Application and WC' TOVYN OF XARMOIITH BOARD �AL'F$
APPT.TCATiONFOltLICL1VSE/PE�= a r �,` a I�uv 'L 11013
" *Please complete form azui attach all ne.cessary dd 4 I�IE,qLTH DEPT.
Failura to do so will result in the roturn of yodr ap on pac et.
NAMEOFESTAHLI$IiMLNT: Dunkin' Donuts TEL.#�
LOCATIONADDRESS:��S(t'F. Main Street
MAILINGADDRESS:�R9 Main CfrPat S on�+,�m MA�$(�
. OWNER NAM$:_ Salvi Cnut� � TAX TD(,��IN or SSNI. 07 07RqqdR
CORPORATION NAME(IF APPLICAHLE):[`�oe Man�gement Team LLG
MANAOER'SNAME:_.._C)An M?�n.fLa�d TEL.# 781_974_0?90
, MAILIxGADDREss: �ao nn�;., cr�oet-Stnneham AA/ti02184
POOL CERTTFICAI'IONS:
The pool aupervisor mnst be certified ae a Pool Operntor,as required by Stnte lew. Please list the designated
Pool Operator(s)and attach s copy of the certificatlon to t1�1s form.
1. 2,
Pool operators must Bst a minimum oPtwo emplo ees currently certified in basic water sefety,standsrd Fust Aid and
Community Cardiopolmonary Resuscitation(CP�,1'lease list theae employees below and attachcopies ofemployee
certificarions to this form. The Health Department wiU not use past ycars'records. You must provlde new
copies and mnlntafn�tile at your place oF buainess.
1. q,
3. _4.
FOOD PROTECTION MANAGEItS-CERTIPIGAT'[ONS:
Ali food service establishments are required to have at least one futl-time employee wbo is cenified as a Pood
Pirotection Manager,as dafined in the State Sanitary Code for Food Service Establfshments, ]OS CMR 590.000.
Please attech copies ofcenification tp this application. TBe Heak6 Depertment will not use past years'Eecords,
You muat provide new copies and maintnin e 141e at yonr establishment.
�, Denise Russell Cook 2. ;
PERSON IN CHARGE:
Each food establishment m�ut hsve at least one Person In Charga(PIC)on site during hours of operation.
1 Denise Russell Cook 2
HEIMLICH CHItTiFICATIONS:
All food service establishmenta with 25 seats or more must have at teast one emp]oyee trained in the Heimlich
Maneuver on the premises at all times. Please list youremp toyees trained in and-choking procedures below and
attach copies of employee certificnriops to this form..The Heelth Department will not use pest yexrs'records�
You must provide new copies and maintaln a file nt your place of bualness.
1. ' 2,
3, 4.
RESTetURANT 9F,e4TING: TOTAL# �
LODGirrG; OFFICE USE ONLY
� LtCENSBREQUIRED F68 PERMff# LICENSCRHQ[J11tED FGE PERAi1TN LICENSEI2EQUIREU FEE PERMITN
�B&B S55 _ _G�p1N 555 � _,MOTA, � S55 �
. _JNN. S55 _CAMI+ S55 __. _SW1tvfA9NOP00t SBOea
_LODCE S55 _Y'tWll,EgPARK SI05 ._ _WHIRL1+pOL SBOn.�_
aoon ssev�c�e:
- L1C$NS�RF,QURFED FGE PF,1tMIT# -L[CENSEREQUQtGD TFx PSRMITR LiCGNSBREQUIRBD FEE�-�PQLMI'f�p � � .
L,b100SBpT$ $65 �'��}"bYI _CONfQJEMfqL S35 �,_ �NON-PROFiT 330 . .
, � �>I0096ATS 5160 �COMb10NVIC. $GO � �._K710LESAL£ 880 � -
� `- HETAI.LSERVICB: � �RESID.KifCFIEN 580 � .
. , . � LICSNSBREQUIltED £NS PERM17# LICENSERF,QUQtED FEE PERMITA LICENSEREQIIIRED FEE .PERMTfri �
. � . _„cSOtq.R S50 _>2S,OOOsq.& $125 ___ _VENDINO-FOOD E25 .. � . . ��
� _Q5,000-sq.R. S80 _ ,FROZENDESSHItT&f0 �TOIIACCO S55 . � � � �
. NAb1ECIYANGE: . .513 . . . . . � � . . . � t�MOTJ1V�f A[JL' _. $. $5 n0 � ,�
� . . ••"'"pLBASE TIIRN OVBR AND COMPLETB UTRER SmE OF FORM""••* � � ;
�
. j
f
• L�L1�a11�1u8LYt>RLOl\ � • �••�••v',
1Jnder Chapter 152,Sectlon 25C,Subaeation 6,tha Town ofYa�mouth ie now required to hold leauance or ranawal
of any license or peimit to operaie a businass if a parson or company doea not have tt CertiScata of Workar'e
Compeneation Inaurance, THE ATTACHED STATE WORKEIt'S COMPENSATION INSURANC� ,
A1�F1DAViT MUS'F BE COMPLETED AND SIGNED,OR
CSRT.OP INSURANCE ATTACI•ILD� . .
Oft
WORKER'S COMP.APCIDAVt'I'SI(iNAI7 AND ATTACkIED_�,y
Town of Yannouth taxes and lians must be p�d prior to renewal or isauance of yow parmits. PLBASE CHSCK
APPROPRTATELY IF PAID:
XES X NO
MOTEL�S AIYD OTHER LODG7NG L�3TABLISH11iENTS
TRANSIENTOCCUPANCY: ForpurposesofthalimitationsofMotelorHMeluse,Transientoccupancyshallbe
limited to the temporary and short term occupancy,ordinarily aad ca�atomarily assooieted with motal and hofal use,
Transient occupanta must havo and be ablato demaivtrate that they maiMain a prindpd place ofresidence elsewhare.
Transient occupancy a�ya1! ganerally reFer to continuoua occupancy of not mora than thirty (30) days, end aq
aggregate of not more than ninety(90)days within any si�r(6)month period. Use of a gueat unit aa a easidence or
dwelling unit shal{not ba considered ttansiant. Occupancy that is subjed to the ooliection of Room Occupancy
Excise,as defiqod in M.G.L.a 64G or 830 CMR 64G,as amended,ahell ganarally ba considared TransleM.
POOLS
POOL OPI�NING:Ali awimming,wading and wblrlpools w6ich have been cloged forthe saeson must be�ected
by,tho Health Dopertment rior to opaning. Contact the Health Ueparqneat to achedula the inepectiontlrce�(3)days
pnor to opening.P�S�QT$:People are NOT allowad to sit m the pool area until tbe pool has been inspected
and opened.
POOL WATER TTS1'IIVG: Tha wat�must be testad for pseudomonas total coliforu�and stsndard plata count
by a State cartiBeA lab; and submitted to tda Heakh Aepartment three(§)days prior to opening, and quartazly
thereatkor.
POOL CI.03ING:Every outdoor in ground swlrruning pool must be draiued or covared wlthin seven('n days of
closing.
FOOD SEYtVICE
CATERING PQLICY:
Anyonewhocatarswithint6aTownofYazmouthmustnotifytheYarmouthI3ealthD�tby�tl�requlred
Temporary Pood Service Application fortn 72 houre prior to the cetered event. Thesa forms can ba oStained st the
Health Dapaztmont,
FROZEN AES3ERTS:
Frozen desaerts muet be tasted on a monthly basis by s State cer8fiad lab. Tast rasults must ba santto the Health
Department. Failure to do so will resuk ia the susponsion or revocarion of}rour Prozan Deasert Permit u¢til t}ie
above terms hava bcen mek.
OUTSIDL�CAF�S:
Outsida cafes(i.e.,outdoor seatiag wlth w�iter/vraitress sarvlce),must have prior approval&omthaBoard ofI3eaith
OUTDOOR COOKING: �
Outdoor cooking,prepazatioq or display ofany food product by a retail or food aervice ostabllsbment ie pro6ibiteJ.
NOTICE;Pernilts nui snnually from Jsnuary 1 to Decentber 31. Tf IS YOTJR It�3pONSIBII,1'1'Y TORETURN
TI3S COMPLETED RENBWAL APPLICATION(3)AND RBQUIItED F�(S)BY DHCEMBSR 15, �O�1 '
ALL RENOVA110NS TO ANY FOOD HSTABLISAMI,+NC, MOTEL OR POOL (i.e, PAINTING, NBW
EQUIPMENT,ETC.),MCIST BB REPO1tTED TO ANp APPROVHD BY'fHE HOARD OF HEALTH PRIOR
1'0 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI1']�PLAN.
DATE: 11/14/13 SICrNATURE:
�
PILINTNAME&TiTLE: SeIVI COUtO
osasro9 - . � . . . �
r
_ ' � The Commonwealth ofMassachusetts
Department of Industrir�lAccidents
IM11fCINi�d�
600 Woshington Street, �"�Ffaw
� Boston,Mass. 02111
Worlcen'Compe�sads�Imvaste Affi�v&;�
Aoolicut irh�eutls�: �pp�
oeme: nunkin f]nnutc
aad�ees: 16 E Main Street
citv WPct Varmnuth state• �hA tio• 0 674 ohone# 50$ 862�1124—
tvodc site localion(fu�]adch..al• .
O ��8 no��n�r�.0�m�.ar.
❑ I am a sok proprietor sud 6ave ou a�e working in any capxity. .
� I am an employar providing workeis'compeasatim far my c�ployees wodcing�this job.
rom�v..me: C:aoe Manaqement Team LLC
�ihns: 169 Main Street
cu.: Stoneham, MA02180 �.�w. 781-279-0290
�ma�r�ce. TravPlerc Incuran . o.�Ic.,� JPJUB 5B93838 3 13
_ _ ..,,,.�.�,...
❑ [am a sole praprietor,eemmal rnatracMr,or iomeewner(cnde nns)md have hired the contrectors lis[ed bdow who have
t6e followiog warke�s'compereation polices:
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Ye�n'IspHeautet a,�d n dH pealtlea N�Ye Porr da S701 WORK ORD6R aM�6ae dS16RW a d�y apiw[.e. [udenhN MR•
upy dlib ahlemeal mq 6e ArwndM a tEe Omoe d I�ve'tlptlus d Ue 1qA Ar tavenp rerleNtl�e.
��ti�.eay ce� Ns�sApewalHa olP�+J�'!t1Y�Ne lefwwaelae prodded aMw 6 bee ewd arrect
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e.�n��u Salvi Couto reones 781-27Q-0 A�
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