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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH �J i E APPLICATION FOR LICENSE/PERMIT-2019 E�, *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITHLJQUOR LICENSESMUSTRETURNFORMSBYII�OVEMBER IS"a'. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: �.J3 ✓'V3. V LOCATION ADDRESS: 9'](o [Mot.t-k TEL.#: JGFi` vr/ MAILING ADDRESS: --' One CVS Drive E-MAIL ADDRESS: JC-A-SC_ L v9 CUS Ccii-r\ Mall Code 1160 OWNER NAME: CU 5 O k 'w o. Woonsocket, RI 02895 CORPORATION NAME(IF APPLICABLE): C, A,Ar✓.t N MANAGER'S NAME: ' 1 j t (1li TEL.#: MAILING ADDRESS: r' t 2 t vncc�vt S ✓t r. cv( ✓tel/+- - 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 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 M yearsrecords. You must provide new copies and maintain a file at your place of business. r— 1. 2. 0 v 3. 4. m 131 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. 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. `0 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)(3Xa). 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 employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in and-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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 00-1-f-45—(36(--OL( OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 •.ft. $50p >25,000 sq ft. $285 VENDING-FOOD $25 Q =<25,I sq.ft. $150 ` Z/5 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 150.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM 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 INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHEDZ/ 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 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 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 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 MG,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspectedby the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) rior 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: 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits 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 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARDtt�OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ A SITE PLAN- DATE: L� DATE: 1.2.14//if SIGNATURE: PRINT NAME&TITLE: Rev.1023/18 Stephanie Cadorette Licensing Coordinator The Commonwealth of Massachusetts ti 1, Department of Industrial Accidents _lf lt1- 1 Congress Street,Suite 100 Boston,MA 02114-2017 =�y,Jt www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH H THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: CO3� 1) Address: 6(. ` (11A .0 vU City/State/Zip: Phone#: --" Q 7 6:2 Ar p oyer? Check the appropriate box: Business Type(required): 1 I am a employer with 1 st employees(full and/ 5. tail or part-time).* 6. fRestaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3. 0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4), and we have 10.13 Manufacturing no employees. [No workers'comp.insurance required]** 11.0 Health Care 4. 0 We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1.must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation hasother employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my.employees. Belowis the policy information. Insurance Company Name: Insurer's Address: .V€ City/State/Zip: YY cL a L O &C4C Policy#or Self-ins.Lic.# VAS)5./a4:13,/O ( Expiration Date: CJ l-o /" / 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuie.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00:and/or one-year imprisonment,:as well as civil penalties,in the form of a STOP..WORK ORDER and a fine of up to$250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the-pains andenalti s fperjury that the information provided is ti sand orrect Si ature: Date: - s Phone#: '-eO f Official use only. Do not write in this area,to be completed by city or town official •City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia ------1-,' ' A o DATE(MMIDDIYYYY)CERTIFICATE OF LIABILITY INSURANCE 12/27/2017 . 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 ,P `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 have ADDITIONAL INSURED provisions or 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: FAX 99 HIGH STREET PHONE IA/C.No.EMI: (AIC,No): BOSTON,MA 02110 E-MAIL Attn:CVSCaremark.CertRequest@Marsh.com Fax:212-948-5338 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# 502406-ALL-X E&O-18-19 INSURER A:Greenwich Insurance Company 22322 INSURED INSURER B:XL Insurance America Inc 24554 CVS HEALTH CORPORATION AND ITS SUBSIDIARIES AND AFFILIATES INSURER c:XL Specialty Insurance Company 37885 ONE CVS DRIVEINSURER D:ACE American Insurance Company 22667 WOONSOCKET,RI 02895 i INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-009140886-13 REVISION NUMBER: 9 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. IDL R INSURANCE AD POLICY EFF POLICY EXP DL TYPE OF y�ac.+D WVD POLICY POCY NUMBER (MM/DD/YYYY) IMM/D//YYYY) LIMITS LTR A X COMMERCIAL GENERAL LIABILITY RGE300122001 01/01/2018 01/01/2019 EACH OCCURRENCE $ 4,500,000 DAMAGE CLAIMS-MADE X OCCUR PREM SESO(Ea occuErrrence) $ 1,000,000 X SIR: $500,000 MED EXP(Any one person) $ X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY $ 4,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 28,000,000 X POLICY PROT LOC PRODUCTS-COMP/OP AGG $ INCLUDED JEC OTHER: A AUTOMOBILE LIABILITY RAD943782301 01/01/2018 01/01/2019 COMaBINEDtSINGLE LIMIT •$ 5,000,000 (EaX ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) SELF-INSURED PHY.DMG. $ III UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ B WORKERS COMPENSATION See Page Two for Policy Numbers 01/01/2018 01/01/2019 X PERSTATUTE EORH C AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N N/A 2,000,000 (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $ If yes,describe under2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D PBM E&O-PRIMARY MSPG24560533009 04/30/2017 04/30/2018 LIMIT 15,000,000 SIR Each Claim(Inclusive of Defense Expenses) SIR 20,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space is required) a CERTIFICATE HOLDER CANCELLATION CVS HEALTH CORPORATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE AND ITS SUBSIDIARIES AND AFFILIATES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ONE CVS DRIVE ACCORDANCE WITH THE POLICY PROVISIONS. WOONSOCKET,RI 02895 .a. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Yevgeniya Muyamina Vevyrm,yQ /fli �or&cnec I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD f C ® DATE(MM/DD/YYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCE 12/27/2018 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 have ADDITIONAL INSURED provisions or 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 (A/C.No.Ext): (A/C,No): BOSTON,MA 02110 E-MAIL Attn:CVSCaremark.CertRequest@marsh.com Fax:212-948-5338 ADDRESS. INSURER(S)AFFORDING COVERAGE NAIC# CN101226639-ALL-GAW-19-20 i \`i 2 DD INSURER A:Greenwich Insurance Company 22322 INSURED VS HEALTH CORPORATION , INSURER B:XL Insurance America Inc 24554 ONE CVS DRIVE MC2180 Jf i J 0 2 7019 INSURER c:XL Specialty Insurance Company 37885 WOONSOCKET,RI 02895 INSURER D: HEALTH DEPT. INSURER E: - -INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-009368048-28 REVISION NUMBER: 1 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 SUER POLICY EFF POLICY EXP W /YLIMITS LTR INSD VD POLICY NUMBER (MM/DDYYY);(MM YYY /DD/ YI A X COMMERCIAL GENERAL LIABILITY RGE300122002 01/01/2019 :01/01/2020 EACH OCCURRENCE $ 4,500,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 1,000,000 X SIR: $500,000 MED EXP(Any one person) _$ X LIQUOR LIABILITY INCLUDED PERSONAL&ADV INJURY $ 4,500,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 28,000,000 X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ INCLUDED JECT OTHER: $ A AUTOMOBILE LIABILITY RAD943782302 01/01/2019 01/01/2020 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) _ X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) _ SELF-INSURED PHY.DMG. $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION See Page Two for Policy Numbers 01/01/2019 01/01/2020 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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,Additional 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 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 1;/44.. 172:tVaosine,: ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101226639 LOC#: Boston ACC0REA ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. CVS HEALTH CORPORATION ONE CVS DRIVE MC2180 POUCY 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 1,2019 TO JAN 1,2020(Coverage A) Policy# States Covered Carrier RWD300122102 AOS XL Insurance America RWR300122202 WI,AK XL Specialty Insurance Company LIMIT: $2,000,000 DEDUCTIBLE: $2,000,000 EXCESS WORKERS COMPENSATION PROGRAM POLICY DATES:JAN 1,2019 TO JAN 1,2020 (Coverage B) Policy# States Covered Carrier RWE943548302 DC,MA,OH,RI XL Specialty Insurance Company RWE943548402 CT,NC,NJ,VA XL Specialty Insurance Company - LIMIT: $500,000 Excess Workers Compensation Self-Insured Retentions: DC,MA,OH,RI: $500,000 CT,NC,NJ,VA: $1,000,000 COVERAGE A: Workers Compensation:Statutory COVERAGE B: Employers Liability Limits:$500,000/$500,000/$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 effective date of cancellation if we cancel for non payment of premium 1)General Liability Additional Insured-Where Required Under Contract or Agreement language per endorsement CG 2026(04/13): SECTION II-WHO IS AN INSURED,is amended to include as an additional insured: Any person or organization for whom the Named Insured has agreed to provide insurance prior to loss as provided by the General Liability Policy but only to the limit and scope of insurance agreed to by the Named Insured but only with respect to liability for"bodily injury","property damage"or"personal and advertising injury'caused,in whole or in part,by the Named Insureds acts or omissions or the acts or omissions of those acting on the Named Insured's behalf: 1.In the performance of your ongoing operations; or 2.In connection with your premises owned by or rented to you. 2)General Liability Earlier Notice of Cancellation Provided By Us language per endorsement CG 02 2410 93: ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101226639 LOC#: Boston A RD ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,INC. CVS HEALTH CORPORATION ONE CVS DRIVE MC2180 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 Number of Days'Notice 90 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 cancellation endorsement is increased to the number of days shown in the Schedule above. 3)GENERAL LIABILITY CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason,other than nonpayment of premium,advanced written notice will be mailed or delivered to person(s)or entity (ies)by the Carrier according to the notification schedule shown below: Name of Person(s)or Entity(ies): Per the most current schedule maintained by Marsh USA,Inc.and furnished to XL Catlin no less than 45 days prior to the effective date of cancellation. Number of Days Advanced Notice of Cancellation:90 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD