HomeMy WebLinkAboutApplication and WC TO'WN OF YARMOTT['H BOARD OB HEALT$ /y e.MArN Sz. V ��` . ""._�
APPL[CATION FOR LICEN3l�:/PERNIIT�-2
. . *Pleasa complete form amt aitach all nacassary docummts by ��2010 i
Beilure to do so wilt tesult in tha retum of your applicatton paa at. ` �
NAME OF ESTABLISHMENT: Dunkin Donuts TEL.# '� ¢ �; �, ;--�
LOCATIONADDRESS: 14 as �t[S�x $�0�0m MA1l21�2 �� � � �o�
MATLINGADDR$SS: 169 Ma1�1,., �
OWNERNAME: S�Ivi Go�to TAXID(gf,��SSN): fli_07R9�Id6: ;. � �
CORPORATION NAML(IF APPLICABLE): Cape Manaqement Team, LLC.
, MANAGER'S NAME: Fddia [`nrroia TEL.#� '': "�
MAILING ADDRESS:,,�o u+��� - t�,,,S�4II�hgpl, MA 02180
YOOL CERTSFICATIONS:
Tde pool aupervlsor mttst be certifled as e Pool Opernmr,ae required by State law. Please list the designated
Pool Oporetor(s)and attach a copy of the cw�iftcadon to this form.
1. 2.
Pool operators muat liat s minimum ottwo employces curnntty cera5ed in basic water sefbty,standard First Aid and
Community Cudiopulmonary Resuscitadon(CPR). Piease list these employeea below and attach wpies ofemptoyee
certiflcations to this form.The Healtfi Aepartment will not uae past years'records. You must provide uew
copies and maintaln w Ne at yoar place of basiness,
1 � 2.
3. 4.
FOOD PRO'CECTION NfANAGERS-CERTIFICA'('IONS:
Ail food service esteblishments are required to havo at lenst one fu11-tune employee who is certified es a Food
ProtecHon Manager,es defined in the State Sanitary Code for Pood Service EstebUshments, 105 CMR 590.000.
Please attach copies of certificadon to this appllcation. T6e Health Department w�71 not use past yenrs'records.
You muet provide new copien aud maintaiq a S►e at yoar establishment
� Richard Freden 2 _ �
PERSON IN CHARGE:
Lsch food eatablishment must have at lcast ona Aerson In Charge(PIC)on site duriag hours of operadon.
�, Richard Freden 2, �
HSIMII.,ICH C$RTIFICATIONS:
Ail food service cstablishments with 25 aeats or more must have at least ono employ e,e u�ained in the Heimilich
Maneuver on We premises at all timea. Please list your�mp!oyees trainsd in enti-chokwg procedures below and
attach coplea of amployee certi5cadons to this form. The Health Depardnent wlll not use paet yeere'recorda.
Xoa muat provlde aew copiee and maintain a Hle at yonr pince of buaineas.
1. � 2.
3, 4.
R�STALJRANf S&ATING: TOTAL# �
OFP'�CE USE ONLY
IAD61NOt , . _ . , . . . . .. . . . .
LICENSEREQUIItUp FBS PfiRMICN LICBNSBREQUIRFD FE6 PERMI7N LICENSSREQUQtED PEE PERhf17M
8&B � f54 CAHIN S55 _M07'EL Si5 �
, ,�INN E55 TCAtvB S55 �SW1MhIINOPOOL SBOae.
_LODpE S55 � „�'tRA1LSRPARK 5105 ,_WFl1RLPO0L S80ea.
FOOD BERViC6s - .
LICENS&REQU1RfiD RF,6 P&RMITA i]CENSBREQVIRED FEE PERMI'fA WCENSE[lFRS1QtED fEb PPNMITM '
,L0.100S&1T3 E65 ��°� .—CONTM&NTAL S33 - _,,,NON•PROPIT S30 �
>IOOSBATS f160 „COMMONVIC. 460 � �K'kIOLESALB $80
RE1'AQ.SE1tVICE� � —RESID.ICITCHEN S80 �
LICENS6REQUQtFD F6E PERM17fl LICENSEREQULLtFD FEE PERMITN UCENSEREQUIRED FEfi PEItM(TN
_<SOp.R 850 _>25,OOOaq.B. ,S2t5 . VENDINO-FOODS25 ,
„`QS,OOOaq.ft. � S80 �FROZ.END&SSIIRTS90 TQSACCO �533�
NAMECHAYIO6: SIS . A11'IUUN�1'DUE a $ $SrJ.UU
•++••pLSABE TT1RN OV6R AND COIifPL6TE OTT�16It SIDE OP FORM•"••,
ADMRHI3TitAT[O1V . a."—"
1Jndar Chaptar 152,Sactton 25C,Subsaction 6,tha Town ofYa�mouW is now raquired to hold iesuanca or renewel
of eny license or perndt to operata a buainees if a peraon ar compmy doae not have a Caitificata of Workar'e
CornpaeasNon Ineurence. 7'SE ATTACHLD 3TATE �'ORKLR'S COMPENSATION INSURAI�ICE .
AP'FIDAVIT MUST BE.COMPLETED AND SIGNED,OR
CBRT. OF INSU1tRNCE ATTACFILD� - � - -
ON
WORKSR'S COMN.APFIDAVTf SIGN�AND ATfACk1ED�
Town oYYarmouth tases and liane must be p�d pcior to ranewsl or ieeuance of yow permita. PL$ASB CFTBCK
APPROPRIATELY IF PAID:
Y6S X NO
MOTEI.3 AND OTHER LODG7NG ESTABLL4HMENTS
TRANSIENTOCCUPANCY: ForpurposeaofthaUroitatioasofMotelorHotaluae,Transientocca�pancysLallbe
Gmited to tha tamporny and ehort tarm ocwPency',ordtnarlty and cuatomarily aseoaiaked with motal and hotel uea.
Tranaiant occupants must havo and be ablato demonetrata that thay maimain a Prinolpel P1ace ot'c�idenceel�whare•
Tranaiant occupancy ehei! ganaraUy refisr to continuwe oocupsacy of not mora than Uilrty (30) days, and an
agg�egate of not more than ainety(90)days w1Uila any aix(6)month pedod. Uee of a guaet unit as s resideaoe or
dwelling umt ahall not ba considerod uanslant. Occupancy that is aubJad to the oollection of Room Occupancy
8xcise,as defiqad in M.G.L.o.64G}or 830 CMR 64G,as amanded,ehall8anarallY ba conaidarad Translant.
POOLS
POOL OPENING:All swim�n}ng>wading aod w�(p�ole w5iah have bean a(osed forthe eeason must baipepec4ed
by,thoHoslthDapsrtment dortoonmina. ContacttheHealthDepartmeatWachedulethainspeotionfltte�(3.)days
pnot to opening.P�r$�Q.T�:people are I+IOT allowad to sit m the pool area u�7 the pool has bean�nspeated
and opea�ed.
POOL WATER TESTIl�iG: Tha wata must ba teetad for psaudomonae total wliform and atandard plate count
by e�r cardflad lab; sttd submitted to tLe HaeMh Aepartmeat tivee(§) days prior to opaning, and quartorly
ths
POOL CI.OSIING:Svery outdoor in ground ewlmroiag pool muat be drained or wvated wkhin eavea('n days of
closing.
FOOD 3ERVICE
CATERING PQLICY:
Atryonewhocatarswfthint6aTownofYnrmouthmustnoti thaYsrmouthHenith �y�fl�eraquh'ed
Tamp orary Food Servica Applicallon form 72 houre prlor to tha catered evant. Thesa��can.`ba oStainad at the
Health Dapaztmart, ,
F1tOZEN DESSERTS:
Frozen desserta muet be teeted on a moiuhly basis by a State cxrdflad lab, Tast rasulta muet be�to the Health
Departmeirt. Beilure to do so will resuk in the auapension or rovoostion of yrour Prozen Dassert Parnit uutil tlie
above t�ma have begn m�.
OiTfSIDE CAF�S:
Outaida cafts(i.s.,outdoor eoaNng whh waitw/waitress servtce),muet have prlor approval&omthaBoerd ofFIeahh.
i
OUTDQOR COOKIlVG:
Outdoor 000king,preparatioq or dieplay ofany food product by a retail or food eavice astahlishmeuttlaproLibihd•
NOTICE:Pe.cmitsronannuallyfromJanuary7toDecembar3l. TfLSYOURRE3PONSIBII.Y1'YTORBTURN
TI�COMPLETED RENBWAL e1PPLICATION(S).AND RBQUIItEU FEH(S)HY DECEMBSR I5,2009, '
ALL RBNOVATIONS TO ANY FOOD &STABLISfIMENf, MUTEI. OR POOL (i.a, PAII9TiNCi, NHW
EQUIPNIIiN'f,BTC.),MUST BB REPORTBD TO ANA APPROVED BY'1T�ffi BOARD OF HEALTii PRiOR
TO COMMENCEMENT. RENOYATIONS.MAY R$ PLAN.
DATE:� I ^ ���I�/ SIC3NATURE. �
PRINT NRML�&TiTLE:
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__—`�°"-�_-_-_- The Com�onweahli of Massad�aset�
- yepart�next oflndrrstrta!'Accide�s
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_ b00 WeshJngton Sdrey 7'�Floor
Boatox,Mass. 02111
WorBax'Com�salloe IxQance,A�qvi�BWI kMirkal Contractors _. _ .:e,w._._.
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„�: Salvi Couto
aaa�se• c/� Couto Managelnent Grouo LLC 169 Main'Slreet "
citv Stnnnham s�ate: 'MA ' ,: zipfl2a780 ' ed�one# 781 278 0$90 '
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Signatun� patr 11/09/10
P�t,,,�Salvi Couto p�„e# 787-279-0290
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Public Service Mutual Insurance Company
� One Park Avenue
� New York,NY 10016-5807
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
INFORMATION PAGE
NCCI Company No:16152 Prior Policy Number: WC 021915 09
RENEWAL Policy Number: WC 021915 10
t. Named Insured and Mailing Address: Producer and Mailing Address:
Cape Management Team, LLC dba Dunkin Donuts RibeiroDeSousa Insurance Agency
C/O Couto Management Group, LL 7092 Cambridge Street
169 Main St Cambridge, MA 02139
Stoneham, MA 02180-1613 Tel. (617)497-2100
The Insured:Corporation
Other workplaces not shown above:
Named Insured:Cape Management Team, LLC
2. The policy period is from M22/2010 to 4/22/2011 72:01 A.M. Standard Time at your mailing address shown above.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the
states listed here: Massachusetts
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of our liability under Part Two are: Bodily Injury by Accident $ 500.000 each accident
Bodily Injury by Disease $ 500 0 0 policy limit
Bodily Injury by Disease $ 500.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes the following endorsements and schedules:
See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
AII information required below is subject to verification and change by audit.
Premium Basis Rate Per Estimated
Loc. Code Total Estimated $100 of Annual
Classifications St. No. No. Annual Remuneration Remuneration Premium
See Extension of Information Page $20,734
Loss Constant: $0 Expense Constant Charge: $338
Minimum Premium $218 Deposit Premium $21,072 Total Estimated Annual Premium: $21,072
Premium Adjustment Period: Annually
Servicing Office: New England Branch
Countersigned 3/5/2010 at New York, N.Y. by �"`� h�J
Authorized Representative
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY.
Edition 70/97
Copyright. 1987 National Council on Compensation Insurance Page 1 of 6
INSURED COPY
� � Public Service Mutual Insurance Company �`�,
One Park Avenue
New York,NY 10016-5807
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
EXTENSION OF INFORMATION PAGE ITEM#1 \\
NCCI Company No:16152 Prior Policy Number. WC 021915 09 s
RENEWAL Policy Number: WC 021915 10 ;�
1. Named Insured and Mailing Address: Producer and Mailing Address:
Cape Management Team, LLC dba Dunkin Donuts RibeiroDeSousa Insurance Agency
C/O Couto Management Group, LL 1092 Cambridge Street
169 Main St Cambridge, MA 02139
Stoneham, MA 02180-1613 Tei. (617) 497-2100
2. The policy period is from M22/2010 to 4/22/2011 12:01 A.M. Standard Time at your mailing address shown above.
Location Schedule
Location #1: 1050 Main St South Yarmouth, MA 02664-3119
Location#2: 526 Route 28 West Yarmouth, MA 02673-4945
Location #3: 1353 Route 28 South Yarmouth, MA 02664-4509
Location #4: 16 E Main St West Yarmouth, MA 02673-8107
Location #5: 39 Nathan Ellis Hwy Mashpee, MA 02649-3267
Location#7: 156 lyannough Rd Hyannis, MA 02601-2029
Location#8: 792 Main St Osterville, MA 02655-2011
Location #9: 40 South St. Mashpee, MA 02649-46ND
Location #10: 343 Scenic Hwy Buzzards Bay, MA 02532-3446
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY.
Edition 70/97 Page 4 of 6
Copyright,1987 National Council on Compensation Insurance .
INSURED COPY