HomeMy WebLinkAboutApplication and WC . . . . ������
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HEALTH 6EPT.
Dear Sir/Nladain:
Enclosed please find completed application(sj andior invoice(s)
along �vith pat-ment in the appropriate amotmt to cover the cost of
the rene��al `ior the CVS/oharmacy store(sj in your area. Please
l�ote ccny e/zan�es nzrrde o�z t/xe app[ietition t�e�cn-clin; trctcle naf�ze `
c,nr10�� n��ailin� rrdclress. reficl include store ncrfnbers on invoiees
c�nd permits as indicaterl on tlxe applicrdion to insure correct
payment to tlie proper store.
Plecase sef2cl tlze pernzdt(s)/kcense(s) rtfirl a�zy fi{tuf-e renewnl
c[pplications for� this store, with the store na[mber on it, to �riV
attention rit: O�ie CT/S Dr•ive, Licensi�z;Dept., Mail Code 1160,
YVoonsocket, RI 02895. After receiving the licenses, I will make
the necessary copies for my tiles and fonuard the originals to the
stores for posting.
IY you have any questions, please contact me at 401-770-�772 or
by fax 401-652-060�.
S:�2eerely
' �//.N�=.��...�_
r
�onnrae P.Amitrmeo
Licensing Coordintttor
O�ie CtiS Drive/,�l1r�il Code I160
YT'oonsocket, RI 02595
��°f���o TOWN OF YARMOUTH Boazdof
Health
� �"3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
�. 4, a� $ Telephone(508)398-2231,ext. 1241 Health
r,�c NEc. Division
Fas(508)760-3472
To: YannouthBusinessEstablishmenu G/5/P��ZMRC�-I -k�q�k�
From: Bruce G. Murphy, Director �����d��
YannouthHealthDepartznent UE� � 7 2��4
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Board of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yannouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the
fees listed aze 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 Yarmouth Health
Deparkment with a11 required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) orior 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 WhirlpooUVapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Restaurants Over 100 Seats $160.00
Retail Food Service 45,000 sq. 8. $ 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: O,o
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 andlor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGN1/maf
aC�CSC��JC�D
�us �k�
� a � TOWN OF YARMOUTH BOARD OF HEALTH _ UEC � T YO�4
�, APPLICATION FOR LICENSE/P.��I�?2a� � =� 3
" * Please complete form and attach all necess � c� �s�1� ec L PT.
Failure to do so will result in the re �yo�apph�tion pac et.
ESTABLISHMENT NAME: ��10.c -'IF `f�E TAX ID: -� �'
LOCATIONADDRESS: �4La'75�a�.i:�x1 fi� �v.�1.. �al�,rv�a�.iti, TEL.#: �C��C-3qb'`�-
MAILING ADDRESS: C�N2 CJS Oti• 1�JUcY�►�t.l�� ��l- C33�9 �S J
E-MAIL ADDRESS:
OWNER NAME: CV arm , •
CORPORATION NAME (IF APPLIC BLE):
MANAGER'S NAME: �J/a�� l.v�d�a�� TEL.#: �' '7b��
MAILINGADDRESS: PY�Z�-�SO�- W..��oc�.-e{- tLZ ��J
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 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.
1. 2•
3. 4•
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 Tle at your establishment.
1. Z•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�. �� �-���� 2.
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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 Deparhnent 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 anti-chokmg 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#
B&B $55 CABIN $55 MOTEL $110
—INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $il0ea.
FOOD SERVICE:
LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
—>t00 SEATS $200 _COMMON VIC. $60 WHOLESALE $SO
— —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
�<ZS,OOOsq.ft. $150 5� —FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ $ ISO.Qd
'****PLEASETURNOVERANDCOMPLETEOTHERSIDEOFFORM***** �L(� �a7O• �
�..��j7�07l�'j
,
AllMINISTRATION �
Under Ghaptiar I 52,Section 25C,Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal
af any licanse ar permit to aperate a business if a person ar company dves not have a Certificate of Worker's
Compensation Insurance. THE ATTACHEll STATE WORK�R'S CC1MP'ENSATION INSUI2ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNEll,OR
CER7', OF INSURANCE ATTACHBD �
f3R � ,,,/�
WORKER'S COMP. AFFiDAVIT SIGNED AND ATTACHED'
Town of Yarrnouth taxes and liens must be paid prior to renewal or issuance of yaur permits. PLEASE CHBCK
APPRdPRIATELY IF PAID:
YES_�` NO�
MQTELS ANA OT�IER LODGING ESTABLISHMENTS
'1'RANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Tsansient occupancy shall be
limited ta the temparary and short term occupancy,ordinarily and custamarily assaciated with motei and hptei use.
Transient occupants must have and be able to denionstxate that they rnaintain a principal place of residence
elsewhere.Transient occupancy shall generally reFer to continuous occupancy of'not more than thiriy(30}days,and j
an aggragate afnat mare than ninety{44}days within any six(6}month period. Use af a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collectlon of Room Occupancy
Fxcise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
YOOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed Far the season rnust be inspected
by the Health Department prior to opening. Contact the Health Depat•tment to schedule the inspection three{3}
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the ppol has been
inspectea and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total cofiform and standard plate count
by a State certified lab, and submitted to the Health Department thrce {3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnusY be drained oz covered within seven(7)days of
closing.
F401}SERVTCE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the I�ealth Department prior to opening. Please contact the
I-�ealth Deparqnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyane wha caters within the Tawn of Yarmauth inust notify the Yarmouth Heatth Dapartment by filing the
required Temporary Food Service Application forna, 72 houxs prior to the catered event. These fnrms can be
obtained at the Health Department,ar frorn the Tacvn's website at www,yarrnouth.ma.us under Health I}eparhsrent,
Uownloadable Forrns.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sarnple results
submitted to the Health DeparYrnent. Failure to do so will result in the suspension or revocation of yaur Frozen
Dessert Permit untiI the abave terms have been met.
OUTSIDE CAFES:
C}utside cafes{i.e.,outdaor seating with waiterlwaitress service),must have prior approval from tha Board af Health.
auT�aox coo��vc:
Outdoor cooking,preparation,or display of any faod product by a retail ar faod service establishment is prohibited.
NOTICE:Permits run annualiy from January i ta December 3l. IT IS XO[TR RESPQNSIB]LITY T4 RET[TRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQ[JIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATION5 TO ANY FQOD ESTABLISHMENT, iY1QTEL OR PQOL (i.e., PAINTING, NBW
EQUIPMBNT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATI4NS M REQUIR�' A SITE PLAN,
_ __..
DATE: �*a��'SII+� SIGNATURE•
PRINT NAME& TITLE Joanne P Amitrena ,
Rev. 1 V03/14 LfC'eftsthG�f'f,n.nt?rtz*+�f ,,.:
AIG
Coverege is provided by
NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
(a capital stock company)
775 Water Street, New York, NY 10038
(212) 458•5000
XWC -ELITE �
EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITV INDEMNITY POLICV
INFOHMATION PAGE ._,
..— ---..._ ..
POLICYNUMBER: XWC 663•62-55 ��wA�oF: 6636t75
VROWCEH: MARSH USA INC.
99 HIGN STREET
BOSTON, MA 02110
ITEM i. NAMED INSUflED AND MAIUNG ADDXESS
CVS CAREMARK CORPOR4TION
7 CVS DR
WooNSOCKET, RI o2895-6195
ITEM T. STATES IIN WlNCH COVEMOE IS TO APPLYI
SEE ATTACNED SCHEDULE
REM3. VOLICYPEfilOD FliOM: Q�/Q�f2Q�4 TO: O�/Ol)2��5
72:07 A.M.STANOARD TIME AT TXE MAILINQ ADDI�SS SHOWN HE1tE1N
fTEM 4. OUR 4MIT OF INDENWITY
PART ONE•WOPKERS COMPENSATION
STATUTORY EACHACdDENT
STAMORY EACH EMPLOYEE FOfl DISEASE
PAIiT TWO-EMPLOYERS WBILITY
SSOO�OOO FACH ACCIDENT
$rjOO,DOO EACN EMPLOYEE FOfl DISEASE
PARTTWO-STOP�APINSURANCE
$SOO,OOO EACNACCIDENT
SSOO.00O FACH EMPLOYEE FOR DISEASE
ITEM6. VWRRETHiTiON
PAfiT ONE•WOflREAS COMVENSATION AND PART TWO-EMPLOYEf�LIA&LITV COM&NED .
See Form 72164 �+�+A���
See Form 72164 FJ1CH EMPLOYEE FOR OISEASE
ITEM 8. PREMIUM AND PREMIUM COMPUTATION
ESTIMATEDTOTALANNUALREMUNERA770N $2,269,5�9.b�
(tATES PER 8100 OF REMUNEFATION o.ot 39
DEPOSR PflEMIUM $3�5.OrjP
MINIMUM PREMIUM $31 S.OSZ
Premium for Certified Acts of Terrorism Coveraga Under Terrorism Risk Insurance Act 20Q2 as amended by
the TeRorism Risk Insurance Program Reauthorization Act 2007: .
Coverage Provided At No Addttlonal Charga
ITEM 7. THIS POUCV INCLUDES THESE ENDORSEMENTS AND SCHEDULES(AT INCEPTION DA7EI:
SEE ATTACHED SCHEDULE
COUMERSIGNED(wharo repuired by law)8�:
(A THORIZED REPfiESENTATIVE�
DATE ISSUED: OY/OS�ZOIb
72726 (04/03) 0 z003 All rights reserved.
IN WITNESS WHEREOF,the Insurer has caused this Policy to be signed by its President, Seeretary and
Autnorized Representative.
� � r�
President Secretary
NATONAL VNION FIRE INSURANCE COMPANV OF RTTSBUflGH,PA NATIONAL VNION%flE INSUIIANCE COMPANY OF RTTSBUPGH,PA
This Policy shall not be valid unless signed below at the time of issuance by an authorized representative
of the insurer.
�9 a�>.Q�_
uthorized Hepresentatrve
SIGNUJ
FORMS SCHEDULE
EFFECTiVE DATE: 07/Ot/2014�
NAMED INSURED: CVS CAREMARK CORPORATION
POLICY NO. XMC 883-85-55
M11N001 SELF-INSURED RETENfION EMORSEMEM
58293 (0383) CANCELLATION CdDITIOW AMENDED
84470 (0Y9Q) MN AMElpATORV ENOORSENENf
87153 (1005) IPi0Y1LEDGE OF OCCURRENCE
72727 (0403) EX ifC lUD EMPL LIAB [lDEM PoLICY - fORM
7213Y (1788) DC AMElAATORY EMORSELffNT
74148 (1798) RI AMENDRTORY EI�ORSEAffNT
72182 (0804) Sp#WLE OR STATES COVERED
72184 (0205) YWR RETENI'ION SWEOULE
732Y3 (0899) OH /WENDATORY ENDORSENENf
73745 (OBIXi) VA AMENDATORY ENOORSEMEM
73803 (0398) NJ MfEfApTWtY ENDORSEMENT
78052 (0114) AI6 0.5. CRIVACY Ati! DATA SEC
7806Y (0601) INOUS7RIAL AID �TRCRAFT
81810 (0403) NC IWENDATORY EPDORSEMENT
83243 (1003) CT ANENDATORY EIDDRSEMEM
83873 (NO3) AMEPDATORY EtWORSEMEMT
88814 (0813) Ef'ANONICS SNJCTIONS ENOORSEMEM
88844 (0705) AMElDATORY ENDT - COVERABE TERR
eO00B (0208) REqIEATION AND ATHIETIC EYENT COV
83857 (7110) OH STOP OAP INfEMIdUL TORTS EXTN
115324 (0573) MIENDMEM OF CLAIMS REPORTINO OUTIES
EXCESS WORKERS COMPENSATION �
ENDORSEMENT
7his endorsement,effective 12:01 A.M. 01lO1/2074 fortns a part ot
policy No. XWC 663-62-55 issued to CVS CAREMARK CORPORATION
by NATIONAL UNION PIRE INSURANCE COMPANY OF PITTSBURGH, PA
MASSACHUSETTS AMENDATORY ENDORSEMENT �
The following conditions are added W this policy:
1. Arry money received by you under the provisions of this policy shall be deposited in such bank, or
with the Treasurer and Receiver General of the Commonweatth, as the Department of industrial
Accidents may determine, and any such money shall be held in trust for the payment of any liabilities
incurred by you under Chapter 152,General laws as amended,and no use or disposition of any such
money shall be made without the approval of said Departrnent. No such money shall �assignable
or subject to attachment or be liable in any way fw your debt unless incurrad under s�d Chapter 152.
2. If any party to this policy desires to cancel lhis policy, such cancellation shall not become affective for
a period oT at least thirty days following rmtice, by registered mail, to the Department of Industrial
Accidents of the Commonweatth of MassachuseNs of said cancellalion.
3. No commutation of any liability incurred by you under said Chapter 152 during the period this policy
is in effed shall be made without the approval of the Department of Industrial Accidents ot the
Commonwealth of Massachusetts.
All other tertns, conditions and exclusions shali remain[he same.
A THORIZED REPRESENTATIVE
64470(2/96)
� The Commonwea/th ofMassachuse#s
Department of Industrial Accidents
Office of Investigations
60a R'ashi�gton Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apnlicant Information Please Print I.eeib(Y
Business/OrganizarionName: �S/Phazmacy # ��,t,�
Address: �bs 5��� �'��
City/StatetZip: P�k�yl�2aYl�.r�'�'l��A ��hone#: ��"�-77—�(o`�a'— _
Are yoa an employer?Cheek t6e sppropriate boi: Business Type(required):
1.� I am a employer with employees(fuli and/ 5. �Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or paRnership and have no �, �p����or Sales(incl.real estate,auto,etc.)
empioyees working for me in any capacity.
[No workers'comp.insurance requiredJ $• ❑Non-pmfit
3.❑ We are a coiporaYion and its officers have ezeroised 9. ❑Entertainment
their right of exempflon per c. 152,§1(4),and we have I O.Q Manu#acduing
no employees. [No workers'comp. insurance required]s
4.❑ Wo aro a non-profit organization,staffed by volunteers, I 1.0 Health Care
with no employees. [No workers'comp.insurance req.] 12.0 Other
`�Y ePPlicant that checks box#1 must also fitl out the sation below sdowing Uieir workms'eompensation poticy infotmatioa
"If the cmpora[e ofTicers have exemptad themseives,but the eorporation has oU�er employces.a workers'eompensation policy is iaquired md such an
orgaaization should ch�k box#I.
I am an emp(oye►that is providirsg workers'co�npensation lnsuwnce for my employees. Below is the po[icy information.
InsuranceCompanyName: New Hamshire Inaurance Company
Iasurer'sAddress: 175 Water Street
New York, NY 10038
City/State/Zip:
WC043409060
Policy#or Self-ins. Lic.# Expiration Date: Ol/Ol/2015
Attach s copy of the workers'compensadon poGcy d�laration page(showing the policy num�r and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a
fine up to$I,i00.00 andlor one-year imprisonment,as well as civi]penaldes in the form of a STOP WORTC ORDER and a fine
of up to$250.00 a day against the violator. Be advise�d that a copy of this statement may be forwarded to the Office of
Investigations of the DIA For insurance eovetage verification.
I do hereby ce ' ,und th ins and pe+ralties of perjury that the ixformation provdded ebave is vue and corv�ect
��� � 12-15-14
Si ture: Date:
Phone#: 4 0 70-5
Offuia[«se only. Do not wriYe in Ueis area,to be completed by clty nt town ofJlciaL
City or Town: PermitlLicease#
Issuiag Authority(circle one):
1.Board of Health 2.But(ding Department 3.City/Town Clerk 4.Lieenaiag Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/aia
,�+coRO� CERTIFICATE OF LIABILITY INSURANCE DATE�MIIIDD/YYYY�
�- ,ti,��,<
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONPERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, DCTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES �
BELOW. THIS CERTIFICATE OF INSURANCE�DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIlF11
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poliey(ies)m t be TION IS WANED, subjeet to
the terms and conditions of the policy,cerlain policies may require an endorsement. spte flc does not confer rigMs to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT .
MARSH USA,MC. NanE:
99 HIGH STREEf . PxouE FAI�C No:
eosroN,r�w ozno E�""'� LTH DEP
Adn:CVSCarema�k.CertRequest�marsh.can faz212-94&5338 aoorsEss:
INSURE 5 AiFORMNGCO NAICk
S02406ALL-GAW-15-16 INSURERA: �H2111PShNQIRGIl211CQCA. Z3BA�
INSIIRED INSURER B: ��I UN011 F2 IIIS ri0 PIIIS�IRJh PA ��$
cvs H�ran�coaroanrioN
FOR�RLY KNOWN AS CVS CAREMARK CORPORATION INSURER C:
AND ITS SUBSIDIARIES AND AFFILIA7ES INSURER o:
ONECVSDRNE
WOONSOCKET,RI 0289$ INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYG006095260.27 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. NOTlMTHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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 rypE OF INSURANCE � UB PoLICY EFF POLICY EXP
LTR POLICY NUMBER MMIDDIYYYY MMID Ud�T$
A GENErtu unelun GL 4267820 01I072075 01/0112016 EnCH OCCURaENCE $ 4,500,000
x COMMERCULL GENERAL LIABILITY D q r ���
PR M SE ccurtenca 3
CLAIMS-MADE �OCCUR MED EXP(My are peraon) $
X SIR: �WO,000 PERSONALBADVINJURV S 4•���
X tJQUORLIABILININCLUDED GENEan�nGGREGa� $ 28,OOD,000
GEN'LAGGREGATELIMRAPPLIESPER: PROOUCTS-COMPIOPAGG $ �NCLUDED
X PO�ICV PR0. LOC $
B AUTOMOBILEIJABIl1TY 3874965�AOS) 01/�1�1$ �i/����is COM8INE�SINGLELIMIT ���,Q�
Ea acciEent
B X qN�A�O 3814966(VA) � 01107Yt015 0�/0�12076 BODIIYINJURY(Perperson) $ .
B ALLOWNED SCHEDULEO 3g�qgg]�Mq� OV01I2015 01N112016 BOOILYINJURV�PerecaEe�rt) $
AUTOS AUTOS
NON-0VMIED PROPERTV DAMAGE $
x HIREDAUTOS X qUT05 PerecciOeN
SELF-INSURED PHY.OMG. � g
UMBRELULNB p�CUR EACHOCCURRENCE $
EXCESSIJAB CWMS-MADE AGGREGA7E $
DED RETENTION$ � $
p WORKERSCOMPENSATION SeePaqeTwoforPdicyNumbers 01/01/Z075 01/012076 VNCSTATLL oni-
AND ENPLOYERS'LIFBILRY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N E.LEACHACCIDENT $ Z'�'�
OFFICER/MEMBER EXCLUDED? � N�p
(MaiMatoryinNN� E.L.DISEASE-EAEMPLOVE $ Z•����
H v�%.aesvine untler 2A00,000
DESCRIPTIDN OF OPERATIONS Gebw E.L.DISEASE-POLICV LIMR S
OESCRIPTON OF OPERATIONS/LOCATIONS I VEHICLES(Attac�ACORD 101,AUtlNbnal Remarke Sehetlule,H mora spce Is requlreU)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EaTENT REW IRED UNOER THE
LEASE OF THE PREMISES OR UNDER ANY OTHER WWTTEN CONTRACT OR AGREEMENT. VARIOUS LOCATIONS,STORE#161,735 8 944. .
CERTIFICATE HOLDER CANCELLAT70N
THE TONM OF YARMOUiH SHOULD ANY OF 7HE ABOVE DESCRIBEU POLICIES BE CANCELLED BEFORE
ATRJ:BRUCE MURPHY THE EXPIRATION DAiE THEREOF, NOTICE WILL BE DELIVERED IN
BOARD OF HEALTH ACCORDANCE WRH THE POLICY PROVISIONS.
1146 ROUTE 28
S011�H YARMOUTH,MA 02664 ��
AUiNOR�D REPRESENTATNE �
ot Mareh USA Ina '..
. Yevgeniya Muyamina ��p>;�u.. IJZ[c�fa�ne� .
m 1988-2010 ACORD CORPORATION. All rights reserved. �.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �
AGENCY CUSTOMERID: 502406
LOC#: Boston
i��� �
ACOKO ADDITIONAL REMARKS SCHEDULE Paye 2 ot s
A6ENCV NAYEDINSURED
MARSH USA,INQ CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CORPORATION
rouCr Nue�eErs ANO ITS SU&SIDIARIES AND AFFILIATES
ONE CVS DRIVE
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 Liabilily Insurance
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 7,2015 TO JAN 1,N116
Ins.Co. PoGcy q Stales Corered
A 011953112(MN) MN
A 011953116 ND,WA,WI,WY
A 011953110(FL) PL
A 011953109(CA) CA �
A 011953115 IL,KY,NH,UT,VT
A 011953113(AZf AZ
A 011953117(A05)AL,AR,CA,DE,GA,HI,IA,ID,IN,K5,lA,MD,MI,M0,M5,MT,NE,NM,NV,NY,OK,OR,SC,SD,TN,
TX,NN
A 011953114(PA) PA
A 01195311(ME� ME
E%CESS WORKERS COMPENSATION PROGRAM
POLICY DATES:JAN 1,2015 TO JAN 7,2076
B 9883930 DC,M4,OH,PA
B 9883931 CT,NC,NJ,VA
Ezcess Workers Compensation Sal4lnsu�ed Relentions:
DC,MA,OH,PA E500,000
CT,NC,NJ,VA E1,000,000
COVERAGE A:Workers Compensa6on:Statutory
COVERAGE B:Empbyers Lia6idy timils:$500,00018500,OOOl$500,000
COMMON POLIGY CONDITIONS
A.CanceOatlon �
2.We�Cartier�may cancel ihis policy by maiNng w tlelivsy b Ne firsl N�In5ure0 wriqen no6ce of cancella6on a�IeaSC
a.10 tlays before the eRecUve tlaie otcance9a6on if we car�cel(a rwn paymenl of premium -
i)General Liability AtlaiUonallnsure0-Where Required UMer Con6act or Agreement language per entlors�nent 61712(17J(I6):
SECTION II-WHO IS AN INSURED,'s amendetl lo inclu0e as an atlditional insured:
My persm wo�gai'va6on to whom you 6emme od'gale0 W incWEe as an a0tlitional insured under ihis pdicy,as a result of any conUact or agreemem yni enler inb which requires you lo fumish inwrance b Nal
pe�wn w o�ganaa6on of tAe type qovirkd by U�is pdicy,bul only with respect ta IiaUiNty arising out of your operations a premises owneO by or rented to you. However,Ne nsurance provi0ed will not exceed Ihe lesser
oF.
� �The coverage allor limits of Ih's poNcy,or
�The coverage antlbr limils requved by said contraG or agre�ment.
2)Gene21 Labiiry Eatlier Notice of CaxelWibn Provided By Us language per endorsement CG 02 2410 93:
ACORD 701(2008107) 0 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: S02406
LOC#: Boston �
AC�� ADDITIONAL REMARKS SCHEDULE Page 3 of s
L..� — —
AGENCY NAYEDINSURED
MARSH USA,INC. CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CORPORATION �
vouCv NUMBER AND ITS SUBSIDIARIES AND AFFILIATES
ONE CVS DRNE
WOONSOCKET,RI 02895
caaw�e Nac coue
EFiECTIVE DATE:
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 any stalutorily perrttilletl reason o�her Ihan nonpayment of O�um,Ue number of days required for no6ce af canceAlation,as provitletl in parapraph 2.of either tlre CANCELLATION Common Policy CondNm or as
amendetl by an appliwble state cancellation endorsemen4 is increased b Ne number of days slwwn in Ne Schedule above.
3)General Liability Advance of Cancepa6on to Enfi6es ONer The Naned Insured Limited to E-Mail Nofification per ChaNs ManuscupteMorsemen[
In Me evenl tl�at Ne Insurer cancels this policy for any reason other ihan non paymen�of premium,entl �
i. ThecanceBa6oneffeclivedateispnatothispolicysexpire6ondate;
2. The First Named InsureO is under an exis6ng con4acWal obGgalA�n b nofiy a cerMcate halder when Ihis policy is canceNetl(hereinailer,ihe'ceAiAcate Fble�s�');antl has p�ovidad b ihe Insurer,eiNer diiectly or
Ihrough ils bmker of rarord,ihe email address of ihe contact at such enfity,
aM Ihe Insurer raceived Na i�rfortna6on afler pie First Named I�uad received nolice of cancelWion of ihis pdicy and prior to Nis poGcys cancellabon eHecfive tlate,via an electronc spreadsheel Mat is acceptffile m
Ihe Insurer,
Ihe Inwrer will provitle�vice of cancellabon(ihe'Pdvice'�via e-mal to such Cartif�cate Holders.
Pmof of Ihe Insurer emaling Ihe Ativice,using tlie intomation providetl untler ihis policy by ihe Firs�Named Insured,wiN serve�proof Ihat ihe Insurer has fully satisfietl ils oblga6ons under ihis entlasement.
This endorsement does not aRecl,in any way,cov�age pmvided under ihis pWuy or tlie cancdla6on of Ihis policy or ihe eHective tla�ihereof,ror shall ihis endorsemen�imesl any righls in any enfity no�insuretl under
ihis policy.
The folbwing Defindqns apDN�o Nis endorsement:
7.Frsi Named Insuatl means tl�e Namea Insured shown on Ne OeclaraM1ons Page M Nis poGcy.
2.Insurer means ihe insurarcz wripany shown n ttie heatler on tl�e Dedaralb�Page M Nis poticy.
All oNer tems,con0itions anU ecclusbns shali reman Ihe sama.
ACORD 101 (2008I01) �2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD