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HEALTH D�'�'T.
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�h� appr�p�iat� ar�ou��t�a co�e�the ��st ���he reraevv�6 for the �`I�/pha�a�y store(s�
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fle � att��sf� ��6� irll�ns�ckg# �?3 �2�95e �fte�' rece�ving the lic�r�ses, I wi69
rs�ake#9�e �aeces�ary copies for r�y il�s ar�d forvvar� the origir��ls to #he stores for
pos�i�g,
�f�c��a have ��y q�est's��s, please �ont�c� r�� a�t�0�-770-�27� �r by �ax 401-�5�-1280.
My e-maii address is: don�a.chevaiier@cvshealfh.cors� :
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. a TOWN OF YARMOUTH BOARD OF HEALTH
; APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form and attach all necessary documents by December 16 2016.
Failure to do so will result in the return of your applicahon pac et.
ESTABLISHMENT NAME: T —
LOCATION ADDRESS: L(��' V�� 'L f� 'TEL.#: 5��� 7 f ��{�(2'g
MAILING ADDRESS:�5�12 C�S i7,/':✓? 1'WC l��.f�C tx��C 3�S�[�G�c-2"
'�
E-MAIL ADDRESS: . C
OWNER NAME: S ✓�hn t�v�c c v '1 v�C..
CORPORATION NAME( APPLICABLE): �,U c� C.� ,],�' G .
MANAGER'S NAME: �-' TEL.#: 2.�
MAILING ADDRESS: `
POOL CER'I'IFICATIONS: �
The pool supervisor must be ce ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a eopy of the certification to tlus form.
1. 2.
_ � �
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � Z ( �
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. �' w �*�
J � �.�
r
1. 2. (J � �,,.}I
3. 4. -i 1, �::u
FOOD PTtOTECTION MANAGERS-CER'TIFICATIONS: �1�
All food service establishments are required to have at least one full-time employee who is certified as a Food �£ -'�
��...�
Prot�tion Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ' --�
Piease 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 establisbment. �
� �
1. � 2. ; ���_.
. �
PERSON IN CHARGE: ;' 6 ,,j
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. W
O
� _ /v1 � �� � T.� p, .
ALLERGEN CERTIFICATIONS: /��'
All food service establishments are required to have at least one full-time employee who has Aliergen certification,
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3xa). Please attach
copies of certification to this application. The Health Department will not nse past years'records. Yon must
provide new copies and msintafn a file at your establishment.
1. 2.
HEIMLICH CERTIFICATIONS: ���
All food service establishments wiW 23 seats or more must have at least one employee trained in the Heimiich
Maneuver on the premises at all times. Please list your employees irained in anti-chok�ng pmcedures below and '
attach copies of employee certifications to this form. The Health Department will not nse past years'records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4,
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGWG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�B S55 CABIN S55 M07'EL 5110
1NN S55 CAMP S55 �SWIMMING POOL Sl l0ea.
�.ODGE S55 TRAILERPARK $105 _WHIRLPOOL S110ea.
FOOD SERVICE:
LICENSE RE QpU�IItED FEE PERMlT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
a�0 SEATS 5200 _COM ONTV C $60 WHOLESALE S80
RETAIL SERVICE:
—RESID.KITCHEN S80
LICENSE REQUIItED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50sq ft. S50 >25,000 ft. 5285 VENDING-FOOD S25
Z<25,OOOsq.ft 5150 �(7 =FROZETT�ESSERT S40 �IiDBACCO 5110
NAME CHANGE: S 15 AMOLTNT DUE = S /Sb.�O
••*•*PLEASE TURN pYER AND COMPLETE OTHER SIDE OF FORM*•***
�- ('v okt�-l S-(3?$-OZ-
}
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 Woxker's
Compensation Insurance. TIiE 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 to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For piuposes of the limitations of Motel or Hotel use,Transient occupancy shali 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 thai they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than tlurty(3U)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 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,shali generally be considered Transient �
POOLS
POOL OPENING:All swimming,wading and whirlpools wluch have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schednle the inspection three(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,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:
Atl food service establishments must be inspected by the Health Depariment prior to opening. Please contact the
Health Department to schedule the inspection three{3)days prior to opemng.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the ',
reqmred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obta�ned ai the Health Department,or from the Town's website at www.varmouth.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,w�th 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 terms have been met
OUTSIDE CAF'�S:
�utside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Heatth
j OUTDOOR COOKING:
j Outdoor cooking,preparation,or dispiay of any food product by a retail or food service establishment is prohibited.
i
1 NOTICE:Permits run annually from January 1 to December 31.TT IS YOUR RESPONSIBILTf Y TO RETURN
, TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. I
�
� ALL RENOVAITONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I
i EQUIPMENT,ETC.),MUST BE REPORTED TO APPROVED BY THE BOARD OF HEALTH PRIOR I
TO COMMENCEMENT. RENOVATIONS UIRE A SITE P� .
DATE: ��` �I�1 � � VY SIGNATURE: �
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ACORU� DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE ovotizo,�
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 HO�DER.
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:
99 HIGH STREET PHONE F�
ac No:
BOSTON,MA 02110 E-MAIL
Attn:CVSCaremark.CeRRequest(�Dmarsh.can Fa�c:212-948-5338 ADDRESS:
INSURER S AFFORDING COVERAGE NAIC#
502406-ALL-GAW-17-18 iNsuReR a:Greenwich Insurance Canpany 22322
INSURED INSURER B:XL IfISU�8nC2 Af112fIC2 IfIC 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�8�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 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 ppLICY NUMBER MM/DD/YYYY MM DD/YYYY LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY RGE3001220 01/O1/2017 O1I01/2018 EACH OCCURRENCE $ 4,500,000
CLAIMS-MADE � OCCUR PREM SES EaEoccu ence $ 1,000,000
X SIR: $500,000 MED EXP(,4ny ane person) $
X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY $ 4,500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 28,000,000
POLICY❑PR� �LOC PRODUCTS-COMP/OP AGG $ INCLUDED
X JECT
OTHER: $
A AUTOMOBILE LIABILITY RAD9437823 01/01/2017 01/0112018 COMBINED SINGLE LIMIT $ �,p�,��
Ea accident
X ANY AUTO _ BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accidanq $
x AUTOS X NON-ONMED PeOa�R��DAMAGE $
HIRED AUTOS AUTOS
SELF-INSURED PHY.OMG. S
UMBRELLA W►B OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MAOE AGGREGATE $
DED RETENTION$ $
B WORKERS COMPENSATION See Page Two for Policy Numbers 01101/2017 01/01/2018 X STATUTE ERH
AND EMPLOYERS'LIABILITY
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $ 2,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 2,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POIICY LIMIT $ 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AddRional 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&944.
CERTIFICATE HOLDER CANCE�LATION
THE TOWN OF YARMOUTH .�n5A1 U fl �O�� 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 a ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28 ' : ��-- � '
SOUTH YARMOUTH,MA 02664 `---•�_,- �_ ,
" AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Yevgeniya Muyamina �grs�ys,�it.. l?Ztt�fam�aa�e
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/07) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: S02406
LOC#: Boston
ACO� ADDITIONAL REMARKS SCHEDULE Page 2 of 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: Certificate of Liability Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2017 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 1,2017 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 Company
LIMIT:$500,000 _ _ _ ___ _ _ _ __ — _ _ _
Excess Workers Compensation Self-Insured Retentbns:
DC,MA,OH,RI: $500,000
CT,NC,NJ,VA: $1,000,000
COVERAGE A: Workers Compensafion:Statutory
COVERAGE B: Empbyers Liability Limits:$500,000/a500,0001$500,000
COMMON POLICY CONDITIONS
A.Cancellation
2.We[Carrier]may cancel this policy by mailing or delivery to the first Named Insured written notice of cancellation at least:
a.10 days before the effec6ve date of cancella6on if we cancel for non payment of premium
1)General Liability Addifional Insured-Where Required Under Contract or Agreement language per endorsement 61712(12106):
SECTION II-WHO IS AN INSURED,is amended to include as�additanal insured:
My person or organizatan to whom you become obligated to include as an additional insured under ihis policy,as a resuli of any conUact or agreement you enter into which
requires you to fumish insurance to that person or organization of ihe rype provided by this policy,but only wiYh 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 allor limils of ihis policy,or
The coverage andlor limits required by said conVact or agreement.
2)General Liability Earlier Notice of CancellaGon Provided By Us language per endorsement CG 02 2410 93:
Number of Days'No6ce 90
ACORD 101 (2008/01) �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: S02406
LOC#: Boston
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ACORO ADDITIONAL REMARKS SCHEDULE Page s of s
AGENCY NAMEDINSURED
MARSH USA,INC. CVS HEALTH CORPORATION
ONE CVS DRIVE,MC 2180
POLICY NUMBER - WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTIVE OATE:
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 cancellatbn endorsement,is increased to the number of days shown in the Schedule above.
3)General Liability Advance of Cancella6on to Entities Other The Named Insured Limited to E-Mail Notification per Chartis Manuscript endorsement:
In the event that the Insurer cancels ihis policy for any reason other than non payment of premium,and
1. The cancella6on etfective date is prior to this policy's expiratbn date;
2. The First Named Insured is under an exisGng contractual obligation to notify a cerlificate holder when this policy is cancelled(hereinafter,the"certificate Hokler(s)");and has
provided to the Insurer,either directly or through its broker of record,the email address of Me contact at such enGty,
and ihe Insurer received ihis information after the First Named Insured received notice of cancellaGon of this policy and prior to this policy's cancella6on effeclive date,via an
electronic spreadsheet that is acceptable to the Insurer,
the Insurer will provide advice of cancella6on(the"Advice")via e-mail to such Certificate Holders.
Proof of 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
oblgations 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 entiry not insured under this policy.
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The following Definitions apply to this endo�sement:
7.First Named Insured means the Named Insured shown on the Declaratans Page of this policy.
2.Insurer means the insurance company shown in Me header on ihe Declaratans 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