HomeMy WebLinkAboutApplication and WC V(i'L''l'Va7�IIVC
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HEALTH D;��'T.
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t�e app��priat� a�oura�t� coe�er the cos� ��the reraew�l for the C�S/pha�ac� s�o�e�s�
in yo�sr ar��. �l+e+�� ��t� �ra�t c�a�e�e� �aefe�r� #��ap�Ii�at�a,�a�a�at��t��rr��
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!�e �: a�f ���i� ��6� ir�/���oc�k�# �2E ���95o P+fter rec�i�ing the licenses, I will
rr�a�e t�e �e�es���,e �opies f�r rny ile� ��d fiore�ar� the origona8s tv the stores $or
po��i�g.
�fi y�u hav� a�y q��st�o��, p�ease con��c� �� a���01-770-�27� ��- by�ax 401-65�-128�.
My e-maii address is: dos��a.chevaiier@cvsheal�h.com
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d TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT-2017 �
`� *Please complete form and attach all necessary documents by December l6,1�16.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: �. T • """ �
LOCA'TION ADDRESS: y fp S'^ °t t3'�F�r'o� JE U P TEL.#: S�Y 3?"� Q�Z (p
MAILING ADDRESS:
E-MAIL ADDRESS:_��Q � C�V1�.l� i�c"� 1�S�Ns4 1.-, , �C.i�''v-�
OWNER NAME:
CORPORATION NAME(IF APPLICABLE):�i V�i �(`1C���ct C-�/ �iG`� �-
MANAGER'S NAME:� n I7�Q!_�,��r�X'1 F l --� TEL.#: � S'(,�i� 3_[-�-(,/�!Z�O
MAILING ADDRESS: ���—�� °f f4�Qf� /E if
POOL CERTIFICATIONS: R� j`�C
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 eopy of the certification to this form.
1. 2_
Pool operators must list a minimum of two employees currendy certified in standard First Aid and Gommunity = � �
Cardiaputmonary Resuscitation(CPR),having one certified employee on premises at ail rimes. Please list the � ,Z �n�
employees below and attach copies of their certifications to this form.The Heaith Department will not use past r-. �
�Q3tB'!'e'�L03'SI3. v4S�ffiFI3S gS�l�7l��*l�EW�t►����lltl����3�II e!�I&���4ll!'�►IB�p Qf L►2lS11�E,SQ. s O ���
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1. 2. � �% e�,
3. 4. � p ��'-
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FOOD PROTECTION MANAGERS-CER"i�ICATIONS: /`' �
Ail food service establishments are reqnired 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 Aealth Department will not use past years'records. ., � '
You must provide new copies and maintain a�le at your establishment. ��
I. 2. , �. �
PERSON IN CHARGE: � �
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �
� ..�
i.��!�pr'r-� Q�"P X� ��� 2. nC� t����n C,' �
ALLERGEN CERTIFICATIONS: � � �
All food service establishments are red to have at least one full-time employee who has Allergen certification, ����
as defined in the State Sanitary Code for Foad Service Establishments,105 CMR 590.009{G)(3xa). Please attach
copies of certification to this application. The Health Department will not use past years'records. You mvst
provide new copies and maintain a file at your establishment. '
1. 2. '
HEIMLICH CERTIFICATIONS: �
All food service estabiishments with 25 seats or more must have at least one empioyee trained in the Heimlich
Maneuver on the premises at atl times. Please jist your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Departnnent will not use past years'records.
You must provide new copies and maintaia a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT q LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
BBcB $55 _CABIN S55 MOTEL SI10
INN $55 CAMP $55 _SWIMMING POOL SI l0ea
_LODGE $55 =?'RAILERPARK $105 _WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICEIdSE REQIIIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT#
0.100 SEATS 5125 _CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 _COMMON VIC. $60 —WHOLESALE S80
—RES1D.KITCHEN $80
RETAII.SERVICE:
LtCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED fiEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50sq ft. S50 >25,000 sq.R $285 VENDING-FOOD$25
�<25,000 sq.ft. $150 � =FROZEN DESSERT$40 =TOBACCO $110
NAME CHANGE: SI S AMOUNT DUE = S ��7 v•O O
'"'•*PLEASE T11RN pVER AND COMPLETE OTHER SIDE OF FORM"*••"
bo�-F-IS-(3"►�-01.
ADMINIS'FRA,1'ION
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 INSURANGE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouih taxes and Iiens mvst be paid prio o renewat or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCtJPANCY: For purposes of the limitations of Motel or Hotei 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
eisewnere.Transient occupancy shaii generaiiy refer to continuous occuparscy�f nu i��re ihatz t�irty(�?j�ys,and
an aggregate of not more thar►ninety(90}days within any s'vc(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transien� 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 eonsidered 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 prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pooI has been
inspected and opened.
POOL WATER TESTING: T'he water must be tested for pseudomonas,total caliform and standazd plate count
by a State cerkified Iab,and submitted to the Hea1th 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 OPEIVING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection t}u�ee(3}days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yannouth Heatth Department by filing the '
reqnu�ed 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 Heaith Departrnent,
Downloadabie Forms.
FROZEN DESSERTS:
Frozen desserts must be tesEed by a State certified lab prior to opening and monthly therea8er,with sample results
submitted to the Health Department. Failure to do so wiil result in the suspension or revocation of your Frozen
Dessert Permit until the above temis have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board of Health.
; OiJTDOQR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establistunent is prohibited.
;
NOTICE:Pernuts run annualiy from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER l6,2026.
�
' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW �
� EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE P
DATE: (o�`3ll` ( C� SIGNATURE:
PRINT NAME&TTTLE: D01111c'� CI12VclIlE1'
Rev.�0/IL16 Licensing Coordinator
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AC R� DATE(MM/DD/YYYY)
��, CERTIFICATE OF LIABILITY INSURANCE o,�oti�o,�
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY 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), AUTHORI2ED
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:
PHONE F�
99 HIGH STREET ac No:
BOSTON,MA 02110 E-MAIL
Attn:CVSCaremark.CertRequest(aD,marsh.com Fax:212-948-5338 ADDRESS:
INSURER S AFFORDING COVERAGE NAIC#
S02406-ALL-GAW-17-18 iNsuReR n:Greenwich Insurance Company 22322
INSURED INSURER B:XL IfiSUf811C@ Af172fIC2 If1C 24554
CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180 iNsurteR c:XL Specialty Insurance Company 37885
WOONSOCKET,RI 02895 INSURER D:
INSURER E: �
INSURER P:
COVERAGES CERTIFICATE NUMBER: NYC-007875800-23 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/OD/YYYY MM/DDY/YYYY LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY RGE3001220 01/O1I2O17 O1/O1/2018 EACH OCCURRENCE $ 4,500,000
CLAIMS-MADE �OCCUR PREM SES EaEoccu ence . $ 1,000,000
X SIR: $500,000 MED EXP(My one person) $
X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY S 4,500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 28,000,000
POLICY❑PR� � LOC PRODUCTS-COMP/OP AGG S INCLUDED
X JECT
OTHER: $
A AUTOMOBILE LIABILITY RAD9437823 01/01/2017 01101/2018 COMBINED SINGLE LIMIT $ 1�000,000
Ea accident
X ANY AUTO _ BODILY INJURY(Per person) $
--
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE $
NON-ONMED Per accident
X HIRED AUTOS x AUTOS
SELF-INSURED PHY.DMG. S
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
8 WORKERS COMPENSATION See Page Two for Policy Nurr�ers O1/O1/2017 OIIOI/ZO'IS X STATUTE ERH
AND EMPLOYERS'LIABILITY
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $ Z,OOO,OOO
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 2,00�,O�IO
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addkional Remarks Schedule,may be attached if 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
THE TOWN OF YARMOUTH s ,{(�4� U{J, 201, 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 s ; �r-� f � � •— °�
SOUTH YARMOUTH,MA 02664 �_-�------ .,_
"' '" AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina ��,�it. IYLt.t.�+'+a�acosc�
�O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: S02406
LOC#: Boston
'�"'�� �
ACORO ADDITIONAL REMARKS SCHEDULE Page 2 of s
AGENCY NAMEDINSURED
MARSH USA,INC. CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180
POLICY NUMBER WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDU�E TO ACORD FORM,
FORM NUMBER: 25 FORM TITIE: Certificate of Liability Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2077 TO JAN 1,2018(Coverage A)
Policy# States Covered Carrier
RWD3001221 AOS XL Insurance Arnerica
RWR3001222 WI,AK XL Specialty Insurance Company
LIMIT: $2,000,000
DEDUCTIBLE: $2,000,000
EXCESS WORKERS COMPENSATION PROGRAM
POLICY DATES:JAN 1,2017 TO JAN 1,2018(Coverage B)
Policy# States Covered Camer
RWE943543 DC,MA,OH,RI XL Specialty Insurance Company
RWE9435484 CT,NC,NJ,VA XL Specialty Insurance Company
UM1T;$500,000 _ _ __ _ _ _ _ _ _
Excess Workers Compensa6on Self-Insured Retentions
DC,MA,OH,RI: $500,000
CT,NC,NJ,VA: $1,000,000
COVERAGE A: Workers Compensation:StaWtory
COVERAGE B: Empbyers Li�ility Limits:$500,OOOIa500,0001$500,000
COMMON POLICY CONDITIONS
A.Cancellation
2.We[Carrier]may cancel this policy by mailing or delivery to the first Named Insured written noUce of cancellaUon at least:
a.10 days before the effec6ve date of cancella6on ff we cancel for non payment of premium
t)Gener�Liabilily Additional Insured-Where Required Under Contract orAgreement language per endorsement 61712(12I06):
SECTION II-WHO IS AN INSURED,is amended to include as an addi6onal insured:
Any person or organizatan to whom you 6ecome obligated to include as an additional insured under this policy,as a result of any contract or agreement you enter into which
requires you to fumish insurance to that person or organizatan of the lype provided by this policy,but only with respect to liability arising out of your operations or premises owned
by or rented to you. Fbwever,the insurance provided will not exceed the lesser of:
•The coverage anlor limits of this policy,or
•The coverage andlor limits required by sad contract or agreement.
2)Generai Liability Eadier Notice of Cancellation Provided By Us language per endorsement CG 02 2410 93:
Number of Days'Notice 90
ACORD 107(2008/01) �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: S02406
LOC#: Boston
�"""� �
A�O!�D ADDITIONAL REMARKS SCHEDULE Page 3 of s
ACaENCY� NAMEDINSURED
MARSH USA,INC. CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180
POLICY NUMBER � WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
For any statutorily permitted reason other than nonpayment of premium,the number of days required for no6ce of cancellation,as provided in paragraph 2.of either the
CANCELLATION Comrran Policy Condition or as amended by an applicable state cancellation endorsement,is increased to the number of days shown in the Schedule above.
3)General Liability Advance of Cancellation to Entities Other The Named Insured Limited to E-Mail Notificalion per Chartis Manuscript endorsement:
In the event that the Insurer cancels this policy for a�y reason other than non payment of premium,and
1. The cancella6on effective date is prior to this policy's expiratbn date;
2. The First Named Insured is under an existing contractual obligation to nolify a certificate holder when this policy is cancelled(hereinafter,the"certificate Ho�er(s)");and has
provided to the Insurer,either directly or through its broker of record,the email address of the contacl at such enGry,
and the Insurer received this information after the First Named Insured received notice of cancellaGon of this policy and prior to this policys cancellation effec6ve date,via an
electronic spreadsheet that is acceptable to the Insurer,
the Insurer will provide advice of cancellaGon(the"Advice")via e-mail to such CeRificate Holders.
Proof ot the Insurer emailing the Advice,using the information provided under this policy by the First Named Insured,will serve as proof that the Insurer has fully satisfied its
obligations under this endorsement.
This endorsement dces not affect,in any way,coverage provided under this policy or the cancellaGon of this policy or the effective date thereof,nor shall this endorsement invest
any rights in any entity not insured under this policy.
The following Definitions apply to this endorsement:
1.First Nart�d Insured means lhe Named Insured shown on the Declaraiions Page of this policy.
2.Insurer means the insurance company shown in the header on the Declarations Page of this policy.
All other terms,conditbns and exclusions shall remain the same.
ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD