Application and WC : . TOWN OF XARMOU7'H$OAR1T OF�EAtL'SX'�'��DdNKiN DoN C C�i��M�s DD
APPLtCATION FOR LIC'.EAISEfi'ElE1V13'1'-201�Ma rN 5 .
NOV 7 � i �'1Q
*Please compl�e tiorm end attach all ne,cessary doaimmm� y �.
Failure w do so wilt reauft in tha return of your applicsUon pac et. FiEAL I n u c r � .
NAME OF ESTABLISHMENT: Dunkin Donuts TEL.#
LOCATION AAARESS: 14 ast am reet
MAILINGADDRESS: 1RQ Main Street, StoneharrL, MA 02180
OWNER NAME: Salvi ,�y�to TQYy ID(F�1N ot SSNI' 01-MRS11 dR
CORPORATION N.AME(IF APPLICABLE); Cape Manaaement Team� LLC.
MANAGER'S NAME: F'Irlio f'nrroia TEL.#�oa �� n�no
MAIf,.INGALIDRESS: �� ����+ Ct�@pt Sfnnoham_ MA,Q 1�80
POOL CERTIFICATIONS:
T6e pool supervisor muet be cerlitied ea a Poal Operntor,ae required by Stwte Inw. Please list the designeted
Pool Opereror(s)and ettach a copy of the certiScation to this form.
1. 2:
Pool operators must list a mmimum oftwo employees currently certified in basic water safety,standard First Aid and
Commuuity Cardiopulmonary Resuscitation(CPR). Pleasc llst these employees bclow and attach copies ofemptoyee
cei�tifications to tt�is foim. The Health Department will not use past yeers'records. You must provlde new
copies and maintaln a C�le et your pluce of bnsiness.
�
1. 2.
3. 4•
F(�OD PROTECTION MANAGERS-CEItTIFICA'�10NS:
All food service establishments are requ'ved to have at least one full-tune emptoyee who #s certified as a Food
ProtectiodManager,as defined u�the State Sanitary Code for Food Service Establislvnmts, 105 CMIt 590.000.
Please attach copies of cerdficadon to this application. The Heelth Department w�71 not use past yenrs'records.
You muet provide new copies and maintain a Sle at yoar establishment
i Ingrid Rodrigues 2, `
PERSON IN CHARGE:
�ach£ood establishment must have at least one Aerson In C6arge(PIC)oa site during hours o£operation.
i, Ingrid Rodristues 2. �
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Fleimlich
Maneuver on the prcmises at alt times. Please list yourem�loyees uained in anti-choking procedures below and
attach copiea of amployee cextiScadons to this form. The Heelth Deparduent will not uae pnet years'records.
Xoa must provide new copies and maintaln a 61e et your place of business.
1. � 2.
3, 4.
RESTAURANi"SEATING: TOTAL#
OFFIC�USE ONLY
LODOING: . . . . . . . .. . . . � .
LIC4�NSEREQUIRGp F&6 PfiRMITM UC6NS&REQUIRFD FEE PERM17'M L�CGNNSHREQUFRED k'6F, YERMI7N
�8&H � S53 _CAHIN S35 _,,,M07FL S55 __� � .
_ INti S55 __CAMP S55 _SWIMI�9NOPOOL SBOae.
_IADOE S55 � ,,,_YRAII,�iRPARK 5105 ,_WFllR4POOL SSOee.
� FOOD9ERVIC6: - .
LICENS$REQU11tfiD F7iE PERMIT^NC�L llCENSEREQUIRID PEE PF.RMITq LICEN9EREQLIHED FEE PE]tMlTe '
y0.100SEA1'S E$5 �y�O —CON1'MENTAL S35 � "NON•PROPff S30 �
_ _>IODS&ATS E160 ,_COMMONVIC. 160 ___._ .�H'FI04ESAL6 S80
R&7AQ.SEkVICE: � —RESID.KITCHEN 580 -
LICEid$6REQUQtFD FGfi PERM13'fl LICENSEREQUIRFD FEE PERMfIN LICkTISEREQUIRED FEE PERMtTN
`<SOsq.R S50 _>25.00Op.fl. .5225 T� . ,_VENDQJO-FOOD$25 . _„
„`QS,OOOsq.ft. - SBO �FROZENDESSCRT S40 �TODACCO S55 _��
NAA#ECH.WGE: S15 . . AMOUNTDUE ��
•++�•pLEASE TURN OV6R AND COMPLETE OTHETt SIDB OF FORhi•""•"
. . ADMINI3TRATIOlV a...��
Undar Chaptar 152,Section 25C,Subeec6on 6,the Town of Yarmouth is now required to hold ieauanca or renawel
of any licenae or pernilt to operata a business if a peraon or company does not hsve a Ce�tiScate of Workar's
Compansation Inaurance. THE ATTACHED 3TATE WORKER'S COMPENSATION IN3ITRAIVCE
AFFIDAViT MUST BE COMPLE7'ED AND SIGNED,OR
CFdtT.OF INSURANCF,ATTACF�D__ _ ,
OR
WORKBR'3 COMP.AFFIDAViT 5ICiN�AND ATTACHED_�,
Town of Yarmouth taxes and liane tmust ba paid prior to ranewal or'ssauance of your permits, PLBASE CHL'CK
APPROPRTATELY IF PAID:
X&S X NO
MOTELS AND OTHER LODGING E3TABL7SHMENTS
'CRAN3IEN'COCCUPANCY: Forpurposesoftha8mttetionsofMotelorHMeluse,Transie�rtocc�pancyshallbe
Gmited to the temporary and ehort term occupsncy,ordinarlly aad cuatomwily associated with motal and hotel use.
Transient occupanta must have and be ableto demonstrata that they mnJntaia a p[incdpal Place ofT�idencx eleawhare•
'Cransient occupancy ehall generatly re£er to cot�tisruous becupancy of not more than thirty (30) days, and en
aggregate oFnot more thsn ninety(90)days within any six(6)modth period. Uae of a guost wilt as a treeidenca or
dwelling umt shall not be considered transiant. Occupxncy that is subjed to the coliection of Room Ocoupancy
Bxciae,as defined in M.G.L.a 64G or 830 CMR 64G, es amended,ahall ganerally ba conelda�'ed Trm�sient.
POOLS
POOL OPENIIVG:All swimming,wading snd w6irlpools wbich have bean closed fortha eeason muet be ivap�
by,theHealthDapartmentpriortoopening. ContscttheHealthDepartmeuttoacheduletheinspecfionftnea('s)days
pnor to opening.PI.LA,SE NOTH;Paople ara NOT allowed to ait m the pool aren unt7 the pool has bee�t lnapectad
and opened.
POOL WATER'CESTIIVG: Tha wat�must be teetad for pseudomonas total coliform and atsndard plste count
by a State certi8eti Ixb; and submitted w the Aeakh Aapaztmant thrce(�)days prior to opaning, end quartarly
theresftor.
POOL CL03ING:Every outdoor in ground awirruning pool must be drained or covered within saven('�daYs of
closing
FOOD SERVICE
CATERING PQLICYt
ArryonewhocatarawlthinthaTownofYarmouthmustnotiPytheYarmouthkIealthD�artby�thetequa'ed
Temporary Pood Sarvice Application fortn 72 hours prior to the catered evert. Thesa forms can ba obtained at the
Health Dapartmant. ,
F120ZEN DESSERT3:
Frozen desserta muet be tested on e monthly basis by a State csrdSad lab, 'Pest rasults must be sent to the Health
Departmc�nt. Feilure to do so will resuk in the susponsion or rovooarion of your Frozan Deesort Permit until tha
above tarms hava been mat.
4UTSIDE CAF�S:
Oute3de cafes(i.e.,ouWoor aesting wlth waitedwaitress service),must have prior approval fromthe Board ofHealth.
OUTDOOR COOHING: �
Outdoor cooking,praparalloq or dieplay ofany food product by a rofail or food aorvico astahlishment ia pro6ibited.
NOTICE:Permits run a��m�ally from Jenuary 1 to Decanbar 31. 1T iS YOUR ItE3PONSIBILY!'Y TOItETURN
TI�COMPLETED RENBWAL APPLICATION(5)AND R6QUIltBD FEH(S)BY DfiCSMBSR 15,2009, •
ALL RBNOVATIONS TO ANY FOOD &STABLISI�NT, MOTEL OR POOL (i.a, PAINTING, NSW
EQUIPMENT,STC J,MUST BS REPORTED TO AN1J APPROVBD BY THS BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATtON5 MAY REQUlRE A SITE PLAN.
DATE: ���Q�(`� SICiNA �
PRINT NAME&TiTLE: �g,�v� LoJ-'cd , rv�,em I��
osnsro9
� . - `—�°"_--_-_ The Cora�»onweahh ofMassachasetls
`-����__- l�artnrent ofindaatrial Accide�s
-__ = MMc/N�M/
-_ = 60o w��,�s� �"`�.
=-= , Bosro»,Maxs. 02113
Worloers'Can eatior Le�rance.AfBd�vl�Bail bfi�IFdeeMed Cont�ti�eMrs
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• $a�Vl COUtO . . .... . . . : . . � . � . .
�• c/o Couto Mananemen! Graup,LLC 169 Main Street
�{y gtnnnh-�m etate• �ure � �pn2q sn :�e� �g7 Z79 n�90
T am a lnomeown�paXforinin�all wadc myea►f. ProJect 7'ype: Now Conscruccion[JRemodel
I am a sole 'eWr aod'ltave nu ona w' i»an it . : ` AddiUon
Iam an,emPluYer�nm'iding w�lc�s'compeneakion far my m�ployces wodeing on tbis job. .
,14.East Main-St.
Y o h lUl� 4 5Q8. ,: 24` .
Public Servic� Mutual ;_ WC 021915 .
❑ I acn a sole pm�xletor,genera�cawlraetor,or home�wwew(clrcle owij and have Lh�od the�ro�aractae lieted below who haye
iho folbwing wo�ktxs'compensation policas:
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Mpy:�fMb:wtmia�t�ouiy.Mtor�nrUWee1M.O�ce-aflmeYtptlo�afiW.D1A�eN'er'a�rtaNatlw. : �.. . ... - .. . -
/do bere6y c an r ina ea/peiwfBea o Met Mt i�al�bn p►erlJed ebero lt Aiwe�wl cerro�
Sign,tup natt '�'�/09/09
P�„�Salvi Couto phonea 781-279-0290
•mddweony a.s.ewrYeYepbarea�oaeaai�bYdlYareo�m��f6e1.�.�� , , . .
dly'u*tewa: .Pemlf/llamie 9�Bo4dis�Departsmt. .
❑shaekHiwne�lere�eeabreqdred . � . . . . []9d�401Boe .
px�,x►uyat�ae.t
maf�petan�t � PhNeSi �O�a
tmam s�mm� . .
: , . Public Service Mutual Insurance Company
� ( One Park Avenue
4 New York, NY 10016-5807
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WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
EXTENSION OF INFORMATION PAGE ITEM #1
NCCI Company No:16152 Prior Policy Number: WC 021915 OB
ENDORSEMENT Policy Number: WC 021915 09
1. Named Insured and Mailing Address: Producer and Mailing Address:
Cape Management Team, LLC dba Dunkin Donuts FiibeiroDeSousa Insurance Agency
C/O Couto Management Group, LL 1092 Cambridge Street
169 Main St Cambridge, MA 02139
Stoneham, MA 02180-1613 Tel. (617)497-2100
2. The policy period is from 4/22/2009 to M22/2010 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: 16jE 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.
Edkion 10/97
Copyright,1987 National Council on Compensation Insurance Page 5 of 7
INSURED COPY