HomeMy WebLinkAboutApplication and WC , ,, ,3
� RECEI��FD TOWN OF YARMOUTH BOARD OF...H��.LTH L���� i=;����� �ic�
; _ �CT 2 5 '���ry APPLICATION FOR LICENSE/PEF���.�,� _��,
,�� f. , .;� ` D�i� 20 ZQ12
' * Please complete form and attach all necessaiy documen s�'°y D�'ecem�b' �1 S 2012.
LICENSIi'�{G� �7EPA'a,ilure to do so will result in the return of your application pack t. HEA�LTF� DEPT.
ESTABLISHMENTNAME: S C�l �'I � T ID• -�����°
LOCATION ADDRESS: o� �' �;�, M�TEL.#: � -�J'71 0��
MAILING ADDRESS:��NQ �'�S �l � MI��1 �?,t�iv�A tbJ`���LV`��Gl�-�" 2<2 Q�I�
OWNER NAME: CVS P aPmaCy, �1C•
CORPORATION NAME{IF APPLICABL ):
MANAGER'S NAME: � ��ti TEL.#: �l"7 �1 S �
MAILING ADDRESS: 2. P OCJ1� �"Z:�
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.
________ �Q,�F}g�{�TFC'£I9�T=MA��C=F-�R-� - GERT��ICATI�NS:_ - -
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�le at your establishment.
l. 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 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-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�le at your place of business.
l. 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 �
LODGE $55 TRAILER PARK $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 ;
— — — ;
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 ;
� <25,000 sq.ft. $80 �13-6�F3 _FROZEN DESSERT $40 �TOBACCO $95 .-O Z '
NAME CHANGE: $15 AMOUNT DUE _ $ I 7S• �O
I
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** '
I
�
i
4
i
� �
� ADMINISTRATION �
.
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth 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
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:
� YES NO
�
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be j
' limited to the temporary and short term occupancy,ordinarily and customaxily associated with motel and hotel use. ''
iTransient 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 I
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 inspl ction threen 3)days �
prior to opemng.PLEASE NOTE: People are NOT allowed to srt in the pool area until the poo has been spected
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.varmouth.ma.us under Health Department, �
Downloadable Forms. ;
i
FROZEN DESSERTS: I
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results C
i submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen i
j 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 establishment is prohibited. ,
_ ._ - . _ ___ _ _ __ _ ____
,
_�
NOTICE:Permrts 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 COMMENCEMENT. RENOVATIONS MAY QUIRE A SI E PLAN.
DATE: �9� i2�. SIGNATURE:
PR1NT NAME& TITLE: �oanne P. Amitrano
Rev. 10/09/12
(
�
. . . •
�+���1'1�'1�/� G3C����1��D
One CVS Drive Woonsocket, RI 02895 DEC 2O �t���
HEALTF� �EPT.
i
1 t� t�
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/phaxrnacy store(s) in your area. Please
note anv chanaes made on the application re�arding trade name
and or maitina address and include stope number�s nn invoices
and permits as indicated on the application to insure correct
paVmerct. to the ppoper store.
Please se�cd the permit(s)/ficense(s) and any futus�e renewal �
applications for� this sto�e, with the store number on it, to my
attention at• One CYS Drive, Licensin�Dept.. Mail Drop
23062A, Woonsocket, RI 02895. After receiving the Iicenses, I
v��i?1 makP the necessa..�� CQ�IPS fr�r my f t�s �� forv��ard t�:e
originals to the stores for posting.
If you have any questions, please contact me at 401-7'70-5772 or
by fax 401-652-0608.
�incerely
�.,A `��---
Joanne P.Amitrano
Licensi►tg Coordinator
One CUS Drive/Mai!I3rop Z3062A
Woonsocket,RI 02895
• � T'he�srxnrnanwealth af Mnssac�iusetts
��pur�ment�rf I�dustr�al Accad�nis
U�ce nJ`Inve�t�gatin�s
6U�1 Wa�chingtvn Str�et
Sus#nr�,MA 112111
r�w.�ass ga�Jdia
'�'`+�rkers' Compensation Insu�a�ce Aiffiti�vit: Gener�l�usiunesses
App�c.ant Infc►rmati�n Please Print Le�bly
CVS/Pharmacy # �� � �
B�usi��sslt)rga,nization N'ame;
Atldress: �J� ��� �CJ —
City/�t�te/Zip: �eS�' �I'�ZO�.+�,� N��Phane#: .JU�7 ��'��a"�
Are you aa emptoyer?Check t#te aFpropri�te baaz Business TYpe(re€�ired):
1.� I am a employer wit� emplcryees(f�l andJ 5. �Retail
or part-time).* 6, ❑RestaurxntiBaslEating Establ'a�ment
2.❑ I a�n a sole ps'a�srietar or par�nership and have no 7. ❑Of�`ice andlur 5ales(incl.real estate,auto,etc.)
employees working for me in auiy capaeity,
[Na workers'camp.in�utance required� 8, ❑I�to�-prc>fit
3.❑ We are a corporation and:i�s ot�icers have e7cercised 1. ❑Entertainme�t
t�eir right vf exempticrn�er c. 152,§1{4),and we have 14.�Manufacturing
no employees.[No waricers'cornp.insurance required]* 11.D Health Gare
4.Q W�are a non-profit arganizatian,s�ed by volunteers,
cvith no emgloyees.[No workers'comp.ias�rance req.J 12.(�Other ',
��Y�P'Ptica�t€hai checks bnx#1 mvst also fili tait the se�tion tselow sho�ving tbb�ir wc�cers's�mpensation poliey informatian.
*:[f the eocporate officers haye�empt$si ti�emseTves,bat the corparstiox�hsa other employces,a work�s'�mpeasstian palicy i�requir�d aad such an
orgau�tion should eheck baar#l.
I am an empdayer that is prvv�tling workers'cas��rsatu�v�r�tesurance for��ry employees. Belo�v is ihe pnlicy irtfarm�vn.
�����,�������, New Hamshire Insurance Company
175 Water Street
Insuxer's Address:
New York, NY 10038
CitylSEate/Zip:
Palicy#or 5elf-ins,i,ic.# 4 3 0 9 74 0 9 �x��q��D��; O 1/O 1/2 013
Atttaeh a cc�py of the workers'campensation paalicy d�l�rat�n p�ge(stwr�ving the policy number and e�ir�ti4in date}.
Failure to secure coverage as requirec�un�r Sectian 25A o€MGL c. LS2 can l�ad tc�the impnsition ofcriminal penalties of a
fine ug tcr$I,3{?(?.OU and/or one-year i�nprisonment,as well as civi�penalries in the farm of a S'TC}P WORCC.t3RUER and a fine
of up ta$250.�a day agai�ast the violator. Be advised t�at a copy of this stater►3eaa#may be forwarded ta the Office of
Inv�stigatians of ttxe DIA far insurance coveragc verification.
I do leereby ,r��er the pa�ns a r�penult�es of�rerjury tliat tlre,ariformulior�provirled abrrve is tru�arad cvrrec�
Si e. � Uate: `t ~��-•
�,�e�: 401 770 5772
0,,�`'iciat use only. �u not�vrite rn this area,to be cvrnplet¢d liy ci�ty or fowr�a,j,�Rciat
City or Tawn: ��-R.I�t.Ot9ib� Permit/Lacense#
Ts ' s `rcle on�j:
.Bosrd o€Heslt ,Build�ag Degartmen� 3.CitylTawn Cterk 4.Lieensi�ng Bcsard 5.�Seleetmen's Uffice
6.
Canfaett Persan: Phane#c �DQ r�48—Z2� f X�Z`�/ '
�.��ga��a��
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT UF INDUSTRIAL ACCIDENTS
OFFICE OF INSURANCE
3elf Insurer CVS/Caremark Coruoration and its subsidlaries
Reinsurer National U�nion Fire Insarance Campanv of Pittsbureh,PA
Contract Period from Oi/01/2012 to Ol/Q1/2013 �
Contract is a �
Catastrophe PoGcy XX Policy No XWC 119-24-74 ;
Aggregate Excess
Self Insurer's Retentian $SOQ,000
Maximum Liability:of Insurer Part One: Statutorv Part Two: $500.000
The contract contains the following conditions:
1} It is understood and agreed that any money received by the Self-Insarer under the ,
provislons of this contract shall be deposited in such bank, or with the Treasurer and
Receiver General of the Commonwealth, as the Department of Industr�al Accidents
may determine, and.any sach maney shall be held in tr�st far the payment of any ;
� liabilities incurred by the Self-Insurer e�nder Chapter 152, General Laws (Ter.Ed.) as �
amended, and no ase or dispos�tion of any such money shatl be made without the '
approval af said Departmen� It is further understood that no money shall be
ass�gnable or subject to attachment or be liable in any way for the debt af the Self- :
Insarer unless incurred under 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 for a period af at least thirty
days following not�ce to theDepartment of Industrial Accidents oF the Commonwealth
of Massachusetts,by registered ma�l,of such cancellation.
3) No commutation of any liability 3ncurred by the Self-Insurer under said Chapter 152,
daring the period t�is contract is in effect shall be made without the approvai of the
Department pf industrtal Accidents of the Commanwealth of Massachusetts.
Seif Insarer CVS/Caremark Cornoration and its sabsidiaries
By
Reinsurer National Union Fire I surance Com an of Pittsbur h
PA.
� By
Jaseph A vide, hief Underwriting Officer
4