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HEALTH D�"�'T.
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�¢�c�osed �lease#i�d �ompiet�d �pplic�to�n��� ar�dlor a���si�e�s� �I��g �ri�h pays�en� i�
the appr�ap�'�at� ar�our�t t� c��e�t�e �ost �f�he �ener�v�l for the ��S/pha�rnac� s�ore(�)
in y�iur ar�a. �le�� ��� a�a�r c1�a�a�s ���Pe c��a ��r�a��li�at.�o�r rd��� !r°acte
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� ir�slecat�d�aa i'i��a� �9c�n t� �a�s�t�� ����ect���rrr�n#te� th��a���rer st�r�.
�fe�e sea�d#h� ��a��t(s�1la��r�s�(�� a��t���r f�tte�re r���ra1 ap,�3�c��`�ons �S��a��
s#�� �r�th the stor� �u����'�a� r #� �rr atd�nlr�ra at. t?r�e �1/S L3�r��� L���r�sr�
1}e t ai� C€�d� � 6� �/�n�oclk�# i �2�95, �fte� rec�ivirag the licenses, I will
r��ke t�ae �ecess�r�r �og�ies f�r r�ay il�s ��d fiorvvard tF�e �rigona8s to the stores for
p���i�g.
��yt��a have a�y q�est���a�, please �ontact �� a�t�#01-770-2�7� or by�€ax 401-fi5�-12�0.
i1�y e-maii address is: dor��a_chevaiier@cvshea9th.com
Ssr�c�re/y '
Donaaa �h�valoer
�9ceras6ng C�ordir�ator
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� TOWN OF YARMOUTI3 BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form and attach all necessary documents by December 16,2D16.
Failure to do so will result in the reiurn of your application packet.
ESTABLISHMENT NAME. V d►'� C° T
LOCATION ADDRESS: -� TEL.#: ' �6' (p
MAILING ADDRES •
E-MAIL ADDRESS: 0 � G
OWNER NAME:
CORPORATION NAME( APPLICABLE): �G
MANAGER'S NAME: � c ' ' TEL.#: .�' r'^ �Cj� � ,
MAILINGADDRESS: dl—lsn i2�.)��P ��,5� '
POOL CER'TIFICATIONS: �
The pool supervisor must be �rtified'as a Pooi Operator,as required by State law. P2ease list the designated
Pool Operator(s)and attach a eopy of the certification to this form.
' l. 2.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the =�n� n �
employees below and attach copies of their certifications to this form.The Heatth Department will not use past A -Z �
ye�rs'rpcords, You must gro��e�Qw�o�ies and�aai�tain�fl��t y��•r�i_asp of h»sfi��s, � � ��
= w ��
1. 2. p N �q '
3. 4. ro � �`�� '
-1 -r ��'
FOOD PROTECTION MANAGERS-CERT'IFICATIONS: �
All food service establishments are required to have at least one full-t�employee who is certified as a Food
Protection Manager,as defined in the State Sanitary Code for Food Serviee Establishments, 105 CMR 590A00.
Please attach copies of certificationto this application. The Aealth Department will not use past years'records. �.;,,,�.- ;y
You must provide aew eopies and maintain a file at yaur establishment. �_ - ',._
�-�
1. 2. , -�
�',T
PERSON IN CHARGE: � �,,,,_�
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �.���
1• ���� G�1��� 2. �1 c� C � � ;._pJ� �
�
ALLERGEN CERTIFICATIONS: �� t ����
All food service establishments aze req"uired t'o have at least one fuil-time employee who has Allergen certification, � � 4�
as de fine d in t he S t a te Sani t a ry Co de for F o o d Service E s t a b 1i s h ments,105 C M R 590.0 0 9(G}(3 xa}. Please a tt a c h -�''"�
copies of certification to this applicarion. The Health Department will not use past ye�rs'records. You must ,
provide new copies and maintain a t`ile at your establishmen�
1. 2.
HEIMLICH CERTIFICATIONS: �i ZS datS
All food service establishments wi s or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please Zist 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 Fle at your place of business.
I. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT q
BBcB $55 CABIN S55 MOTEL S1I0
INN S55 CAMP S55 SWIMMING POOL Sl IOea.
_IADGE $55 77tAILERPARK $105 _WHIRLPOOL S110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LFCENSE REQUIRED FEE PERMIT#
0-100 SEATS SI25 _CONTINENTAL S35 NON-PROFIT S30
>!00 SEATS 5200 COMMON VIC. S60 WHOLESALE S80
—RESID.KITCHEN S80
RETAIL SERV7CE:
LtCENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sG.ft. $50 >25,000 sq.ft. S28S VENDING-FOOD $25
ZQ5,000 sq.ft S 150 �9 _FROZEN DESSERT$40 _TOBACCO $110
NAME CHANGE: b15 AMOLTNT DUE _ $ � /2S�QO
"**•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**;•*
�„o�F-rs-r�r—o-Z
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required ta hold issuance or renewal
of arty license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurauce. 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 taxes and liens must be paid prior t enewal 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 hotet use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
eIsewhere.Transient occupancy snaii generaliy refer to can4inuor�s oecupancy of not more th�w t�irty(30}aays,and
an aggregate of not more than ninety(90)days within any six(�month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient Occupancy that is subject to the collec6on 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:Ali swnnming,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 sehednle the inspection tLree(3)
days prior to opening.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,totai coliform and standard p2ate coimt ;
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 OPEl�TING:
All food service establishments must be inspected by the Health Deparhnent prior to opening. Please contaci the
Heaith Department to sehedule the inspection three(3)days prior to opexung.
CATERING POLICY:
Anyone who caters within the Town of Yannouth 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
obtauied at the Health Department,or from the Town's website at www.yannouth.ma.us.under Heatth Degarhnent,
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 Heaith Department. Failure to do so will result m the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
i OUTDOOR COOKING:
; Outdoor cooking,preparation,or dispIay of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31.IT IS YOUR RESPONSIBII.ITY TO RETURN
TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
,
' ALL RENOVATTONS TO ANY FOOD ESTA$LISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I
� EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF I-IEALTH PRIOR '
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE P N.
DATE: SIGNATURE: W� C� �
PRINT NAME&1'ITLE:
r :
Rev.10/12/l6 �i�ensi�� COordinator
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DATE(MM/DD/YWY)
ACORD� CERTIFICATE OF LIABILITY INSURANCE o,�oti2o,�
�.---'"
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), AUTHORIZED
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 FAX
99 HIGH STREET c �vc No:
BOSTON,MA 02110 E-MAIL
Attn:CVSCaremark.Ce�tRequest(o�marsh.com Fau:212-948-5338 ADDRESS:
INSURER S AFPORDING COVERAGE NAIC#
502406-ALL-GAW-17-18 iNsuRER n:Greenwich Insurance Canpany 22322
INSURED INSURER B;XL If1SUf811C2 Af112f1C8(fIC 24554
CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180 iNsuReR c:�Specialty Insurance Company 37885
WOONSOCKET,RI 02895 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: Nvc-oo�a�58oa23 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 1MTH 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 POL�CIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDI SUBR pOLICY NUMBER MM/OD/YYYY MM/OD/YYYY LIMITS
LTR
A X COMbiERCIAL GENERAL LIABILI7Y RGE3001220 01/0112017 01/01/2018 EACH OCCURRENCE $ 4,500,000
CLAIMS-MADE �OCCUR PREM SES Ea occuE ence $ 1,000,000
X SIR: $500,000 MED EXP(My one person) $
X LIQUOR LIABILITY INCLUDED PERSONAL 8 ADV INJURY g 4,500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2A,000,000
POLICY� PR� � LOC PRODUCTS-COMP/OP AGG $ INCLUDED
X JECT
OTHER: $
A AUTOMOBIIE LIABILITY RAD9437823 01IO1/2017 01/01/201E COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
X ANY AUTO _ . BODILY INJURY(Per person) $
--
ALLOWNED .SCHEDULED
� BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE $
NON-OWNED Per accident
X HIRED Al1TOS X AUTOS
SELF-INSURED PHY.DMG. S
UMBRELLA LWB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
B WORKERS COMPENSATION See Page Two for Policy Numbers O1/O1/2017 01/01/2018 X STATUTE ERH
AND EMPLOYERS'LIABILITY
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $ 2,��4�
OFFICERlMEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additlonal Remarks Schedule,may be attached if more space is requiretl�
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 A ,�n5A1 I1 fl 9O�7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:BRUCE MURPHY �° �7 L 1 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28 r_�- _ � -
SOUTH YARMOUTH,MA 02664 �------
"' ' AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina ��s�s-s,�ct. I?Zu�'rairsiiaacc
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: S02406
LOC#: Boston
�'�� �
ACORO ADDITIONAL REMARKS SCHEDULE Page 2 ot s
AGENGY 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: Cert�cate of Liability Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN t,2017 TO JAN 1,2018(Coverage A)
Policy# States Covered Carrier
RWD3001221 AOS XL Insurance America
RWR3001222 WI,AK XL Specialry Insurance Company
LIMIT: $2,000,000
DEDUCTIBLE: $2,000,000
EXCESS WORKERS COMPENSATION PROGRAM
POLICY DATES:JAN 1,2077 TO JAN 1,2018 (Coverage B)
PoGcy# States Covered Carrier
RWE943543 DC,MA,OH,RI XL Specialty Insurance Company
RWE9435484 CT,NC,NJ,VA XL Specialty Insurance Comp�y
UMIT;$500,000 _ . _ _ _ _ _ _ _ _ _ _ _ _
Excess Workers Compensatan Self-Insured Retentions
DC,MA,OH,RI: $500,000
CT,NC,NJ,VA: $1,000,000
COVERAGE A: Workers Compensatiai:Statutory
COVERAGE B: Empbyers Liability Limits:$500,0001$500,OOOl$500,000
COMMON POLICY CONDITIONS
A.Cancellation
2.We[Carrier]may cancel this policy by mailing or delivery to the first Narned Insured written notice of cancellation at least:
a.10 days before the effec6ve date of cancellation if we cancel for non paymenl of premium
1)General Liability Additional Insured-Where Required Under Contract or Agreement language per endorsement 61712(12I06):
SECTION II-WHO IS AN INSURED,is amended m include as an additional insured:
My person or organization to wfwm you becbme obligated to include as an additional insured under this policy,as a result of any conUact or agreement you enter into which
requires you to fumish insurance to that person or organizatbn of Ihe type provided by this policy,but only with respect to liability arising out of your operations or premises owned
by or rented to you. However,the insurance provided will not exceed the lesser of:
�The coverage anlor limits of this policy,or
�The coverage andlor limits required by said contract or agreement.
2)General Liability Earlier NoGce of Cancellation Provided By Us language per endorsement CG 02 2410 93:
Number of Days'NoUce 90
ACORD 101 (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
ACO� ADDITIONAL REMARKS SCHEDULE Page 3 of 3
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 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 notice of cancellation,as provided in paragraph 2.of either the
CANCELLATION Common Policy Condition or as amended by an applicable state cancellatan endorsement,is increased to the number of days shown in the Schedule above.
3)General Liability Advance of Cancellation to EnGties Other The Named Insured Limited to E-Mail Nolification per Chartis Manuscripl endorsement:
In the event that the Insurer cancels this policy for any reason other than non payment of premium,and
1. The cancellatan effective date is prior to this policy's expiration date;
2. The First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is cancelled(hereinafler,the"certificate Holder(s)");and has
provided to the Insurer,either directly or through its broker of record,the email address of the contact at such entity,
and the Insurer received ihis information after the first Named Insured received notice of cancella6on of this policy and prior to this policys cancellaGon effeclive date,via an
electronic spreadsheet ihat is acceptable to the Insurer,
the Insurer will provide advice of cancellaUon(the"Advice°)via e-mail to such Certificate Holders.
Proof of the Insurer emailing the Advice,using the informalion provided under this poticy by the First Named Insured,will sene 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 cancellation of this policy or the effective date thereof,nor shall this endorsement invest
any rights in any en6ty not insured under this policy.
The following Definitions appty to this endorsement:
1.First Named Insured means the Named Insured shown oa the Declaratans Page of this policy.
2.Insurer rr�ans the insurance company shown in the header on the Declaratbns Page of this policy.
All other terms,conditions 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