HomeMy WebLinkAboutApplication and WC �
� � � TOWN OF YARMOUTH BOARD OF HEALTH ������ �
.. � APPLICATION FOR LICEN � � �� � ��
��:, .., � . � �,:�4, � 9 LU 13
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, * Please complete form and attach all nec�`` s X` . �e
Failure to do so will result in the��rn ;� � �1 .
ESTABLISHMENT NAME: S al'N1 C� � 3 TAX • � ��'�
LOCATION ADDRESS: c�v�,�c�. l.-�S� c;;,,,�,TEL.#: C3 �'� I '�'��9
MAILING ADDRESS: O N�. Cv s �/�-- rv� L 11 lflC� �C�N5�C.I.�.�r i L2 U�-��r� �
E-MAIL ADDRESS: ���!>!N�Z.. s lim��i's��O � C.�f 1 C.`Yi�LC' m�R-�L• C.�%rn
OWNER NAME:______ CVS Pharmacy, nc. ybi-�7o�s��z r��c �o�-bs2-0608
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: _`j�-Q.QIr�?,►� �7C,`R�S2 TEL.#: 1_""-�� �-1
MAILING ADDRESS: (�iV Q.C.,�(� `J'�• M G i l(n0 Wi�C�5�.�- ,2Z u t3�-9s�
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. I
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),having one certified employee on premises at all times. Please list ',
the employees below and attach copies of their 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.
�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 ;
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
. !
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.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen 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 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�le at your place of business.
I
1. 2. ;
3. 4. '
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RESTAURANT SEATING: TOTAL#
_ __ _ _ i
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
_LODGE $55 =TRAILERPARK $105 _WHIRLPOOL $80ea. ,
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#
<50 sy.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25
�<25,000 sq.ft. $80 , —� =FROZEN DESSERT $40 �TOBACCO $95 �
NAME CHANGE: �is AMOUNT DUE _ � �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*�*** �O•U7 ��� I
$ON !
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' ADMINISTRATION �
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Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required.to hold issuance or renewal of i
any license ar 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 j
(
CERT. OF 1NSURANCE ATTACHED (
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
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Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK �
APPROPRIATELY IF PAID:
YES NO
f
MOTELS AND OTHER LODGING ESTABLISHMENTS ;
�
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be I
limited to the temporaty 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 i
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 �
1� 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
prior to opentng.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.
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 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 of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. �'I
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NOTICE: Permits run annually from January 1 to December 31. IT IS IIHUR RESPONSIBILITY TO RETURN :
THE COMPLETED RENEWAL APPLICATION(S)AND R�.�L-��I�ED FEE(S) BY DECEMBER 13, 2013.
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
COMMENCEMENT. RENOVATIONS MAY REQ A SITE AN
` ._�-_ . .....
DATE: `c�'' ��1 �3 SIGNAT`URE:
� enn P Amitr�� � �
PRINT NAME&TITLE:
Rev. 10/08/13
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SEP-24-2013 TUE 06�33 AM CVS RISK MGMT FAX �0, 401 770 6989 P, 03
C�;f�71FfCATE O��XCESS IhlSt1RANCE
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To:Der.i t Af Industr{a{Accider�ts
on�Con{�r�ss sireet
10��' F'IoorSu(te i4o
Rostan, MA Q2114
C1ATE:.-._..._�➢Sl�CV30 24T3
SI�/Maderne'
Thfs aerflfl�s lhat a Workore Comp�nsatlon Exaesa frtsurancA Pollcy has fieen fsaued mxi delivered to the empfoyer nemad below,and
that by GasUHncn and d�iivery o(eaEd policy and tho Ciling of fhls cartlficalo of Inaurence,It Is pdrnitiod that said v7cceas pallcy Was e(iect(ya
�r�the cipt��taled t�aloW and Ihe1 the�:ov��age provfdod thernfn ig eppilcable to beneflte under the Warkars Compensallon Act o(tho slate
. u�....�.`1�q.,_. ��id thai s�Id policy shaq ramai�1n full Force and eflect unlf(90 daya eftor racefpt by tha divlBlon of labor a1 noHca of
l:s cancelldtlon or exp(rati�n apolor non-renew&I. .
; � Namu af�rnptoyer lnsured ._ CVS�aremark Corar� ,
Addraas 1 GVS pR,WooNSbCK�T,Ftl D2895-s196 �
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Addresa _1.T.$..yy����5`ST���Ld.E. YaRK,�NY 10038� ,
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Pollcy Limlt$s7A`fUTORY Pallcy Ltmit$��_`
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, 3peclfic Retentlon$6�).pc3���� ��und f'srcentage N/A ^�� `
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(Pe�r occ:ur�elzca} MInlmum Loes Fund$ N/A __�� _ .
P�Ilcy T'erm,�y�._ ��`�`_ Esilrcwled Loss Fund$ `
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� Policy Tarm�q_____^
tf mnre thap one In»urer la provlding cuvarege,you m�st provide seperete certlticate6 for each lnsurer. ' •
FNtS CERTICICpT� OF lNSURANG� N�ITNER A�FIRAAA7)VELY NOR NEOATIVELY AMENbs, �XTENPS OR ALT�HS TH�
Ct>VERAc3E(s)AFrC>RUEi�pY THE PO�ICYpCS)tISTED oA!1'HIs CERTIFICA7�. '
' • NA'CIONAL UN10N(NS CO
. I rance Company •
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Authorized Apent ��� ' '
• � 175 Water Slreet N�3w York,NY 1003$ '
CL65F3�B9 �
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r �� The�'Qr�z�nvnwealtla ofMassachusett�ss � �r��,tForm
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�epa�ttt vf Irsa'ustrial A�cide�ts
t?,f'ftce of 1'nvestiga�ir�ns
� 1'�angress Str�et,Suit�I110
:: Bpstvr�,h�A t�21�4-2(I:t 7
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Wa�kerss Compemsation�usurance Affidavi�» �ener�l]Businesses
A�pi�caz�t In�Qrmatian Pl�e�se Pri�t Le,�i_l�lv
Businessft�rga�zization Narne: cvs/Pharmacy #431s
438 Route 28
f�d(�:I'�SS:
Weat Yarntiouth, MA 02673 508-771-4429
. �:l�f�a�a���1jJ: ��10I1��.
Are yvu aaa emp�ayer?Che�k t�e appropriate b�x: Br�siness Typ�(required):
l.� �am a employ�r with empioyees(futl and/ 5. [�Retail '
t�r part-time)* 6. [�RestaurantlBarlEating Fstabiisl�merat
2.❑ T�xt a sale propri�;tor ar partnership and have no 7. ❑Of�ice azcrUor Sales(inc1.real est�te,auto,etc.)
employees worku�g for me in any capacity. 8. 0 Non-proft
[No wc�rkezs'comp.insurance required]
3,❑ We are a corpoxatinn and its officers have exercised 9. ❑Entertauunent
their right of ex�tnptian per e. I52„§1(4}y and-we have 10.�Manufactut�ing
na ernpioyees.[t�To werkers'co�np�insurance required]* 11-�Health Care �
4.❑ We are a uon-prafit organ�zation,sf�f�ed by vvlunteers,
with na empinyees.[No workers'camp.u�stuance req.] 12.�4ther
'Any Applicant tt�at checks box#I mvst also�II onYthe seetian betow showing their warkers'comgensatiaa paticp infomaatioa
**I#'the cazgorata ofFis,ers have sxemgted themselves,but the;eorporatian�as athcr employees,a workeas'compea3.vaNan�liey is reQuired�nrl such an
argan�tiau sbautd check box�l.
I am an e»�player t�is pr�vi�'iig wt+rkers'enmperrsann�#�rsurance far my e�rl�e�s. Below�s tlre pvlBcy ir�fvrmalion.
����������,���i New Hampshire Insurance Company
175 Water Street
insurer's Address:
CityLStatelZip: New York. NY 10038
019358776 O1/Ol/2014
Policy#or S�:lf:ins.Lic.# �xp�ratitrn Date: '
Attach a copy ofthe w�rrkers'co�npens�tian poliey dleclaration page(shvwing the policy aumber and e�piration date).
