IF APPLICABLE): �Ssrrinur�¢�+S ('�S�hunr�rs�.v L.1..C .
MANAGER'S NAME: Kc�.�:�1;� F�,�dR -T� TEL. #�g- 443�t���
MAILING ADDREss:_Dnt �'�� ^� �lo�, �.�1�,��r��,`�.t csa�t4�S'
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 cunently 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. 1'he Health Department will not use past years' records. You must provide new
copies and maintain a file at your ptace 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 Cpde for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department witl not use past years' records.
You must provide new copies and maintain a fde at your est�blishmen�
1.�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.
HEIlVILICH CERTTFICATIONS:
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-chokmg 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.
l.� �(�� 2.
3. 4.
RESTAURANT SEATING: TOTAL# -
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S50 _CABIN $50 _MOTEL $50
--- - — ----- — ____ — _ __----_ - _
_ - _ _- _
_INN_ _ __ -$50 - -_ - CAMP $50 _SV�IMIvIII�iGPOOL$75ea.
_LODGE $50 _TRAII,ERPARK $100 WHIItLPOOL $75ea. �
FOOD SERVICE:
LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIRED FEE PERMff# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAII.SERVICE: �RESID.IQTCHEN $75 '
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIltED FEE__I?ERM�T#
_<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20
1 45,000sq.ft. $75 � rb _FROZENDESSERT �35 �TOBACCO $50 �d��
NAME CHANGE: $10 AMOUNT DUE = S 1��5,�
•"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�h�k R
ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal
of any license or pennit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORIiER'S COMPENSATION IlYSURANCE
AFF�IDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF 1NSURANCE ATTACHED � '
OR
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: �
— _ -- _---- _ _ __
-- -- _ - _ _- _ _ �
� —���---- � � ��
MOTELS ANA 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 motet and hotel use.
Transient occupant5 must ha.ve and be able to demonstrate that they maintain a principal place ofresidence 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, sha11 generally be considered Transient. '
POOLS
i
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 Department to schedule the inspection five(5�days ;
pnor to opening. ;
�
POpL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ,
by a State certified lab, prior to opening, and qua.rterly therea.fter. '
;
POOL CLOSING: Every outdoor in ground swimming pool�nust be drained or covered within seven(7)days af
closing. �
FOOD SERVICE ;
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmetrt by filin�the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department. i
r
FROZEN DESSERTS: �
Froaen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health �
_ Depa�tmeni. Failtue-t9-do�vuill_result_it�ihe-suspension or revcication of yc�ur-�aaen-Dess�rt-�'����i�-tl�----- �
above terms ha.ve been met. i
OUTSIDE CAFES: r�
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTD04R COOKIlYG: '
Outdoor cooking,preparation,or display af any food product by a retail or food service establishment is prohibited. ,
f
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, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-A�ENT, MOTEL 4R POOL (i.e., PAINTING, NEW ,
;
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
� TO C4MMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i
� I
DATE: � ` (')'� SIGNATURE: �o �—�� I,
T��a I
PRINT NAME&TITLE: �'C��0.1,..���„�,,,�j,('oi�Yr�C�4uCt � �''�
ion�io6 �I',
V pharmac�y�
Expect something extr��
One CVS Drive,Woonsocket,RI 02895•401-765-1500
� I� �� [� �l ��r� f� D
DATE: August 10, 2007 Al)G 1 3 2007
Town of Yarmouth NE4LTH DEPT.
1146 Route 28,
South Yarmouth, MA 02664
RE: Business License
Massachusetts CVS Pharmacy, L.L.C.
Dba CVS/pharmacy#944
484 Station Avenue
South Yarmouth, MA 02664
Dear Sir or Madem:
Please be advised the above-referenced store is scheduled to relocate to 453 Station Ave..
South Yarmouth. MA 02664-1849 on approximatel�u � ; ��>
Thank you for your assistance in this matter. If you have any questions, please feel free to
contact me at 401-765-1500, extension 4192.
Sincerely,
��-K9. c`�. •�
Erika L. Austin '
Licensing Coordinator ;
Licensing Department ';
/ela '
! �
' Tl�e Commomvealtb of�tassachusetts
DepaRwient of Ind�shnial Accidents ;
M�'IN���i '
600 R'ashiagton Stree� 7�'Floor
Bosto�e,Mas� D211i
- ------- woric�s'com tioa I.s.rsaee,a►ffiaa.�it:B�ii • bi�/Ekedrical co■aactors
, .:. . , . . _ ,,. �. ,� �: a_ . .
,
name: C�S IOhArrnc-�L �Q��
�s• �1�3 �-}�.�hrn� IA�
�, ��In T,G��cx.� sa�• �� aQ C?aldo� �� Sr'bF-34�{-(�to
wark site locffii�rfnll addressl:
❑ I am a homeowne.r performing alI wak myself. Project Type: ❑New Car�uctio�►�Remodel
I am a sole 'etor and have no�e w in an ❑Buil ' Additian '
I am an emP�Y�'P��i�S w�kers'comp�tia�fa�my e.mployees working aai this job.
�,US �f1�,'j�,Ll,gl,tl._,,�.� - ___ _
� �
U '
. R� �, , t� `7 � I��
� ���
❑ I am a sole proprietor,g�al c�tnctdr,or tiomeo�vier(circle oee)and have hic+ed tbe ca�lractors listed below who have
the following wotkets'co�on polices:
emaot a�r ..y....� �.,
�» �,�`a,'
.
a��m�e- W„
3l�t"�'
- -.__ —_ __----___ ---
-------- -- _�— _ __— _�.___ —_
�
Fai�re�sec�e er�a�a�e as reqd�al uder Sa1Ya ZSA�f MGL 1S2 eu idid b tl�e i�itMa�[vi�i�d pnaMia�[a�ae�p b S1,3MN adl�r
su�an'isprheamt aa we9 as eM pmlqa h tlie E��ta 3TOt WORK ORDEH aad a Ape�[318�.N a day��e. I�eders�d tlut a
cepy�f Wt�my be firwarded 1s t�e OAloe�f��t tke DIA t�t avcrage vra'Mtatlw
I�o benby rn�ir dY sud pe�ltrea ojperJrrry t/ut tlYe fufor�r�pro►dded aboae Js trxe aNd oem�
�� � �� � la lrn
Pru►t name � L•� Phone# �7.l��.�,7�`�`1''7�_
e�ai ase ssly aa.ot wiite I�thi,are.c.ne a�pleted by eily.r In.a.ffiehi
cilY or te�vec pera�e�e# ��
❑ehcct if�meaia/e trapsme b neqaired �'s(I�oe
.DIf�Mt De�atieM
�ct pe�ss,: - . _ phose�• �
' --_
�s�-� _ —
TQWN OF YARMOUTH
B(JARD�F HEALTH
PERNIIT TO OFERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #07-059 FEE: $75.00
In accordance with re�ularions promulgated under authority of Chapter 94,Section 305A and Chapter
11 l,Section 5 of the�eneral Laws,a permit is hereby granted to:
Massachusetts CVS Pharmacy, LLC, 453 Starion Avenue, South Yarmouth, MA
Whose place of business is: CVS/Pharmacv#944
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, 2007 BOAxD oF HE�.�: �I����anSl�,�'/2.J�Y., ��C�uia�rtuut
VARiANCE EFFECTIVE 08/15/02: J�O���.J��l(t/t� �
Carpeting allowed in food aisles; �lC�fll',(�,/�C1��XItWIt
Tiles required around all cooler areas_ Q,tttt � 1�lUUIt, �.,/V
Au�ust 26,2007 Bruce G.Mutphy,MPH,R.S.,CH� �
Director of Health �
(
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #08-041 FEE: $50.00
This is to Certify that Massachusetts CVS Pharm�cy,L.LC d/b/a CVSlPharmacy#944
453 Station Avenue South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AiVD Di TB 1'i'ION OF TOBA O PRODi J('T
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
This�er�it is�ant�i��C$�for�t'tv with Article VI�the San�tar�r Code of The Commonwealth of Massachusetts,and
exp s ece er e§s sooner suspend or revo e .
Au�ust 26.2007 BOARD OF HEALTH: 1�. � .ik1�., ��,�.plXlttlUt
` S�,IC�� ��lC¢��,lClAtllil�ft ,
JtvG�ext s.5$�wt, Ceeacf�
:�actacicl�.A�tcl)exma.ft
fltut C�xeexr�uunc, J`�.�.1V.
Bruce G.Murp y,MPH,R. .,
Director of Health