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HomeMy WebLinkAboutCVS Pharmacy #1866 - 12/31/2020—�a 7 00Gq II FOR BOARD OF HEALTH USE ONLY Permit # Issued ,'_ FOOD ESTABLISHMENT PERMIT APPLICATION "V 0 (Application must be submitted at least 30 days before the planned opening date) Establishment Name C, He 6 J Establishment Address a(Q� Cllw✓LG/ Establishment MailingAddress if different CVS/pharmacy ( ) One CVS Drive Mail Code 1160 Woonsocket, RI 02895 Establishment Telephone No -S— K2 r7� Applicant Name &Title: Stephanie Cadorette --VS/pharmacy One CVS Drive Applicant Address Licensing Coordinator fail Code 1160 Woonsocket, RI 02895 Applicant Telephone No.: `/&MOD-l/ D' 24 Hour Emergency No.: GIG/7(PS Applicant Email nonpharmacypermits@cvshealth.com Owner Name & Title (If different from applicant) Owner Address CVS/pharmacy One CVS Drive Owner telephone number Mail code 1160 Woonsocket, RI 02895 Owner email: nonpharmacypermits CV Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. rporation Name Title Address 11 An Individual ATTACHED A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 5�d 0`— NW- 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: / SEWAGE DISPOSAL: / DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Persons) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training 0- . (,�v?.) t Name of pest control company routinely inspecting the premises for evidence of pests ki ,r' If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. O Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: frAnnual etail Food $125.00 0 Mobile Food Consession Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ❑a Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 E] Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 0 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (fimeRemperature controls required) (Check all that apply): Non-PHF's - non -potentially hazardous /ood(no time/temperature controls required) ftTE - ready -to -eat foods (Ex. sandwiches, salads, mu/fins which need no turtherprocessing) -, ale o.11 ommercially Pre -Packaged Non-PHFs ] PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held r - e of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly - Delivery of Packaged PHFs ry ❑�. Sale of Raw Animal Foods Intended Susceptible Population Facility EJ Reheating of Commercially to be Prepared by Consumer ] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill 0 Offers RTE PHF in Bulk Quantities [J Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies 105 MR 590 aD d ffie, rat Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all stale tax returns and paid state taxes required under law. /� Social Security Number or Federal ID: /) ! F-� ,V / Signature of Individual or Corporate Name: �-jU/a f`-� -M e C.�r� TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. a U:s 0N� Signature of Individual or Corpor e Vame By. C rporate Office ( andatony, if Applicable) _��� *"Social Security No. (Voluntani) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �/ Please Print Letribly Business/Organization Name: CVS PHARMACY # d , Address: Phone J Are you an employer? Check the a propriate box: Business Type (required): 5. [0 Retail 1. 2 I am a employer with employees (full and/ or part-time).* 6. ❑ Restaurant/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. 8. ❑Non-profit 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 has other employees, aworkers' 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. Below is the policy information. Insurance Company Name: XL SPECIALTY INSURANCE AMERICA Insurer's Address: SEAVIEW HOUSE 70 SEAVIEW AVENUE City/State/Zip: STAMFORD. CT 06902-6040 Policy # or Self -ins. Lic, # RWD300122101 Expiration Date ( Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure 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 and penalties ofperjury that the information provided above rjr true and correct. 401-770-2112 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gowma CERTIFICATE OF LIABILITY INSURANCE o1 1812018orc Yl 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 I NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(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 MARSH USA, INC. 99 HIGH STREET BOSTON, MA 02110 Attn: CVSCaremark.CerlRequesl@Marsh.com Fax:212-948-5338 CONTACT NAME: PHONE FAX IAIC-110 Fall NC No: E-MAIL ADDRE S: INSURERS AFFORDING COVERAGE NAICN INSURER A: Greenwich Insurance Company 22322 CN101226639-ALL-X E&Q19-20 INSURED CVS HEALTH CORPORATION INSURER B : XL Insurance America Inc 24554 INSURER c: XL S ecialt Insurance Com an 37885 ONE CVS DRIVE MC2180 WOONSOCKET, RI 02895 INSURER D: Illinois Union Insurance Go 27960 INSURER E : INSURER F : GOVERAGES CERTIFICATE NUMBER: NYC-010399804-01 PPVIRInm MI IMBER: o 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 LTR TYPE OF ADDLSUBR POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACHOCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occunence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ AGGREGATE LIMIT APPLIES PER. PRO POLICY JECT LOC GENERAL AGGREGATE $ GEHL PRODUCTS-COMP/OPAGG S $ OTHER: A AUTOMOBILE LIABILITY RAD943782302 O1N1/2019 01/0112020 LEA EDSINGLELIMIT Ea acclden! $ 5,000,000 ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ XIX HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY - PROPERTY DAMAGE Per accident $ SELF -INSURED PHY.DMG. $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTIONS $ B G WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑N NIA See Page Two for Policy Numbers 01/0112119 0110112020 X PER OTH- STATUTE ER EL EACH ACCIDENT $ 2,OOQ000 EL DISEASE -EA EMPLOYEE $ 2,000,000 (MantlMorym NH) If yes, describe undr e E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS below D MCE&O- PRIMARY - MSP G71207353001 11/28/2018 11/2812019 LIMIT 10,000,000 Subject to SIRS for various perils DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of Insurance CVS Health Corporation formerly known as CVS Caremark Corporation and its Subsidianes and Affiliates One CVS Drive Woonsocket, RI 02895 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Yevgeniya Muyamina 'Oqgv�en,a JYLcc�am:_n.� i 91988-2016 ACORD CORPORATION. All rights no ACORD 25 (2016/03) s The ACORD name and logo are registered marks of ACORD d)\\)})) \) ƒ\\\\\\\ \0 \> \\\\\\\ \\///\/ // // d0000000 \NcE \}EE \� \/#{\/} !}j%©ZJ 3 J�,)/ \}\\ �}\ \ \ \\ \ z Li ( , )) »{§22\\ a} ` \ \ \um E 5 } Town of Mansfield r6 Park Row, Mansfield, Massachusetts 02048 Health Department I Amy Donovan -Palmer, MPH, RS, HeaAb Agent October 16, 2019 Retail Food establishment vendors: Your current food establishment permit in Mansfield will expire on December 31, 2019. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 27, 2019. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. 1. Food Establishment Permit Application (Attached) 2. Tax Certification Form (Attached) 3. Workers' Compensation Insurance Affidavit: General Business. (Attached) 4. Workers' Compensation policy declaration page The Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address for all positions. As a retail food establishment, the following fees may apply: $125 Reta0/ood Establishment • $10 MilkAnd Cream re are several new requirements based on the MA DPH adoption of the 2013 FDA Food Code. The following documents must be on site during inspections. 1. Vomit and Diarrhea Clean up Procedure (example attached) 2. Pest Control contract and/or receipts from routine inspections of the premise The Plastics Waste Reduction bylaw is now fully in effect. According to this by-law, no retail establishment shall provide thin-film, single -use plastic check-out bags. Check-out bags can only be a 100% recyclable paper bag containing at least 40% post -consumer recycled content or a reusable check-out bag. Phone (508)261-7366 Fax (5O8)261-7425 Emailadpalnrer maitsfieldoia.coni Please contact the Health Department if I can be of any further assistance. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Food Establishments Fee Caterer $35 Milk & Cream $10 Pushcart $50 Manufacture Frozen Desserts/Ice Cream per freezer $25 Mobile Food $100 Residential Kitchen $100 Retail Snack Food, no PHF $50 Retail Food $125 HACCP review and approval $100 Restaurants Seating up to 100 $175 Restaurants Seating 101-200 $250 Restaurants Seating 201+ $300 Supermarket $400 Farmer's Market $25 Temporary (per day) $50 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) Any establishment that generates FOG and does not have FOG containment $50 Critical Violation re -inspection fee $100 Plan review $100 Tobacco and Nicotine Delivery Products $150 Health. RE: License Renewals Dear Sir/Madam: Enclosed please find completed application(s) and/or appropriate payment(s) for the License Renewal(s). Please note any changes made on the application(s). When/if new license(s) is/are issued, please send it to Mail Code 1160 at the address below. After making the necessary copies for my files I will forward the originals to the stores for posting. Thank you for your cooperation in this matter. If you require additional information or have any questions, please contact me at 401-770-2112 or email SLaScolaC�CVS.com. Sincerely, S&Akaare zaScda ead&wft Stephanie LaScola Cadorette Licensing Coordinator One CVS Drive MC 1160 Woonsocket RI 02895 Enclosure(s) Christopher George From: Lascola-Cadorette, Stephanie <Stephanie.Cadorette@CVSHealth.com> Sent: Friday, November 15, 2019 3:08 PM To: Christopher George Subject: RE: Mansfield Board of Health - Food Establishment Permit Application Ecolab handles the pest control for the state of MA. Stephanie Lascola Cadorette ( CVS Health I Licensing Coordinator I Office: (401) 770-2112 1 Fax: (401) 429-6501 1 One CVS Drive, MC 1160, Woonsocket, RI 02895 1 Stephanie.lascola@CVSHealth.com From: Christopher George[mailto:ceeoree@mansfieldma.com] Sent: Thursday, November 14, 2019 1:58 PM To: Christopher George <caeorge@mansfieldma.com> Subject: [EXTERNAL] Mansfield Board of Health - Food Establishment Permit Application To Whom It May Concern, You've recently submitted a Food Establishment Permit Application to the Mansfield Board of Health. We are unable to process your application until the following items have been remitted: Name of Pest Control Company routinely inspecting the premises for evidence of pests. Please let me know if you have any questions. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. 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