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Home My WebLink AboutCVS Pharmacy 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: RETAIL FOOD In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. CVS PHARMACY INC. Whose place of business is: CVS PHARMACY #1866 261 CHAUNCY STREET PERSON(S) IN CHARGE: ERIC FURTADO, MANAGER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RF-4 BOARD OF HEALTH MichaeC-%UCCean, Chairman Milk & Cream O Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: CVS PHARMACY INC. having a place of business at: CVS PHARMACY #1866 261 CHAUNCY STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: RF-4 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued RF-4 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address CVS PHARMACY #1866 261 CHAUNCY STREET 3) Establishment Mailing Address (if different) ONE CVS DRIVE, LIC. DEPT WOONSOCKET, RI 02895 4) Establishment Telephone No (5 5) Applicant Name & Title DONNA CHEVALIER 6) Applicant Address 7) Applicant Telephone No.: 339-6711 ONE CVS DRIVE, WOONSOCKET, RI 02895 (401)770-2278 24 Hour Emergency No.: (401) 765-1500 (508) 339-8914 8) Owners Name & Title CVS PHARMACY INC. 9) Owner Address (If different from applicant) ONE CVS DRIVE MC1160 WOONSOCKET, RI 02895 Owner's telephone number (401) 765-1500 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. fi A Corporation Name Title Address An Individual - -SEE- -- - --- _ - APartnership ATTACHED ---- - Other legal Entity--- -_ _--- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ERIC FURTADO, MANAGER Address: 1261 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: FAX: E-mail: Alt E-Mail: 508) 339-6711 24 Hour Emergency No: (401) 765.1500 (508) 339-6914 ION NA.CHEVALIER(cDCVSHEALTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: 'KAILLY THULL, DISTRICT MANAGER Address: L Telephone No: (401) 765-1500 24 Hour Emergency No (401) 765.1500 i FAX E-mail: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) I 16) No. of. Food Employees: 1 7) DAYS/HOURS: M-SAT 8 AM-9 PM SUN 8 AM-7 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ 20) Location: ❑d Permanent Location 22) Establishment Type Mobile Mobile Start Date: [y] Retail ( 8,145 Sq. Ft) Moblie End Date: Mobile Comments: 21) Length of Permit: JI Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 !,. ] Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 [j Milk & Cream $10.00 [_ jI Mobile Food & Consession $75.00 �] Manufacture Frozen Desserts/Ice Cream `- $25.00/freezer ❑] Pushcart $25.00 # of Pushcarts: 0 I _] Residential Kitchen $100.00 C] Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (lime4emperature controls required) Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) RTE- ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing) IV Sale of Commercially Pre Packaged Non-PHFs I; Sale of Commercially Pre -Packaged PHFs �,...I Delivery of Packaged PHFs I Reheating of Commercially Processed Foods for Service Within 4 Hours [. I Customer Self -Service of Non PHF and Non - Perishable Foods Only F I Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer [_] Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged f Retail Sale Offers RTE PHF in Bulk Quantities ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service LI Retail Sale of Salvage, Out -Of -Dale I____ _ _ _. __ or Reconditioned Food To be completed by the Board of Health -- - _-- __-- - _ Total Permit Fee: $100.00 Payment is due with application ❑ waived 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 o tat copies of 105 CMRMT000 and ire federal Food Code. 24) Signature of Applicant: `�I IIM\.kA �VI�tiVCi ,J U 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. 25) Social Security Number or Federal ID: 05-0340626 A 26) Signature of Individual or Corporate Name: 0 Vo I/ II Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: CVS PHARMACY #1866 ADDRESS: 261 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-6711 FAX NUMBER: OWNER OF BUSINESS (401)652-0616 CVS PHARMACY INC. TELEPHONE OF OWNER: (401) 765-1500 FEDERAL ID/SS NUMBER: 05-0340626 FEE: $10.00 PERMIT NUMBER: RF-4 �� SIGNATURE: a,,`!jj/�__— DATE: I 1 2 6 - ( / 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. Lv A)(ozy-�4� - A Signature of Inclividual or Corporate Name By: Corpor40fffifice4andatory, if Applicable) Melanle K. Luker 11 Assistant Secretary n 4o ) \ .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. R:\Healtb\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth ofli'fassachusetts UlfDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lel?ibly Business/Organization Nan Address: i (. I C. City/State/Zip: Phone dal Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with _ employees (full and/ 5. KRetail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ 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 4. ❑ no employees. [No workers' comp. insurance required]* We I LE] Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 ran an employer that is providing worker ' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: I I) b Policy # or Self -ins. Lic. #_ 1`� `� _ Expiration Date: ) Attach a copy of the workers' compensation policy declaration page ootowing 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 hnprisonmenf,- as well as civil penalties in the forrtfaf a STQP WORK ORDER and. a fine = _, of up to $250,00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. _._ ._ I do her•eo _rerkly, under the pains the information provided above is true and correct. " Date' �� /� �� Signature y\ Phone #: 3� 01 " 4 C, 15 i Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE (MWDORYYY) 191Dolnn Is THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificato holder is an ADDITIONAL INSURED, the policy(ios) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate tlBe$ not confer rights to the certificate holder in Hou of such endorsement(s). PRODUCER CONTACT MARSH USA, INC. AME _ 99 HIGH STREET PHONE-^�--------- gli`E.nl— BOSTON. MA 02110 E•M� Ann CVSGaremark.CvIRequw@marsh core Fax.212-948 5330 oB.WS ._ APFGR0ING COVERAGE INSURE8I41 -- NA lap S02406 ALL_GAW-17.78 WA INSURER q: Mfp INSURED - CVS HEALTH CORPORATION INSURER D. XL InSUranae America IOC 2455d _ INSURER c: XL Specially insurance Company --- 37885 INSURER D : WWCVS DRIVE. MC 2190 'ONSOCKET, RI 02895 O INSURER E: HSVRER F: nVCOA ACO -11 nnnr-n. ............... ... .... 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 TR _TYPE OG INSVRANCE ADDLISUBR POLICY NUMBER POLICY EFP MMIDDMNY P T OUCYEXP , MMIDO/YYTy '—"—— LIMITS COMMERCIAL GENERrAL LIABILITY CLAIMS -MADE L,U OCCUR EACH OCCURRENCE DA AMT RELATE ' P SES Ea unonce g S__ MEP EXP Rry ane person) --I S PERSONAL S ADV INJURY _ $ ` GENL (_ AGGREGATE LIMIT APPLIES PER PRO. POLICY JF.CT I� LOC GENERAL AGGREGATE S PRODUCTS. COMP/DIP AOG --- S �_-- CO!l BINEO SINGLE LIMI 5 — i1B AUTOMOBILE OTHER'. LIABILITY AAUTO _ AOSCHEDULED TOSS AUTOS AUTOS HIRED AUTOS AUTOS NEO j AUTOS BODIIv fNJURV (Per pnrson) -- DIMLY INJURY (Per ecriuenp PROPERTY DAMAGE Per acuegCl S -----. _ 5NO i -'--"—'— S �_ b UMBRELLA LIAR EXCESS LIAe OCCUR CIAIMS,MADE'� - —I EACNOCCURRENCP 5 AGGREGATE -- $ DED RETENTIONS $ --- —"- CIWORKERS I COMPENSATION ANDEMPLOYERSUAOILDY YIN ANY PROPRIETORIPARTNERIEXECUTIVF. N iNIA OFFICEHMEMBER EXCLUDEC'> (Mandamry In NU) II yyB6 tlesflibe Lntle, DESGIRIPTIO.N OF OPERATIONS Eelem ( See Page TWO lot POICY Nuncans IOt101R017 0U01120 88 ,.. X PER TH- F..L. EACH ACCIDENT _ — 5 2.000,000 E L DISEASE - EA EMPLOYEE S 2,00D,GOP E.L. DISEASE - POLICY LIMIT 15 _ 2,000,Op0 I DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, AUrfitkm l Remarka Schedule, may DIP amcheU If more space Is regvireVi CERTIFICATE HOLDER CANCPII ATH-IM CVS HEALTH CORPORATION, FORMERLY S1 AS CVS CAREMP.RF.COP,PORATIOM AhiD ITS SUTI$UB$IIJIP.RIES AND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE AFFILIATE$ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WITH THE POLICY PROVISIONS. GI:E CV:, DRIVEACCORDANCE WOONSOCKE. RI 02895 AUTHORIZED REPRESENTATIVE --^� W Mari11 USA Inc. Yevgenna Muyamma 9 ISSS-curs AFORE) COMPURA I IUN. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ENTITY NAME: CVS Pharmacy, Inc. Personnel Name Management Title Home Address Business Address Phone Helena B. Foulkes President 12Q Brown St. Providence RI 02906 One CVS Drive, Woonsocket, RI 02895 401-765-1500 Carol A. DeNale Senior Vice President/Treasurer 75 Poplar St., Watertown, MA 02472 One CVS Drive, Woonsocket, RI 02895 401-765-1500 Thomas S. Moffatt Vice President/ Secretary 29 Homestead Circle, Kingston, RI 02881 One CVS Drive, Woonsocket, RI 02895 401-765-1500 Linda M.Cimbron Assistant Secretary 45 Bridge Street, Warren, RI 02885 One CVS Drive, Woonsocket, RI 02895 401-765-1500 Melanie K.Luker Assistant Secretary 9 Coldbrook Drive, Cranston,Rl 02920 One CVS Drive, Woonsocket,R1 02895 401-765-1500 Jeffrey E. Clark Assistant Treasurer 2 Joy Lane, Hingham, MA 02043 One CVS Drive, Woonsocket, RI 02895 401-765-1500 **CVSHealth Dear Sir/Madam: One CVS Drive Woonsocket, RI 02895 Enclosed please find completed application(s) and/or 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 anv changes made on the annlir_ati„n ranarw"" fr..4e maKe the necessary copies for my posting. Fier receiving the licenses, I v the originals to the stores for If you have any questions, please contact me at 401-770-2278 or by fax 401-652-1280. My e-mail address is: donna.chevalier@cvshealth.com Sincerely Donna Chevalier Licensing Coordinator One CVS Drive/Mail Code 1160 Woonsocket RI02895 CVS Pharmacy / caremark / minute clinic / specialty