HomeMy WebLinkAboutApplication and WC e � a ! : �����' .
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HEAL�'H bEPT.
Dear Sir/Madam:
Enclosed please tind completed application(s) and%or im oice(sl
along ��ith payment in the appropriate amotmt to cover the cost of
the rene��al for the CVS/phannacy store(s) in your area. Plecrse
note any ehc�n�2s rnade on the ttpp[ierrtiori t•e�cirrliria trade rzc�me �
r,t?d ot' mailina address, and include stot•e nurnbers o�z invoices
rand permits tas indicr[ted otz the applicr[tion to insz�re cof•reci
pccymei�t to the pf�oper Store. �
Please serzd t/se pej•rrxit(s)/License(s) a�zd anv futaire r•enewa!
applicatiojzs jor this store, wi11x the store �zarmber on it, to �ny
crttention at: One CVS Drive, Licensi�z;Dept., Mrtil Code II60,
YVoonsocket, RI 02895. After receiving the licenses, I will make
the necessary copies for my files and forward the originals to the
stores for posting.
If you have any questions, please contact me at 401-770-�772 or
by fax 401-652-0608.
Sincerely
�_ ��"-`—
i
�'
�oa�v:e P. �mit�•mxo
Licensi�zg Coordinator
One CYS Drive/liail Code II60
Ii'oo�asocket,RI UZS95
\
�` j.
��°����Q TOWN OF YARMOUTH Bo�dof
Health
� —_. :�- �`� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
�: �,r � �,'� :r Telephone(508)398-2231, ext. 1241 Divis n
�A G Nf Fa�c(508)760-3472
Ta Yannouth Business Establishments GVS�PH�A�MAc-4 #'/3 ��������
From: Bruce G. Murphy, Director �k� � 7 20�4
Yarmouth Health Department
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth
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 Yarmouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed afFdavit) 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 WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Restaixrants Over 100 Seats $160.00
Retail Food Service<25,000 sq. ft. $ 80.00 � 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: O.00�
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf
` p�6 0
� TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATIONFORLICENSE/PER1VfI�Fs,�+a,2Q� ,y �"� �< UE� �� � ?Q�4
* Please complete form and attach all necessary do�e'n�`$ iA� b t
Failure to do so will result in the return of ap�lica�fto ao DEPT.
ESTABLISHMENT NAME: ' S �M� '1 . S T ID:
LOCATIONADDRESS: �(�110 � �' � z-►�., �Iqrv�a.�.�•, MA TEL.#: �'�J°'�'I-'g �
MAILING ADDRESS: ON¢. CJS Q,�• i�x�5o tL2 a a2�i5
E-MAIL ADDRESS:
owNERrraME: C'VS Pharmacy, •
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: C'y<tti.�SC,��1C1e.c.. TEL.#: tj`�-1$— ��_rj�fa
MAILING ADDRESS: ��+�- GJSty�. U.xx9'�S6Ciy- �22 ��&9 C
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. 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 rivo employees currently certified in basic water safety, standazd 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 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 Deparhnent 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. l.�n,'�'�W�. SC�UC.�i-�- _ 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 Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
l. 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 $ll0 .
—INN $55 CAMP $55 SWIMMINGPOOL$ll0ea '
LODGE $55 1'RAILERPARK $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#
�<Zq >25,000 sq ft. $285 VENDING-FOOD $25
S,OOOsq.ft. $150 ��J —FROZENDESSERT $40 _TOBACCO $ll0
NAME CHANGE: $15 AMOUNT DUE _ $�5 0.00
*'"***PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM***** '��C� � �Q�
��ct'7'7�?�7
� � 1
,
ADMIIVISTRA'I'ION
Under ChapYer 152,Section 25C,Subsection 6,the Town of Yarmouth is now rcquired to hold issuance or renewal
of any license or pernait to operate a business if a person or company does npt have a Certifieate of Worker's
Compensation Insurance. TIIE ATTACFIEA STATE WORK�R'S COMPENSATION INSURANCE
AFFIDAVIT IYIUST BE COMPLETED AND SIGNED,OB
CERT". QF INSURt�NCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yannouth taxes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO_..
MOTELS AND OTHER LODGING ESTABLISHMENTS
1'RANSILNT OCCUPANCY: For purposes of the 1 imitations of MoYel 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 ahle to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thirty{30)days,and
an aggregate of nok more than ninety(90)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 collection of Roorn dccupaney
Excise,a5 de�ined in M.G.L. c. 64G ar 830 CMR 64G, as arnended,shall generally be considered Transient.
raoLs
P40L G/PENING:All swimming,wading and whirlpools which have been closed for the seasan must be inspected
by the Health Department prior to apening. Contact the Health Department to schedule the inspection three(3)
days prior to opaning, FLEASE NOT`E: People are NO'T allowed to sit in the popl area unril the paai has been
inspected and opened.
POOL WATER TESTING: The waier must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Departsnent three (3) days prior to opening, and quarterly
Chereafter. ��
Pt}OL CLdSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days af
closing.
Fd011 SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establashments must be inspected by the I Iealth Departrnent prior to opening. Please contact the
Health Department ta schedule the inspection three{3) days prior to opening.
CATERIlYG POLICY:
Anyone who caters within the Town of Yaamouth rnust notify the Yarmouth Health Departrnent by filing the
required Temparary Food Service Agplication form 72 haurs prior ta the catered event. Thesa farms can be
obtained at the Health Department,ar from the Town's website at www.varmouth.ma.us under Health Department,
Docvnloadable Forms.
FT20ZEN DESSERTS:
Prozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
I7essert Permit untii the above terms have been met.
QUTSIDE CAFES:
Qutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board ofHealth.
OUTDOOR COOHING: '
Qutdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prahibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSISLLI'1'Y TO RET[7RN
THE COMPLETED RENEWAL APPLICATION(S}AAtD REQUIREI}FEE{S}BY DECEMBER I5, 2614.
ALL RENOVATIONS TQ ANY POQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIPMENT,ETC.}, MUST BE REPORTED"I"Q AND APPROVEI}BY THE BOARD OF HEALTH PRTOR
TO COMMENCEMENT. RENOVATIONS MAY QU ' SITE N.
DATF: ��.-���'I STGNATURE:
PRINT NAME& TITLE: �oanne P. Amitrano '
Rev. 11f03fl4 ' '
AIG
Coverege is provided by
NATIONAL UNtON FIRE INSURANCE COMPANY OF PITTSBURGH, PA
(a capital stock company)
175 Water Street, New York, NY 10038
(212) 458-5000
XWC-ELITE �
EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITV INDEMNITY POLICY
INFORMATION PAGE ._
PoucrNunnee�c XWC 663-62-55 ner+Ewa�oF: 6636775
PROWCER: MARSH USA INC.
99 HIGH STREET
BOSTON, MA 02110
ITEM 1. NAMED INSUNED AN�MAILING ADDRE55
CVS CAREMARK CORPORATION
7 CVS DR
wooNSocKET, RI oz895-6�95
ITEM 2. STATES (IN WHICH COVEM6E IS TO APPLY) �
SEE A7TACHED SCHEDULE .
REM3. POLICYPEPoOD FAOM: O�/O�/PO�A TO: O�IO�/ZO�S
72:01 A.M.STANDARD TIME AT TNE MAILINQ ADDRESS SNUWN HEREIN
fTEM 4. OUP UMIT OF INDEMNIT`/
PART ONE•WORKERS COMPENSATION
STATUTORY EACM NCCIDENT
STATUTORY EACHEMFLOYEEFOfl DISEASE
rnrtr rwo-ernr�orEns un�un
�SQQ,��� EACHACCIDENT
SSOO,OOO EACN EMPLOVEE FOR DISEASE
PARTTWO•STOVGAPINSUflANCE
$500,000 EACHACpDENT
$54�,UOO EACH EMPLOYEE FOfl OISEASE
ITEM 6. YOUR REfEN710N
PART ONE•WORKERS COMPENSATION AND PART TWO-EMPLOYERS W&L1TY COMBINED
See Form 72164 encHacaoewr
Sea Form 72164 FACH EMPLOVEE FOR DISEASE
I7EM 8. PRENUUM AND PRENXUM COMPUTATON
ESTIMATEDTOTALANNUALREMUNEAATON $Z,269,519���
RATES PEN 8100 OF NEMUNERATION o.ot 39
���o�,��M 33�5.os2
MINIMUM PPEMIUM 83�5.�52
Premium tor Certified Acts of Tertorism Coverage Under Terrorism Risk Insurance Act 2002 as amended by
the Tertorism Risk Insurance Program Reaulhorization Act 2007:
Coveraga Provided At No Additional Charge
ITEM 7. THIS POUCV INCLUDES TMESE ENDORSEMENTS AND SCMEDULES IAT INCE7TION DATEI:
SEE ATTACHEO SCHEDULE ��yy (� /�
COUNTERSIGNED iwhen repu'val Dy Wwl 8V: ��P1' �"""^'u
(A 7HORIZED PEPfiESEMATIVEI
DATEISSUED: OY/OS�ZO�A
72126 (04/03) O�003 All rights reserved.
IN WITNESS WHEREOF, the Insurer has caused this Policy to be signed by its President, Secretary and
Authorized Representative.
'7�L � r`'i��
President Secretary
NATIONAL UNION FIflE INSURANCE COMPANV OF PITT5811NGH,PA NATIONAL UNION FlFlE INSUIiANCE COMVANY OF NTTSBURGM,PA
This Policy shall not be valid unless signed below at tne time of issuance by an authorized representative
of the insurer.
I
�.�'a.� �---
uthorized Representative
SIGNUJ
FORMS BCHEDULE
EFFECTIYE DATE 01/01/2014�
NAMED INSURED: CVS CAREMAFK CORPoRATION
POIJCY NP. %MC H83-82-65
MAN001 SELF-INSURED RETENfION El�ORSENEM
SBZB3 (0383) CANCELLATION CONDITION AMEIMED
844T0 (019H) NR AMElDATWtY ENOORSEMENf
67153 (10�) 1010MLEOGE OF OCCURRENCE
721T� (0403) EX MC NID E/IPL LIAB I10EM VOLICY - FORM
72731 (1198) DC IWEHDATORY ENOORSEMENT
72/48 (N88) RI MiENDATORY ENDORSENENT
7218Y (0809) SGHEWLE OF STATES COVERED
7216! (0205) YOIRt RE7ENTIqi SCHEWLE
73Y23 (0809) ON ANElDATORY EWOORSEMENT
797{6 (0003) VA AMElN1ATORY ElWORSENEHT
738IXi (0388) NJ AMENDA�ORY ENOORSEMEHf
78062 (0174) AIG U.S. PRIVACY MO DATA SEC
78081 (0601) INOUSTRIAL A[D AIRCRAFT
819/0 (0403) NC MIEIMAT�tY ENWRSEFIEM
832{3 (1003) CT AMEt�DATORY ElWORSEMEM
83873 (7103) AMENDATORY ENUDRSEMEM
89844 (0813) ECO�RCS SNICTIONS EMORSENENf
89844 (0708) AMENDATORY EII�T - COVERAl:E TERR
80008 (0208) RECREATION NiD ATFiLETIC EVEM COV
83941 (1110) OH STOP fiAP IHfENTIMIAI. TORTS EXTN
1153R6 (0613) AMEIi01ffNT OF CU1[MS REPORTIN6 WTIES
i .
EXGESS W4RKERS COMPENSATtON �
EtfQOR3EMENT
This endarsement,eNective 12:01 AM. Ot10112014 fmms a part of
po�icy No.XMiC b63-b2-55 issued to CVS CAREMARK CpRPORA7lON
by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
MASSACHUSETTS AAAENDATORY ENDORSEMENT
Tkre foibwing conditions�e�ded to th#s policy:
7. My money received by you under the pmvisions of this policy shali be deposited in such bank, or
with the Treasurer and Receiver Generai of the Commonweatth, as Yhe Department of Industrial
Accidents may determine,and any such money shall be held in Wst for the paymeni of any IiabilHies
incurred by you under Chapter 152,General taws as amended,and�w use w disposition oi any such
money shall be made withaut ihe approval pf said DepartmenL Np such marey slrall be azsignable
or subjact to atiachment or be Iiabte in arry way for your daDt uniess incurted under said Chapter 452.
2. tt anY partY 4o fhis poGcy desires ta cance!{his poiicy,such ca�cetlatbrr shaii not�come effectiue{ot
a period pf at least thirty days following rn�tice, by registered mail, to the pepardnent of Industriai
Accider�ts oT the CommanweaHh of Massact�usetts of said canceHation.
3. No commutation of any G�ility incurced by you under sarck Ch�tsr 152 durittg the period ttus policy
is in effect shall be made without tbe approval of the Department of Mdustrial Accidents of the
Commonwealth of Massachusetts.
P1t other}8rms, con�tiorts and exciusions shaii remain the same.
�- - -- - _" —
� THORIZED REPRESENTAitVE
644T0(2196)
� The Commonwealth afMassachusetts
Department of Industrial Accidents
Office oflnvestigattons
600 R'ashington SYreet
Boston,MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavitr General Businesses
Aualicant Information Please Print Le�ib1Y
Business/0rganizationName: CVS/Pharmacy # � �
Address: �1(o �vk-�- � —
CitylState/Zip: �`'��'' l�m�"'� �'0 Phone#: �l 3�`� � ����
Are you ao employer?Check t6e appropriate boa: Busiaeas Type(required):
1.� I am a employer with employees(full and/ 5• ���
or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. �p}fice and/or Sales(incl.real estate,suto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] g• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§I{4),and we have 10.�Manufacturing
no employees. [No workers'comp.insurance rryuuxd]•
4.❑ We are a non-pro6t organizadon,statfed by volunteers, I 1.❑Health Caze
with no employees.jNo workers' comp.insurance req.] 12.0 Other
"Any applicant Naz checks boz#t must also fill out 16e sation below ehowing their wmkers'�mpeusation policy infaimation.
"•If the uxporate officers 6ave ezempted t6emselves,but dre co'pmation hes oUur employces.a wodcers'compensntlon poticy is required md such an
organintion should check boz Mt.
I am an eixployer that is providing worJrers'compensadox insurnuce for my employees. Below is the policy informatiox.
Insurance Company Name: New Hamshire Insurance Company
175 Water Street
lnsurer's Address:
New York, NY 10038
City/State/Zip:
WC043409060
Poticy#or Self-ins.Lic.# Expiration Date: Ol/Ol/2015
Attac6 a copy of the workers'compensalloa poticy declaraHon page(showing the poticy aumber and expiraiion date).
Failure to secure coverage as required under Seckon 25A of MGL a 152 can lead to the imposirion of criminal penalries of a
fine up to$I,i00.00 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 violatoc Be advised that a copy of this statement may be forwarded to the Office af
Investigaaons oF the DIA for insurance coverage verification.
I do heseby ce ' ,un r th pains and pexaltie�ojperjury thru tlbe injormatian prwdded above is true and cora�ect
_.
12-15-14
Si ture: Date:
Phone#: 40 770-
OJ�cia[use only. Do not write in this areq m be completed by ci}y or town ojJ"iciat
City or Town: Permit/Licease#
Issuing Authority(circte one):
1.Board of Health 2.Building Department 3.CftytTawn Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mess.gm,�dia
,4co� CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDIYYYY)
� ,ti,9,�,<
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, IXTEND 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) m t be TION IS WAIVED,subject W
the terms a�M conditions of the policy,certain policies may require an endorsement. sfate i dces not confer rights to the
certifcate holder in lieu of such endorsemenys).
PRODUCER CONTACT
M4RSH USA,INC. NAME:
99 HIGH STREET PNONE � Na.
eosroN,rnn ozno EMA�� LTH DEP
Atln:CVSCaremaAc.CeitRequestQmarsh.can Faic212-94&5338
INSURER 5 AFFORDING C NAIC p
SO2406ALL-GAW-ibi6 INSURERA: NewHampshielnsutanceCo. 23841
INSURFD INSURER B: ���I UNOII Fl211IS CA PItl5bI119h PA 1�J445
CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK WRPORATION wsursEn c:
AND RS SUBSIDIAPoES AND AFFILIAlES ir�,qunEre o:
ONE CVS DPoVE
WOONSOCKET,RI 02895 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NVG006095260.21 REVISION NUMBER:t
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NATH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1LTR T'/PE OF INSURANCE �DL S ppUCY NUMBER NMIODYIYYYY M�MIUDDIYVYY UM�
A GENexn�unelurr GL42678N1 01/0112015 01/0112016 EqCM OCCURaEncE y 4,500,000
X COMMERCIAL GENERAL LIABILITV � 7,000,000
PR IS o rteriw S
CWMSMADE � OCCUR MEDEXP(Myanepeison) S
X SIR: $5110,000 PERSONALBADVINJURV f 4•�•�
X LIOUOR LIABILf7Y INCLUDED GENERFLAGGREGA7E E 28•�•�
GEN'LAGCaRECaATELIMRAPPLIESPER: PRODUCTS-COMP/OPAGG S INCLUDED
x POLICV PR0. LOC s
B AUTOMOBILE WIBILITY �14J85(AO$) ���Q��2(11$ 01/07�2�iF) COMBINEO SINGLE LIMR ��0�
Ee accitlent
B X pNV AUTO 3614986(VA) O1I01R01S Ol/07@016 BODILY INJURY(Per peison) S
B ALLOWNED SCHEDULED 3g74987(MA) �1�01�7$ mro�rzms BODILVINJURV(PeraccitleN) 5
AUTOS FUTOS
NON-0WNED PROPERNDAMHGE S
X HIRED AUTOS X AU70S Per aaAtleM
SELF-INSURED PHY.DMG. z
UNBRELULIAB pCCUR EACHOCCURRENCE $
EXCESSLIAB CWMS-MAOE AGGREGATE 5
DED RETENTION $
({ WORKERSCOMPENSATON SeePageTwotmPdicyNurt�es Oi/01Y1015 OiPo7YL016 X wcsTaru- oni-
AND ENPLOVERS'W1BILffY - '
ANVPROPRIETORIPARTNER/EXECUTIVE Y/N E.L.EACHACCIDENT § Z'�'�
OFFICER/A9EMBEREXCLUDED? � N�A
�Mandatory in NX) E.L.DtSEASE-EA EMPLOV E Z•�•�
Ifyes tlesuibe untler z��
OESCRIPTIONOFOPERATIONSbebw E.L.DISEASE-POLICYLIMIT $
DESCRIPiION OF OPERNTION$I LOCATIONS I VEXICLES (AttaM ACORD 101,AEtlitional Rema�lu SchMW¢,H mom spaca Is reqWrW)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EXTENT RE�UIRED UNDFR THE
LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIWS LOCATIONS,STORE iti61,735&944.
CERTIFICATE HOLDER CANCELLATION
THE TONRJ OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:BRUCE MURPHY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
BOARD OF HEALTH ACCORDANCE WITH THE POLJCY PROVISIONS.
N46 ROUTE 28
SOUTH YARWOUTH,MA 02664
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M Marsh USA Ina .
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�1968-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORO
AGENCY CUSTOMERID: S02406
LOC#: Boston
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ACORO ADDITIONAL REMARKS SCHEDULE Page z of s
AOENCY NANEOINSURED
MARSH USA,ING CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CORPORATIINJ
vouCv Nureeen AND ITS SUBSIDIARIES AND AFFILIATES
ONE CVS DRIVE
WOONSOCKET,RI 02895
CARRIER NAIC CODE
EFFECTVE OATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REAAARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TRLE: CertiFicate of Liability InSuranCe
WORKERS COMPENSATION DEDUCTIBLE PROGRAM:
POLICY DATES:JAN 1,2015 TO JAN 1,2016
Ins.Co. PoGcy# SWtes Covered
A 011 9 5 311 2�MN) MN
A 011953116 ND,WA,WI,N^!
A 011953110(PL) FL
A 011953109(CA) CA
A ON953115 IL,KY,NH,UT,V�
A 011953113(A� AZ
A 011953117(AOS)AL,AR,CO3 DE,GA,HI,IA,ID,IN,KS,lA,MD,MI,M0,MS,MT,NE,NM,NV,NY,OK,OR SC,SD,TN,
rx wv
A 011953114(PA) PA
A 01195311(ME) ME
EXCESS WORKERS COMPENSA710N PROGRAM
POLICY�ATES:JAN 1,2015 TO JAN i,2016
B 9883930 DC,MA,OH,PA
B 9883931 CT,NC,NJ,VA
Ezcess Wmkers CompensaWn Sett�lnsured ReleMbns:
DC,M4,OH,PA: $50D,OD0
CT,NC,NJ,VA: $1,000,000
COVERAGE A:WoAceis Compensalbn:StaWtory
COVERAGE B:Empbyers LiabiFty Limi�s:E500,000/$500,000/5500,011�
COMh9�N POLICY CONDITIONS
A.Cancellation
2.We�CarterJ may cancel 1h¢pdicy by mailing w tlelivery lo ihe h5l Name0lnsured wrillen no6ce of cance9a6on at kast:
a.10 tlays befae the efiectire tlak olcancellaM1on il we cancel for non paymenl of premium
1�GenerW LiabJity ACdiAonal InsureA-Where Required Under CoMraci or Agreement language per en0orsement 61712(77/06�:
SECTION II-WHO IS AN INSURED,is amende�m indutle as an a0di6onal insured:
My person or o�gani�on lo wlrom you bemme odga�tl b include as an aEdNonal msured uMer ihis pdicy,as a resull of any conVacl or agreement you enter inlo which requires you w tumish iraurarp;e lo ihat
parwn a organi�ion of ihe type pmvided by ihis policy,but only wilh respeq to IiaDiNry ansing oul ot youroperat'nms or Dremius ownetl by w rentetl lo you. However,Ne insurance provideG wBl not exmed�he Icsser
a:
�The coverage artbr limils M ihis polity,or
�The co.erege ardlor Nmils requireG by sad mn6act ar agreement �
2)General LiabiVry EaAier Notice of CanceRaM1m Pmvidetl By Us lam,�uape per en0orsemeM CG 02 2410 93:
ACORD 101 (2008/01) �2006 ACORD CORPORATION. All rights reaerved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMERID: 502406
LOC M: Boston �
ACO� ADDITIONAL REMARKS SCHEDULE Page s ot s
AGENCY NAMEDINSUREp
MARSH USA,INC. CVS HEALTH CORPORATION
FORMERLY KNOWN AS CVS CAREMARK CIXtPORhT10N
vaucr uuraEa AND ITS SUBSIDIARIES AND AFFILIATES
ONE CVS DRIVE
WOONSOCKET,RI 02895
cannim ruuc cooe
EFFECTIVE DATE:
ADDI710NAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, .
PORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Num6er of Days'Notice 90
Far any stalutorily pertnitled reason other ihan nonpayment of D�mium,ihe number of days required for notice of cancdlation,as proviietl in para�raph 2.of either tlre CANCELLATION Common PaNcy Cantlition or as
amended by an apptica6le slale cancellation mitlorsemenl,is increased lo ihe number of days shown in Ne Scl�edule above.
3)General Liahildy Pdvance of Cancellalion to En66es ONer The Nartred Insured Limited to E-Mail No6ficalbn per ChaNs Manuscnpl enUorsement
In Ihe event ihat tlie Iraurer cancels ihis policy for any reasan oMer Man non payment af prenium,antl
7. The cancellatlon eHecbve tlak is pna W Nis policys expira6�n tlate;
2. The Fust Nametl Insuretl is untler an e�tisM1�contracWal obligation to notify a certifca�e holtler when Ihis policy is cancelled(hereinaRer,Ne'certificale Hdde(s)'�;and has provitled to ihe Insurer,eilher tlirectly or
Nrough 0s broker oF recorQ ihe email adOress of tAe contaci at such entity,
and Ne Insu2r received ihis ink�matlon aRer Ne First Named Insuretl receivetl notice Mcanceliation of Ihis polky aM prior W tl�is policys cancella6on eRec1ive date,via an elec6onic spreadsheet iha[is acceptab�b
Me Insu2r,
Ne Insu2r will provtle a�lvice of caicellation(ihe°Advbe�via e+nail to such CeNficale Iblders.
Proof of Ne Insurer emading ihe Advice,using ihe intomation povidetl under Nis pdicy by the First Nametl Insure4 wik urve az proof Mat the Insurer has fully satlsfietl i�s obligalions under ihis entlqsement
This endorsement does not afieq,a�any way,covaage provided under tl�is potiq or tlie cancdlation of Nis policy or tl�e eHective date Meraof,iwr shall ths entlorsemen�imest any nghls in any enfily not insuretl wUar
tl�is policy.
The filbwing Defindqns apply to Nis endorsemenC �
1.Firsl Nmred Insu2d means Ne Nametl Insured shown on Iha Declarations Page of Ihis policy.
2.Insurer means d�e insurance company shown m ihe header on ihe Declarations Page of Nis poliq.
All otlier�ms,condilbns antl ezclusiais shall remain Ihe sama.
ACORD 107 (2006/01) . . �2008 ACORD CORPORATION. All righis reserved.
The ACORD name and logo are registered marks of ACORD