Failure to secure cover�a�e as required under Section 25A af TviGL c. 152 can lead to the imposition af cri�niYaaal penaities of a �
fine up to$1,500.4�0 andidr or�e-year imprisonment,as weI1 as civil p�nalties in the£or�n of a STOP"VC�ORK f?RUER and a fizi�
of u�to$250:00 a day a�ainst the`violator. Be a�sed that a copy of ihis st�temeni may be farwarded#a the 4f�a'ice of
Envestigations of the DIA for insuraz�c�caverage verific�tion. i
I dv hereby cer ' ,under the paitrs ad penalties v,fP�ury tftat dhe informat�vn pravided above is tru�and correct
si tur • . 12/12/2013 `
te-
Ph #• 01-7 0-57 �
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Ofjrci�i use y. �v nvt write in t#is"area,ta be camptet�d by city or to�vn o,f,�`�eiat '
City ar Town:_�A-2M��37�f Fermit/I.�c�nse#
ng Au�hori ircte an�)z `
. .�oard afHealfh .Buiidir�g DeparEmen# 3.CitylTown Clerk 4.Liceasiag B�ard S.Selectmen's Uft'ice f
b.
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Cantact Persaae: Phone#: J�B—v?t8—�31 .l'�Z�� ;
wa=w.mass.gov/dia
. . . . CVS/p�'�� R ,- T- ^
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One CVS Drive �Woonsocket, RI 02895 _
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Dear Sir/Madam:
Enclosed please find completed application(s) and/or invoice(s)
along with payment in the appropriate amount to cover the cast
of the renewal for the CVS/Pharmacy store(s) in your area.
Please note anv chanqes made on the application reqardina trade name
and or mailinq address, and include store number on invoices and
permits as indicated on the application to insure correct payment to the
proper stores.
Please send the permit(s}license(s)and anv future renewal applications
for this store, with the store number on it, to mv attention at: One CVS
Drive Licensinp Dept. Mail Drop 23062A Woonsocket, 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, Please contact me at 401-770-5772 or by
fax 401-652-0608
Sincerely
��fi���
Joanne P. Amitrano
Sr. Licensing Coordinator
One CVS Drive/Mai! Drop 23062A
Woonsocket, RI 02895
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A��Rp� CERTIFICATE OF LIABILITY INSURANCE °tizs�;�°""""'
�
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATfVELY 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
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certi�cate 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 STREET PHONE FAX
A/C No:
BOSTON,MA 02110 E•MAIL
Atln:CVSCaremark.CertRequest@marsh!Fax:212-948-5338 ADDRESS:
INSURER S AFFORDING COVERAGE NAIC#
S02406-ALL-�AW-1415 - � iNsuReR n:New Hampshire Insurance Co. 23841
INSURED iNsuRER B c National Union Fire Ins Co Pittsburgh PA 19445
SUBSID ARIES A DOAFFOILIAT SN AND ITS 3�A, n� ���A
�� y�� U =f INSURERC:
ONE CVS DRIVE iNsuReR o:
WOONSOCKET,Ri o2ss5 HEALTH DEPT: INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYc-oo6os52sa2o 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
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 SUBJECT 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 NUMBER MM/DDY� MM/DDlYYYY LIMITS
LTR
A GENERAL LIABILITY GL 681J521 01/01/2014 01/01I2015 E,e,CH OCCURRENCE g 4,500,000
X DAMAGE TO RENTED 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurtence $
CLAIMS-MADE �OCCUR MED EXP(Any one person) $
X SIR: $500,000 PERSONAL&ADV INJURY $ 4,500,000
X LIQUOR LIABILITY INCLUDED GENERaL AGGREGATE $ 28,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ INCLUDED
X POLICY PRO- LOC $
B AUTOMOBILE LIABILITY CA 7062798(AOS) 01/01/2014 01/01/2015 COMBINED SINGLE UMIT 4,OOU.O@0
£a ar^ident
B X ANY AUTO CA 7062799(VA) 01/01/2Q14 01/01l2015 BODILY INJURY(Per persan) $
B ALL OWNED SCHEDULED CA 7062800(MA) 01/01/2014 01/01/2015 BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE $
NON-OWNED Per accident
X H�RED AUTOS X AUTOS
SELF-INSURED PHY.DMG. $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $ I
DED RETENTION$ $
/� WORKER3 COMPENSATION See Page Two for Policy Numbers 01/01/2014 01/01/2015 X WC STATU- OTH-
AND EMPLOYERS'LIABWTY 2,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ '
OFFICER/MEMBER EXCLUDED? � N�A ' '
(Ma�datory in NH) E.L.DISEASE-EA EMPIOYEE $ 2,000,000
If yes,descrit�e under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
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&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 ��;�t�'t. /?2tr�'dirzz.�acc
O 1988-2010 ACORD CORPORATION. All rights reserved. ;
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '