HomeMy WebLinkAboutCVS Pharmacy #1866 - 12/31/2021goq 6
/�'jI
11 FOR BOARD OF HEALTH USE ONLY Permit # Issued( rbA. 11
FOOD ESTABLISHMENT PERMIT APPLICATION max:
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name Cv t �(dyy\, $��
�aw1 CVS/pharmacy
i
Establishment Address �67 One codde 6
1 t
Establishment Mailing Address (if different) Mall coe eR
Woonsocket, RI 02895
Establishment Telephone No
Applicant Name & Title: Stephanie Cadorette L CVS/pharmacy
Licensing Coordinator one CVS Drive
Applicant Address Mail Code 1160
Woonsocket, RI 02895
Applicant Telephone No.: 24 Hour Emergency No,: Applicant Email L q sc'o CvS C�
nonpharmacypermits@cvshealth,COM
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number CVS/pharmacy
One CVS Drive
nonpharmacypermits@cvshealth,corn Mail Code 1160
Owner email: Woonsocket, RI 02895
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
O An Association
partner.
orporation
Name Title Address
'J An Individual
I] A Partnership
A Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: �� ( c �v1r t S � ('
Address:
Telephone No:-,) 3�5 /q 24 Hour Emergency No:
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable) _D/ S f IC J �
�
Name &Title: C1p�(7�_.
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
II l (�
SEWAGE DISPOSAL: Q
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
Name of Person(s) In Ch^^arJJg Certified in Food Protection Management:
Vv��
Name of Person(s) In Charge Certified in Allergen Awareness Training
dIrt`�
'^
Name of pest control company routinely inspecting the premises for evidence of pests Lett ti-
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. 9 Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
Retail Food $125.00 Mobile Food Consession
3 Temporary
FFood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream
r3
Temporary Start Date:
❑-1 Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
'❑I Food Service up to 201 + $300.00 eL Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 i=; Caterer, $35.00
Food Operations: Definitions: PHF - Potentially hazardous food((imeRemperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous(ood(no time/lemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
ommercially Pre -Packaged Non-PHFs Q PHFCooked To Order I] Hot PHF Cooked and Cooled or Hot Held
(or More Than a Single Meal Service
fCommercially Pre -Packaged PHFs Preparation of PHFs For Hot Andry
tD,Il,,
Cold Holding For Single Meal Service ira PHF and RTE Foods Prepared For Highly
of Packaged PHFs
❑3 Sale of Raw Animal Foods Intended Susceptible Population Facility
E 3 Reheating of Commercially to be Prepared by Consumer I] Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Q Customer Self -Service
Customer Self -Service of Non PHF and Non - contact alternative, time as a public health
control)
Perishable Foods Only r1 Ice Manufactured and Packaged for
Preparation of Non-PHFs Retail Sale Q Offers Raw Or Undercooked Food Of
E] Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale E= Vacuum Packaging / Cook Chill
Offers RTE PHF in Bulk Quantities Q 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 of 1 CM 590.000 tl , fe ® r�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 state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/OrganizationName: CVS PHARMACY
A AA, - ;:)-L' t'l1
Phone #: J � 3� �' � 7
Are you an employer? Check the appropriate box:
1.9 I am a employer with employees (full and/
or part-time). *
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
workers' comp. insurance req.]
Business Type (required):
5. [2 Retail
5, ❑ Restaurant/Bar/EatingEstablishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I l.❑ Health Care
12.❑ Other
with no employees. LNo
*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, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: XL SPECIALTY INSURANCE AM ERI CA
Insurer's Address: SEAVIEW HOUSE 70 SEAVIEW AVENUE
City/State/Zip: STAMFORD, CT 06902-6040
RWD300122101
Expiration Date
Policy # or Self -ins. Lic. #
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 a i
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 aga nst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage vercation.
I do hereby certify, under the pains and penalties 0 erjury that the information provided abo a is t/rue and correct.
/- �19 d e.e to.
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.gov/dia
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
VocI have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
I/ I have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
I/ I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature Akwrav � Date: it /v
Applicant Name (please print clearly)
Licensing Coordinator
`Al ��® '
�/ CERTIFICATE OF LIABILITY INSURANCE
DATE IYYYY)
ltizo/2019
lzols
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If $UBROGAT(ON 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.
CONT A T
NAME;
FAX
PHONE we No:
99 HIGH STREET
E-MAIL
BOSTON, MA 02110
Alin: CVSCaremark.CedRequesl@Marsh.com Fax:212-948-5338
ADDRESS:
INSURERS AFFORDING COVERAGE
NAICN
INSURER A: ACE American Insurance Company
22667
CN701226639—X E&O-20-21
INSURED
INSURER B: Indemnity Insurance Company of North America
43575
INSURER C : ACE Fire Undelwdiers Insurance Company
20702
CVS HEALTH CORPORATION
AND ITS SUBSIDIARIES & AFFILIATES
INSURER D : Illinois Union Insurance Go
27960
ONE CVS DRIVE
INSURER E :
WOONSOCKET, RI 02895
INSURER F :
...... .........nn.n n nC\/ICl/lAI \II IaaDCD• d
COVERAGES umm nrl.m lc 1. \.\.,L,"., ... _------- ._.-
OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT
WITH RESPECT
TO WHICH THIS
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED, HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND CONDITIONS
ADDL SUER POLICY EFF POLICY EXP
LIMITS
INSR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDIYYYY
_
LTR
A X COMMERCIAL GENERAL LIABILITY XSLG71567850 01/oV2020 01/01/2021
EACHOCCURRENCE
$ 4,500,000
DA RENTED—
PREMISES (Ea occurrence)
$ 1,000,000
CLAIMS -MADE � OCCUR
X
MED EXP(Any one person)
$
SIR: $500,000
4,500,000
X LIQUOR LIABILITY INCLUDED
PERSONAL &ADV INJURY
$
GENERAL AGGREGATE
$ 28,000,000
GENT AGGREGATE LIMIT APPLIES PER:
INCLUDED
X pR0- ❑ LOC
❑
PRODUCTS - COMP/OP AGG
$
POLICY JECT
$
OTHER: 0110112 220 01/01I2021
ISAH2529449A
COMBIGLE LIMIT
Ea accident)
$ 5,000,000
A AUTOMOBILE LIABILITY
INJURY (Per person)
BODILYLY INJURY
$
X ANY AUTO
OWNED SCHEDULED
BODILY INJURY (Pet accitlenl)
$
AUTOS ONLY
PROPERTY DAMAGE
$
X X NON OVYNED
Per accident
AUTOS ONLY AUTos ONLY SELFINSURED PHY.DMG.
$
EACHOCCURRENCE
$
UMBRELLA LIAB
OCCUR
$
AGGREGATE
EXCESS LIAB
CLAIMS -MADE
DEO RETENTION$
See Page Two for Policy Numbers
0110112021
X STATUTE OEftH
B
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
E.L. EACH ACCIDENT
$ 2,000,000
2,000,000
ANYPROPRIETORIPARTNERIEXECUTIVE
NIA
OFFICERIMEMBEREXCLUDED9 LN]
EL.DISEASE - EA EMPLOYEE
$
(Mandatory In NH)
If Yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 2,000,000
D
MOE&O- PRIMARY
MSP G71207353001
11/28/2018
0413012020
LIMIT
10,000,000
Subject to SIRS for various perils
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CVS HEALTH CORPORATION
AND ITS SUBSIDIARIES 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.
Manashi Mukherjee
Cc> 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Q
0
o
Q
o
0
Q
Q
Q
d-
�t
0
�r
0
v
0
a
0
�
0
a
0
a
0
v-
0
0
0
O
O
NO
N
NO
O
N
N
N
v
N
N
N
u
N
.0
N
Y
O
>O
O
>O
O
O
O
O
O
O
O
O
O
O
O
>O
O
O
>0
U
C0
U
0
U
>>0
U
>>0
u
>O
U
>0
U
>O
U
0
010
0
010
0
0
Q
O
m
N
O
M
O
O
0
O
a�i
u
C
m
2i
fO
U
E
LL
E
U
o
C
ai
AllU
�_
Y
ai
—W
Y
Q
O
ro
U
vyi
O
UJ
C
O
Y
i
O.
h
E
m
O
U
a
S
4i
=
v
m
m
v
�
�
C
v
u
u
u
v
LU
C
J
v�
a
O
Z
w
N
U
Y
U
:�
s
2
v
w:E
O
vj
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.
Signature of Individual or Co
Toiate
Name
By: Corporate Officer (Mandatory, if Applicable)
**Social Security No. (Voluntary) 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:\Userslsleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc