HomeMy WebLinkAboutApplication and WC �
, . . . CVS/PharmacY�
One CVS Drive �Woonsocket, RI 02895
�
�� � � � ��c��od�o
UtC 1 7 2014
HEALTH DEPT.
Dear Sir%Nladam:
Enclosed please tind coinpleted application(s) andior invoice(s)
along with payment in the appropriate amount to cover the cost of
the renewal for the CVS/pharmacy store(s) in your area. Please
note any chanaes made on the applicatio�z re,aaYdin� tracle nrmie
,
nnr/ or mailina trddress. rtnd include store na�r�tbers on invoices
t[ntl permits as IndicateCl on the applictrtion to insure eorrect
payment to the proper store.
Please send the pernxit(s)/license(s) and any fi�ture renewa!
applications for this store, with the store number on it, to my
tcttention at: One CYS Drive, Licer:sina Dept., Mail Code I160,
Woonsocket, RI 02895. After receiving the licenses, I will make
the necessary copies for my files and forward the originals to the
stores far posting.
If you have any questions, please contact me at 401-770-5772 or
by fax 401-652-0608.
Sincerely
i� ��/.t+.e�G—.—e.�.m
�oa�vze P. Amitra�ao
Licensing Coordinator
One CT/S DriveNlail Code II60
Woonsocket, RI 02895
:
�°�_�R`� TO WN OF YARMOUTH Boardof
� _�o
� - - -=� C, Health
0 --\\\�`� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACI-I[JSETTS 02664-24451 Health
Y.� �,r �,'� :r Telephone(508)398-2231, ext. 1241 Division
'"°"E Faac(508) 760-3472
To: YarmouthBusinessEstablislunents CUS�Pt-tA2n��cy �-y313
From: Bruce G. Murphy, Director
Yazmouth Health Departznent ���'��d��°
Date: November 7, 2014 UEt% 17 2014
HEALTH DEPT.
Subject: Increase in License/Pernut Fees
Please be aware that the Yannouth Boazd of Health, under the d'uection of the Yarmouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the
fees listed are the fees effective January 1, 2015. These fees will be due if you complete and
submit the application after January 1, 2015.
However, if you fully complete the application, and submit it to the Yazmouth Health
Departrnent with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) arior to December 31, 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swimming Pools $ 80.00
Public Whirlpool/Vapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Restaurants Over 100 Seats $160.00
Retail Food Service <25,000 sq. ft. $ 80.00 � 80•00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: 80.
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to DeCember 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
BGM/maf
, ��c��a��� �3 �
� TOWN OF YARMOUTH BOARD OF HEALTH D�C � ' 2014
��� APPLICATION FOR LICENSE/PERMI�'=2015
� f.,, a � �''.
` * Please complete form and attach all necessary docutnen�`s'&y D�e �n � DEPT.
Failure to do so will result in the return of yopr applfcation:pac eT:
ESTABLISHMENT NAME C�s (s.`m3.ci,� y��3 TAX ID•
LocATlorr�D�ss: y3Y Rou+e �8 w�� ya�,,ti� oa�,�3 TEL.#: S�'hl—�l'1d`�
�iL�rrGaDD�ss: o�e. c��5 D� �k�soc,� �-2 �as�s
E-MAIL ADDRESS:
OWNERNAME: VS P el'IT1aGy, 11C.
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: S�CQ��-v Na2Gs2 TEL.#: 5Q$-'7'11—(o��j
MAILINGADDRESS: ONQ- CJS�it, v.�CA,y�cSpCk¢,1 �ZZ b�SS
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 Cazdiopulmonary 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.
1. 2•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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.
1. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ��^ �p.S�1 Ju-� 2.
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)(3)(a). 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 a11 times. Please list 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 file at your place of business.
1. 2• '
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT It
B&B $55 CABIN $55 MOTEL $110 ..
—INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRA[LER 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 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
�<ZS,OOOsq.ft. $150 (5�6 �j —FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ $ �SO , Oo
'***'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �l� ��O`�O
c,�2��i?��Il$
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 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
limited to ttte 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 sha11 generally refer to continuous occupancy of not more than thiriy(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 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 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:
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 Temporazy Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health Deparhnent,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,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 COOHING:
_ -Qn:�o�-�c;a�g�p�ga.��±ian��dis����f a�}fnod product by a retiLorfood s�ice�stablishment is grQhiltike�l� _ _ _
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, 2014.
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 QUI SITE PLAI�F:-
DATE: `a����� SIGNATURE:
7oanne P. Amitrano
PRINT NAME & TITLE: Coordinator
Rev. ll/03/14
AIG
Coverage is provided by
NATIONAL UNION FIRE tNSURAPICE COMPANY OF PITTSBURGH, PA
(a capital stock company)
175 Water Street, New York, NY 10038
t212) 458-5000
XWC-ELITE�
EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY
INFORMATION PAOE
POLICYNUMBER XWC 663-62-55 ��wA�oF: 6636775
PnoWcex: MARSH USA INC.
99 HIGH STREET
BOSTON, MA 02110
ITEM 1. NAMED INSUflED AND MAlL1NG ADDRESS
CVS CARENARK CORPORATION
1 CVS DR
WoONSOCKET, RI o2895-6195
ITEM 2. SfATES pN NM1IICH COVEM6E IS TO APPLYI
SEE ATTACHED SCHEDULE
fTEM3. POLICVVEMOD FflOM: OI/O�)YO�4 TO: O�IO�/PO�S
12:01 A.M.STANDARD TMAE AT THE MAILIN6 ADDI�SS SHOWN HEREIN
ffEM 4. WR 11MlT OF INDENBiRY
PARf ONE-WORKERS COMPENSqTION
STAMORY FAG7 NCCIDENT
STATUTORY EACHEMPLOYEEFOfl DISEASE
rnxr rvro-�ariorexs ua�un
5500,000 enncry acaoar
SSOO�OOO FACH EMPLOYEE FOfl DISEASE
PARTiWO-BTOP�APINSURANCE
SSOO.00O EACHACdDENT
SSOO�OOO EACH EMPLOYEE FOR DISFASE
ITEM 6. YWR PEfBiT10N
PART ONE•WORREIiS COMVFNSATION AfID PART TWO-EMPLOYERS LIA&UTY COMBINED
See Form 72164 EACH ACCIDENT
See Form 72164 ENCHEMFLOYEEFOR DISEASE
17EM 8. PRENNUM AND PREMIUM COMGUTATION
ESTIMATEDTOTALANNUALREMUNERAT7UN $z,z69,519.��
RATES PER 8100 OF RENNNEfl/1T10N o.o�39
DEVO&TPREMIUM $315.�52
MINIMUM PNEMIUM $3�S r�SZ
Premium for Certified Acts of Terrorism Covera$e Under Terrorism Risk Insurance Act 2002 as amended bp
the Tertorism Risk k�surance Program Reauthonzatbn Act 2007:
Coverage Provided At No Additional Charge
ffEM 7. THFS POUCY INCLUDES THESE ENDOXSEMENTS/1f�SCHEDULES(AT BJCEViION DATEI: �
SEE ATTACHED SCMEDULE
COUNTEXSIGNED�wMra rpuifW Ey lewl BV:
�A THOXRED REPRESEMATIVE�
DATEISSUED: OY/OS/YO7�
72126 (04/03) a 2003 All rights reserved.
IN WITNESS WHEREOF,the Insurer has caused this Policy to be signed by its President, Secretary and
Authorized Representative.
� `� `�
President Secretary
NATIONAL VNION FlflE INSURANCE COMPANV OF%TTSBUIiGH,PA NATIONAL UNION FlflE INSUNANCE COMGANY DF RiT58UNGH,PA
This Policy shall not be valid unless signed below at the time of issuance by an authorized representative
� of the insurer.
�hp� Representative
SI�NW
FORMS SCHEDULE
EFFEGfIVE DATE: 01/O1/2014�
NAMED INSURED: CVS CAREMAPIC CORPoRATION
POLICY NO: %MC 883-8Y-55
MMq01 SELF-INSURED RETENfId�! EtDURSE1ffNf
58283 (0383) CANCELLATION CONDITIOl1 AMEl�ED
84470 (OYBB) NR AMEN�ATORY ENDORSEMENT
87153 (1005) IQp11LE06E OF OCCURRENCE
72127 (0403) EX MC AID ENPL LIAB IIOEM PoLICY - RORN
7Y13Y (1188) GC AMENDpTORY EIOURSEMENf
7R148 (1198) RI ANElONTORY ENODRSEIffNT
7]18R (0604) Sp1E0ULE OF STATES COVERED
74186 (0203) YpJR RETENfIOi SCHEWLE
73Y23 (0899) M1 AMElmATORY El�ORSENIXi
737f5 (0803) VA AMEIOATORY ENOORSENENT
73903 (0389) NJ IWENUAMRY ENOORSEMEHf
7805� (0/12) AIU U.S. PRIVACY At0 DATA SEC
78082 (0501) IlWUSTRIAL AID AIRCRAFT
81910 (0403) NC AMEpOATORY EADORSEMENf
83Y63 (1003) Cf MIENDATORY EtbORSEMEKf
83873 (7/03) AMEIOATORY ENUURSENEM
898A6 (0813) ECp10NIC5 SANCTIONS EIWORSEI�M
898b4 (0706) /WEIOA70RY ENGT - COVERAff� TERR
80008 (0208) RECREAT[ON A!W ATHIETIC EVEM COV
83887 (1110) OH STOP 6RP IIRENfIONILL TDRTS EXTN
114324 (0613) AMENOMENT OF p.AIMS REPORTINA WTIES
p(CESS WORKERS COMPENSATION �
ENDORSEMENT
This endorsement,eftective 12:01 A.M. 01/01/2014 fortns a part of
policy No. XWC 663-62•55 issued to CVS CAREMARK CORPORATION
by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
MASSACHUSETTS AMENDATORY ENDORSEMENT
The foliowing conditions are added to this policy:
1. My money receiv� by you under the provisions ot this policy shall be depos0ed in such bank, or
with the Treasurer and Receiver General of the Commonwealth, as the Department of Industrial
Acciderrts may determine, and any such mw�ey shall be held in Wst for the payment of any liabilities
incurred by you under Chapter 152, Generel laws as amended,and no use w disposition of any such
money sh�l be made without the approvai of said Departrnent. No such money shall be assignable
or subject to attachment or be li�le in any way fw your debt unless incurted under said Chapter 152.
2. R�y party to this policy desires to cancel this policy, sucn cancellation sh�l not become effeclive for
a period of at least thirty days following notice, by registered mail, to the Department of In�strial
Accidents of the Commonwealth of Massacbusetts of said cancellation.
3. No commutation of any liability incurred by you under said Chapter 152 during the period this policy
is in effed shall be made wittwut tF�e approval of the Departmenl of Industrial Accidents of the
Commonwealth of M�sachusetts.
All other terms, condKions�d exclusions shall remain the same.
i
THORIZED REPRESENTATIVE
644T0(2/96)
� The Commonwea[th ofMassachuseus
Deparbnest of Industriu!Accidents
O�ce of Investigations
600 Washington Street
Boston,MA d2111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Bustaesses
Ap»licant Information Please Print I.eeiblv
CVS/Pharmacy # l.`���
Business(Organizarion Name:
Address: 4 �J�' ��OU,-�- oZ�
City/State/Zip: We$�'���� O�'�3 Phone#: �-�� �4ydy
Are yon an employer?Check t6e sppropriste boz: Busiuess Ty�(required):
1.� I am a employer with employees(full and/ 5. � Retail
or part-time).* 6. ❑RestauranVBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no . 7. �Office andlor Sales(incl.real estate,auto,eta)
employees working for me in any capacity.
[No workers'comp.insurance required] 8• ❑Non-profit
3.❑ We are a coiporation and its officers have ercercised 9. ❑Entertainment
their right of exemption per c. 152,§l(4},and we have 10.Q Manufack�ring
no employees. [No workers'comp. insurance required]• I 1.�Health Care
4.❑ We are a non-profit organizarion,staffed by volunteers,
with no employees. [No workers' comp. insutance req.) 12:0 Other
'Any applieant tNaz checks box#t must also fill out the section below sMwing the'v workers'wmpeosetion policy inturmatioa
•'If the crnporate officew have enempted themulves,but the cotpmation haa other employees.a workers'compensatiompolicy is roquired�d such sn
organization shouid check boz#I.
!am an entployer that fs providing workers'compensatiox insuraece for nry employees. Below is the policy inforination.
Insurance Company Name: New Hamahire Insurance Company
Insurer'sAddress: 175 Water Street
New York, NY 10038
CirylState/Zip:
WC043409060
Policy#or Self-ins.Lic.# Expiration Date: Ol/Ol/2015
Attac6 s copy of t6e workers'rnmpensatiop policy declaratlen page(showing the policy number aod ezpiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead ro The imposition of criminal penalries of a
fine up to$I,St10.00 and/or one-year impri�nmenY,as well as cit�l penaldes in the fotm of a STOF WORK ORDER and a fine
of up to$250.00 a day against the violarar. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for inc��.,�nce covecage verificabon.
I do hereby cem;J'y, th patrs and e ,jperjury thar the information provided above is true and correcL
12-15-14
i nue: Date:
Phone#: 4 0 770-
Offrcial use only. Da not write in this areq w be completed by city or mwn ojJ'rciat
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Healt6 2.Building Department 3.CftylTown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Persan: Phone#:
www.msss.gov�d;a
,4co d CERTIFICATE OF LIABILITY INSURANCE DIITE�NMIDD/YriV)
17/19/Z014
THIS CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERT�FICATE 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: M the certificate holde�is an ADDITIONAL INSURED,the policy�ies)m t be TION IS WAIVED,subject to
the terms antl conditions of the policy,cerfain policies may require an endorsement. state Bca doea not confer rights to the
certiflcate holder in lieu of such e�Morsemen s�.
PRODULER CONTAGT
MARSH USA,INC. �E'
99 HIGH STREET VHONE FAX No:
BOSTON,M4 02110 EJIAIL LTFi OEP
Athr.CVSCarertark.Ce,ff2equesl(�rc�arsh.Com Faz212-99&5338 ADDRE55:
INSURERS AFFORDINGCO WUCY
502406ALL-GAW-iSi6 iNsuaERp: NewHart�pshvel�uranceCo. 23841
INSURED INSURER 8: ���I UINdI FNC If15�•0 PI�lSUllf9h PA 1�5
CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CORPORATION INSURER C:
AND ITS SUBSIDIARIES AND AFFILW7ES INSURER 0:
ONE CVS DRIVE
WOONSOCKET,RI 02895 . �Nsunea E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-W609526(F21 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 IMTH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDI710NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ryPEOFINSURANCE pD L U PO�YNUMBER MMNCDIYYYY MMIDDY�P LJYITS
L1R
A GENERIILLIABILITV GL4267820 01ro1�1$ o�ro�no�e EqCHOCCURRENCE E 4'�'�
X COMMERCIALGENERAILIABILITV PRAEMISES Eaoccurrerica 5 �'�'�
CWMS��MADE �OCCUR MEDEXP(M me non) $
X SIR: 5��� PERSONALBADVINJURY S 4'�'�
X LI�UOR LIABILIN INCLUDEO GENEwu nGGREGn7E g 28,000,0110
GEN'LAGGREGATELIMRAPPIIESPEft�. PRODUCTS-COMP/OPAGCa $ INCLU�ED
X POUCV PRO- L� y
8 AUTOMO&LE LIABILITY 3814985(A0S) 01/01IT015 07I01I2076 COMBMED SINGLE LIM�T ���
_ . . _ . �a a�a e�i_.
B X HNY AUTO 3814986(VA) 07IO1 I2015 0110112076 BODILV INJURY(Par person)� $
B ALL ONMED SCHEDULEO 3974987(MA) 01/01/2015 01101I2016 BODILV INJURY(Peracr.iEenl) $
AUTOS AUTOS
X X NON-OWNEO PROPERiYOFMAC�E $
HIREDAUTOS AUTOS FeramlEaril
SELF-INSURED PHY.DMG. S
UNBRELLALIA6 OCCUR EACMOCCURRENCE $
EXCESSLIAB CLAIMS-MFDE AGGREG4TE $
DED RETENTION$ 3
p WORNERSCOMPENSATION SeePageTxroforPdiryNurMers �l��l/2�75 �7/�i@016 �hCSTATU- OTN-
ANO EMPLOYERS'W&LflY ' 2��
MIYPROPRIETOR/PARTNERIE%ECUTNE v�N ELEACMACCIDEPf� $
OFFICER/MEMBEREXCLUDED? � N�A
(MandetoryinNH) ELDISEASE-EAEMPLOYE S 2•���
rc yes.dasuiee wder 2,000�000
DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT 3
DESCRIPTqN OF OPERATIONS I LOCATION31 VEXICLES (Alfac�ACORD 10t,AJdtlonel RemeM ScMtluN,If mas sp�c�Is�pWreA)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INIERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EX�ENT REW IRED UNDER TNE
LEASE OF THE PREMISES OR UNDERANY OTHER WRITTEN CONTRACT ORAGREEMENT. VARIOUS LOCHTIONS,STORE#161,7358944.
CERTIFICATE HOLDER CANCELLATION
THE TOWN Of YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATfN:BRUCEbA1RPHY THE E%PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS.
1146 ROUTE 28
SOUTHYARMOUTH,MA O2FE1 pUTHpp¢EDREPRESENTATVE
� ot Manh USA Inc.
YevgeniyaMuyamina ��r;�si. /YG[.�'s.nenac
�7888-2070 ACORD CORPORATION. All righfs reserved.
ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: S02406
LOC#: Boston
ACO� ADDITIONAL REMARKS SCHEDULE Page 2 ot s
RGENCY NANEDINSURED
MARSH USA,ING CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CORPORATION
roucv xUraEn AND ITS SU&SIDIARIES AND AFFILIATES
ONE CVS DRNE
WOONSOCKET,RI 02895
CARRIER Nuc cooe
EFFECi1VE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CeRificate of Liability Insurance
WORKERS COMPENSATION DE�UCTIBLE PROGRAM:
POLICY DATES:JAN 1,2015 TO JAN 1,2016
Ins.Co. Poticy tt States CovereA
A 011953112�MN) MN
A 011953116 ND,WA,WI,WY
A 011953110�FL) FL
A 071953109�CA) CA
A 011953115 IL,KY,NH,UT,V�
A 011953113�A� AZ
A 011953117(AOS)AL,AR,CO,DE,GA,HI,IA,ID,IN,K5,LA,MD,MI,M0,MS,MT,NE,NM,NV,NY,OK,OR,SC,SD,TN,
rx,wv
A 011953114(PA) PA
A 07195311�ME) ME
E%CESS WORKERS CAMPENSATION PROGRAM
POLICY DATES:JAN 1,2015 TO JAN 1,2016
8 9883930 DC,MA,OH,PA
B 9883931 CT,NQ NJ,VA
Ezcess Wakers CompensaAon Self-Insured Relentions:
DC,Mq OH,PA: $SOU,OOD
CT,NC,NJ,VA: $1,000,000
COVERAGE A:WOAcers Canpensalion:StaNtory
COVERAGE B:Empbyers Liability Limi�s:$500,0001$500,000/$500,000
COMMON POLICY CON�ITIONS
A.Cancellalqn �
2.We�Cartier�may cam�zl Ms policy Oy mating or delivery b Ne first Named Inswed writt�n nofice of cance112Uon at IeaSC
a.10 days befuR Ihe eRec6ve tlate of cancella6on if we cancel for iron payment of premium
1)General liabiliry Adtlitbnal Insuretl-Where Required UnAer Coniract or Agreement Wnguage per endorsertieM 61712(111(I6�:
SECTION II-WHO IS AN INSURED,is amended[o indude as m adtlitbnal inwretl:
Any pe�son a o�ganizafion ro whqn you become obligated to indutle az an addifional insuretl untler ihis pdiq,as a result of any conuxl or�reement you enler in�O which requires you lo/umish insurance to Ihat
person or organiration of ihe type pmvqetl by Nis pdicy,but only wiN respe�:t b Gabiliry an,sing out of your operations or premises owned by ar renktl lo you. Fbwever,ihe insurance provitletl will nol ewceed ihe lesser
of:
�The mverape an/or limils o(this policy,or
�The coverage antlbr limits reQuued by said conVacl or agreemenl.
2)General LiabBiy EaAier No6ce of Cancellation ProvqeO By Us language per en0orsertient CG 02 2410 93:
ACORD 707 (2008/01) �2008 ACORD CORPORATION. All righffi reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: S02406
LOC#: BOSt00
ACO O' ADDITIONAL REMARKS SCHEDULE Pa9e 3 of 3
AGENCY NAMEDINSUREU
MARSH USA,INQ CVS HE4LTH CORPORATION
fORMERLY KNOWN AS CVS CAREMARK CORPORNTION
PoLICY NUMBER AND ITS SUBSIDIARIES AND AFFILIATES
ONE CVS DRNE
WOONSOCKET,RI 02895
CARPoER NAIC COOE
EFFECIIVE DFTE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
PORM NUMBER: 25 FORM TITLE: Cert�cate of Liability Insurance
Number of Days'Notice 90
For airy slaWmnly permilled reason other than nonpaymeM otDremium,ihe num6er of days requiratl fa no6ce of cancellaAon,�provided in paragraph 2.of either ihe CANCELLATION Comron Policy Condi6on or as
amended by an applicade state cancdlatnn e�i0oisemenl,is increased b tl�e number of days shown in ihe Schedule above.
3)General Li�ility Ativance of Cancellation to Entities Other The Namad Inwred Limi�d b E-Mal No6fication per ChaNs A�anuunptentlorsement
In ihe event ihat ihe Insurer caxeis ihis poticy for any reasai othar than non payment oi premium,and
t. The canceNation eMective dale is prbr io ihis poticys eryiraiion dale;
2. The First Named InsureG is under an eus6ng conVactual abligafion to notiy a ceNficale hoker when Mis polky is caxelkd(hereinafter,Ne'ceNficale Holder�s�'�;and has provitled Po ihe Insurer,either directly or
Mrough its broker of recor4 ihe ematl address of ihe con�acl at sucA entiry,
aM ihe Insurer receiVed Nis infamation afler ihe First Nametl InsureA receiretl notice of cancellation of Mis pdicy and prbr W tl�is policys ca�ella6on eflec6ve date,via an electronic spreadsheet ihal is acceD��b
Ne Insurer,
ihe Insurer will provide advice of cancelWtlon(ihe'Pdvice)via e-mal lo suc�Certificate Fblders.
Proof d tl�e Insurer emailing ihe Ativice,using Ne infoniaUon providad under ihis policy by ihe First Nanetl Insure4 will serve as prooF N�ihe Insurer has fully utisfied ils obtigffions under Ihis entlorsement.
.. _ .. _ .__ ._ _ ___ _ . ._. . . . . __ _ ___._ ____ _ _ . . _
This endorsement dces not afiecl,in any way,coverage provitled unAer Nis policy or Ne cancella6on of ihis poicy a Ne effective date ihereof,nor shall ihis endorsement invest any rghls in any enlity not insuretl under
Nis policy.
The klbwing Definitnns appy lo Nis endorsement:
1.Firsl Name0lnsure0 means the Named Insured shown an Ne Daclaraluns Page W Nk policy.
2.Insurer means ihe insurance cortpany shown in ihe hauder on Ne Declaiations Page M Mis polky.
All other lerms,wndilions and eKdusans shall remain tlie same.
ACORD 707 (2008/Ot) m 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD