Loading...
HomeMy WebLinkAboutCVS Pharmacy #1866 - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. Whose place of business is: Permit Expires: MASSACHUSETTS CVS PHARMACY LLC CVS PHARMACY #1866 261 CHAUNCY STREET June 01, 2010 License Number: RF-49 Food Fee: $50.00 Milk & Cream W BOARD OF HEALTH Permit for the Sale Dr. Raymond Martin, Chairman Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: License Number: Permit Expires: BOARD OF HEALTH CVS PHARMACY #1866 261 CHAUNCY STREET RF-49 June 01, 2010 Dr. Raymond Martin, Chairman Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CVS PHARMACY #1866 LOCATION OF SALE OF TOBACCO PRODUCTS: 261 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8914 OWNER OF BUSINESS: MASSACHUSETTS CVS PHARMACY LLC ADDRESS OF OWNER: ONE CVS DRIVE, WOONSOCKET, RI 02895 TELEPHONE OF OWNER: (401) 770-5772 FAX NUMBER: (401) 652-0608 If a corporation or partnership, give name, title, and home address of officers or partner. SEE AHED --- FEDERAL ID/SS NUMBER: 20-3621694 PERMIT NUMBER: SIGNATURE: DATE: 1 C 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., MASSACHUSETTS CVS PHARMACY LLC 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 June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 Li nse No.: RF-49 Scott Leite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred One CVS Drive I Woonsocket, RI 02895 July 16, 2009 Dear Sir/Madam: 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 application rekardine trade name and or mailing address, and include store numbers on invoices and permits as indicated on the application to insure correct payment to the proper store. Please send the permit(sMicense(s) and any future renewal applications for this store, with the store number on it, to my attention at: One CVS Drive LicensinjZ Dept., Mail Drop 23062A, Woonsocket, Al 22895, 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 401-770-5772 or by fax 401-652-0608. Sincerely Dianne L. Lackey Licensing Assistant Legal Department FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF-49 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: CVS PHARMACY #1866 2) Establishment Address 261 CHAUNCY STREET 3) Establishment Mailing Address (if different) 1 CVS DRIVE, LIC. DEPT. MAIL DROP 23 WOONSOCKET, RI 02895 A U) 2a�� jL 4) Establishment Telephone No: (508) 339-8914 5) Applicant Name & Title: DIANNE LACKEY 6) Applicant Address ONE CVS DRIVE, WOONSOCKET, RI 02895 7) Applicant Telephone No.: (401)770-5772 24 Hour Emergency No.: (401)231.5629( 774) 930-7748 8) Owners Name & Title MASSACHUSETTS CVS PHARMACY LLC 9) Owner Address (If different from applicant): ONE CVS DRIVE, WOONSOCKET, RI 02895 10) Establishment Owned By: ❑ An Association O A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address SEE ATTACHED 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 6? 24 Hour Emergency No: f/ _ FAX:/ 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: l } 24 Hour Emergency No: FAX: 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 Corporate Name (Mandatory) By, Corporate Officer (Mandatory, if applicable) * Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth 'gfMas,raclausetes I3e`Partment off'4dZIS rial Accidents I f Office Znve .fTz f stigaurzns 600 Washing,tart Street .> Easton, IM4 027I1 x�rnx? mess, ot!/dia , II Workers' Compeusation Insurance g 'iaavit. General B,.usin'esseS Applicant: informaaion P'iease Print. I,eoibhl Business/Organization Name: Address: Crne CVS Drive, Mail Drop 2306'2A i City/State/Zip: eT f 7Rg5 Phone #: -"G401YZ61,-1500 f F PL yo❑ an.employ:r? Cue the appropr:aiebob; Business T.ypa.(requiradJ I am aemployeradtltemployees (full and/ 5• x.Retail or part-time).°" I am a sole propr etor or partnership and haven 6' R`stauxaaf/$a LEai no psblikhment employees workine for me in. any capacity, ❑Office and%or Sale (mci. eal testate, auto, etc.) (No workers' comp, insurance required] R. ❑ Non-profit �.. ❑ We are a corporation and.its officers have exercise i their right of exemptionper c. 1'S2 4' 0 Entertainment§1(.'4), andwe'have 10,� NLMufactnainn no employees. )7vo workers' comp, insurance regtae 4. ❑ We are anan-profit cT9 ni,a4o y 'l1,0,Health Care j n .:siafied b :volunteers, with no employees. rNo workers' comp , tnst ratrclTq;] ME Other ' 'Any nppiicnnr Lint checks box Rl muscalsaM cue thesccporibclowshowingibcir Wo.1cm, coznpegsaiion oli -'If the corpomteofhice have exempwd thrntselves; but the co ozation1w older p °y'1°fOmjnu° I oressni>ation should check ban 91. employees; a:.worlcem, campemnuonpoiia1 s tcpiuized: and such an T anz an employer that is pruvLEzg i • r ''o,. u.,-ztrarce�.;,•;r, e, �-1 I Insurance Company Name._New Hampshire Insu� �`�' Pelrx:ictlza� tzeyz;.1- lnsuzer's Address: 70 Pine Strut ! Ciry/State/Zip: Iv w YDM, try 1.27C I Policy # or Self -ins- Lic. ; 6506290 Eapi anon Date: (11 .1 _ t t _ Attach a copy:ofthe workers" compensation, poiicy:declaration.page (�hmvitee titep©Iicy:nttmbe>j.and ex r Failure to secure cove age.as rcguired under Section 2' pi aeon date). fne up to $1,500.00 andlor one-year mtnisonmer t �A. o£ MGL c, T53 can lead+to the imoosifion of crivnznal penalties of a Of up to X250.00 a day against the violator. fie advised. that asdopy, of ch s statem�ni maw! ore STOP O �° ORDER and a line Lavestigau M of the D1A fnr. nsurance coverage verificaiion. 3 he fore*arded to e Ou ee of I do hcraiy certify a?TorJnauun:prnvsaed above rueiarx, zr or ilre, pains anzll 43naLtiec of aerjur thattrz ss .• r Phone #� .. hY//_ Of mial use ono% Da nor tvrire uz. this area, .ro be.'conzpfeied bl!'ciry or inron. offzcial Ciiy or Town: Pect>p3t2 icense Issuitza Authority (circle one): 1. Board of Health 1. Building Department 3. City/Town CLrit 'i Licensin�Board 5. 6. Other Contact 's Office "rv, v.n nss.eov/din Phone n: As of 7/1612009 Massachusetts Avenue CVS, L.L.C. Corporate Officers Name: Zenon P. Lankowsky Title: President Bus Address: One CVS Drive Woonsocket, RI 02895 Name: Carol A. DeNale Title: Vice President/Treasurer Bus Address: One CVS Drive Woonsocket, RI 02895 Name: Thomas S. Moffatt Title: Vice President/Secretary Bus Address: One CVS Drive Woonsocket, RI 02895 Name: Linda M. Cimbron Title: Assistant Secretary Bus Address: One CVS Drive Woonsocket, RI 02895 Name: Melanie K. Luker Title: Assistant Secretary Bus Address: One CVS Drive Woonsocket, RI 02895 CVSSTLLC Pagel of 1 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 17) 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 101112001 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 ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type 91 Retail ( 8,145 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $75 ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution Meals/Day) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 W Milk & Cream $2 ❑ Mobile Food & Consession $50 Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 It of Pushcarts: Residential Kitchen $25 Retail Food $50 Retail Snack Food $10 Tobacco Products No Fee 23) Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) M Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale 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 Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities _._.- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $50,00 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 obtain copies,4f 105 CMR 590.000 pO the federal Food Code. 24) Signature of Applicant: I ���i'�SEl' �— Pursuant to MGL Ch.62C, sec. 49 , I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 20-3621694 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns 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 June 1st of each year. NAME OF BUSINESS: CVS PHARMACY #1866 ADDRESS: 261 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8914 FAX NUMBER: (401) 652-0616 OWNER OF BUSINESS: MASSACHUSETTS CVS PHARMACY LLC TELEPHONE OF OWNER: (401) 770-5772 FEDERAL ID/SS NUMBER: 20-3621694 FEE: $2.00 PERMIT NUMBER: RF-49 SIGNATURE: 70'b y DATE: ?` W /�/