HomeMy WebLinkAboutApplication and WC T>c�r�tc�ay t�ats�
,,,.. � TQW'N OF YARMOIITH BOARD OF REALTH ���a� �;� ;
�`���� APPLIGATION FOR LiCENSElPERMIT-20 � � �`�`""' i
`"' *Please complete form aaad at�ach al]necessary dvcuments "` e et�=5 �OIS - �
Failure to da so will result in the return ofyour appii�atton p ;ket. ' �(87 �'- a , �
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ESTABLISHIVIE�IT NAME:Cape Management Team,LLC DBA flunkin Donuts "���jj); E �; f•ry ° -
LOCATION ADDRESS: 1353 Rt.28 South Yarmouth MA 02664 TBL.#: 508-394-1220 � �- � t
MAILING ADDRESS: 169 Main Street Stoneham MA 02180 �' '*•:
:��� C:'.
E-MAIL ADDRESS:officeC�Dcoutomanaaement.com J ,
OWNER NAME: sal Couto CEO '
CORP(?RATION NAI��IE(Ik'APPLICA$LE}: Dunkin'Donuts
IVtANA�'xEFt'S NAM�: Denise Cook ��.#: 781-279-0290 ----_..___„...._a�..__
IV�AZLING ADDRESS: 169 Main Street Stoneham MA 02180
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POOL GERTIFICATIONS:
The pool sopervisar must be certified as a Pool Operator,as required by State law. Please list the desig►ated '
Pool Operator(s)and attach a copy af the certification ta this form:
l. N/A 2.
Pool operators must Iist a minimum of two employeas currently certified in standard First Aid and Community
Cardiopulmanary Resuscitation{CPR},having one certified employee on premises at all tirues. Flease List the
emplayees below and attac:h capies of their certificstians to this form.The Health Departmen#will not use past '
years'records. You mnstprovide new copies and maintain a file at your place of business. ��
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I. N/A 2, �
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3. 4. i
FOQD PROTECTTQN MAN4GER.S-GERTIFIGATIONS:
All foad service establishments ara required to have at least one full-time employee wha is certified as a�ood
Protection Manager,as defined in the State Sanitaiy Code fnr Faod Service Establishments, 105 CMR 59Q.000.
Please attach copies ofcertificadon ta this application. The Health Department wiil not use past years'reeords. I
You must provide ne�v copies and maintain a file at your establishment.
�.Eduardo Correia � �
PERSC}N IN CHARGE. �
Each food establishment must have at least one Ferson In Charge(PiC)an site durinA hours of aperation.
1. Rachel Murphv 2.
ALI.ERGEN GERTIFICATIONS:
All food senrice establishments are cequired to have at least one Full-time employee wha has Allergen certification,
as defined in the State Sanitary�ode for Food Service Establishments,l0�CMR 590.OQ9(fi)(3)(a)_ Please attach
capies of certification to this applicatian. The Health Department will not use past years'recards. You must
provide new copies and maintain a file at your establishment.
l. Denise Cook 2. Rachel Murohy
HEIMLICH GERTIFICATIONS:
All foad service establishments with 25 seats or more must have at Least one emplayee trained in the Heimlich
Maneuver on the premises at all times. Please list}�our emplayees trained in anti-choking procedures below and
attach copies of employee ce�tifications to this form. The Health Department will not use past years'records.
Yoa must provide new copies and maintain a�le at your place of business.
1. N/A �
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RESTAURANT SBATING: TQTAL# o
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OFFI�E USE QNLY i
LODGING:
LICENSF:REQUIRED F�,E PERh11T# LIGENSE REQ[JIRED 1�E6 P£RhiFT# LIGETvSI%RGQUIRED FEE PERM('T# �
B�B $55 CABIN $SS MOTEi. $110
utNN $55 —G;M9P $55 �SWIMMING POOL$ll0ea.
�LODGC- S53 TRAILERPARK $105 WHTRLPQOL $110ea.
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FQQA SERVCCE:
LIG£NSE REp UTRED FEE (T# LICENSE R@QUIR�D FC� FERhiIT# LICENSE REQUIRED FEE PERMIT# j
L0-100 SGATS $12S ����J�(OZ- —CONTINENTAL $35 NC}N-PRO�tT S3[1 �
>Tb0 SEATS 32Q0 COMMC)N V[C". $60� WHO�.ESALE $80 �
— —RESTD.KITGHEN $SQ
RETA[L$ERV ICE:
L[G�NSEREQUTRED fEE PCRMI"C# LICENSERCQUIREn FEF PF,(tR4[T#i GICFNSF,RF.QUIREI) FFE PERNiIT#
<St7sq ft. $5(1 >25,OU0 sq.ft. $2R5 VEND[NG-FWD $25
-�S,OOOsq.ft. �19Q =PRflZENI7ESSEKT $�10 _TUSAGCO $11Q
NAME GHANGE: $15 A11'ZOUNT DUE = � ,I Z'�J' .Q O
***k*Pt,EASE T[JIt�Y OVER AND CO�IPLETE QTHF.R SIDE UF FOFtYf****�
ADMINIS'TRATIQN t
j Undzr Chapter 152,Sectian 25C,Subsec6on 6,the Tawn af Yarmouth is now required to hold issuance or renewal
of any Iicense or permit to operate a business if a person or camgany does not have a Certificate of Worker's
Gomgensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSUItANCE ATTACHED
OR
VJpRKER'S COMP.AFFID:�VIT SIGNED AND ATTACHED�
Tawn of Yannouth taxes and liens rnust be paid prior ta renewal or issuance of yaur permits. PLEASE CHECK
AF�PROPRIATELY IF PAID:
YES�� NO
MOTFLS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT�CCUPANCY: For purposes of the limitations of Motel or Hatel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient accupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generatly refer ta continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be cansidered transient. Qccupancy that is subject ta the callection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient.
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POOLS j
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POOL OPENING:All swimming,wading and whiripools which have been clased for tt►e seasan must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspectian three(3} �
days priar ta opening.PLEA3E NOTE:Peaple are NOT allowed to sit in the pool area until the pool has been i
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomanas,total colifarm and standard plate count �
by a State eertified lab,and subrrutted to the Health Department three(3}days prior ta opening,and quarterly i
thereai3er. �
PQOL CLOSING:Every outdoor in graund swimtning pool rnust be drained or covered��vithin seven(7}days of
closing. �
FOOD SERVICE f
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SEASONAL FOOD SE1tVICE OPENING. �
All food service establishments must be inspected by the Health Department priar to opening'. Please cantact the
Health Department to sehedule the inspection three(3)days prior to opening. �
CATERING POLIC'i': �
Anyone who caters within the Tvwn of Yarmouth must natify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours pri�r to the catered event. These forms can be
obtained at the Health Dspaxtment,or Lrom the Tocvn's website at www.vannouth.ma.us under Health Department,
I7awnloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen (
Dessert Permit untiT the above terms have been met. �
OUTSTDE CAFES: (
Outside caf'es(i.e.,outdoor seating with waiterlwaitress service),nnust have prior appraval from the Board of Heatth.
OUTDQOR COOHING: !
Outdoor caaking,preparation,or display of any food product by a retail or food service es2ablishment is prohibited. ,
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NUTICE:Permits run annually from 3anuary 1 to December3l. IT IS YOUR RESPONSIBILITY TO RETURN 4
THE COMPLETEI?RENEWAL APPLICATION(�)AND REC�UII2ED PEE(S}BY DECEMBER 15,261 S.
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ALL RENOVATTQNS TO AN'Y FOOD ESTABLISHMENT, MOT�L OR POOL (i.e., PAINTING, NEW i
EQUIPMENT,,ETC>},MLIST BE REPORTED TO AND APPROVED BY THE BC)ARD QF HEALTH FRIOR �
TQ COMMENCEMENT. RENOVATIONS MAY RE IRE A LAN.
DATE: �oi2zizo�s SIGNATLTRE: I
PRINT NAME&TITLE: Sa�vi Couto President
Rev.lONIJ15
_� The Commonwer�ith of Massachusetts
;,� � Depart�nent of Industrial Accidents `
� j � Of�ce of Investigations
600 Washington Street
` ��- Boston,MA Q2X II
3 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Busincsses �
AAAiicunt Infoxmation . Please 1'rint Lc�.ib1Y ,
Business/OxganizationName: Cape Management Team, LLC DBA Dunkin Donuts
Address: 1353 Rte. 28 .
City/State/Zip:S. Yarmouth� MA 02664 Phoue #: 508-394-1220
Are you an employer7 C�eck thc app�•o�riate box: Business Type(required):
1,(� I am A employer with 6 employees(full and/ S. ❑Retait
or part-time).* 6. �]Restaaran�/Bar/Eating Establishmont
2.❑ I am a sole proprietor or partnarship and have no �, �pgce andlor Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. �
[No workers' comp,insurance required] 8• ❑Non-profit � '
3.❑ We are a corporatiaa and its officers have exercised 9. ❑Entertainment '
their right o£exemption per a 152, §1(4),and we have 10.❑Manufacturrng '
no employees. (No workers'comp,insurance required]* �� ���ealth Care
4.❑ We are a non-profit organization,staffed by volunteczs,
with no e�nployees. [No workers' comp.insurance req.] 12,0 Other
� '�Any appiicant tliat checks box#1 must also ffiI out the section below showing d�eir wor[cers'compensation pol icy intormation. '',
"If tl�c corpor�tc oflicers have axempted tliemselves,but 1he corporAtionhms othcr cm�loyees,a workcrs'compensation policy is required and such an
oe�anization should check box#1. �.
I am nn employer tle�rt ls provlding workers'corrtpensatior:lnsurance for rrey employees. Below is tfie policy infornratlon.
Insurance Compa�y Name: AM Guard Insurance Co. �
Insurer's Address: 16 South River Street PO Box A-H ;
citylstate/zip: Wilk�s-Barre. PA 18703-0020 .
Policy#or Self-ins,Lic.# R2WC632118 Expiration Date: 4/22/16
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Attach a copy nf the worlters'comp�nsation policy declaration page(sliowing the policy number apd expiration date}. G
P'ailure ta secure coverage as requirail undar Section 25A of MGL c, 1 S2 can lead tQ the imposition of criminal penalties of a ;
flne up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the forin of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator, Be advisecE tl�at a copy of fihis statement may be forwArded to the Ofiice of
Invastigations of tae DIA for insurance coverage verification.
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I do Jiereby certif� � tn[I penudttes af perjury tfi�tt tfte informat�ort�rovulerl rtGove is true�tnd correcJ.
Si natare: Dafie: 10/14/15
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I'hone#: 781-279-0290 �
O�cial use only. Do not wr#e in tli�s area,fo be coniptete�l by clty or tutvn nf,�ictal.
City or Town: Permit/License#
Issuirig Authority(circle one): �
1.]3oard of Healtli 2.Building De��arfineYit 3.City/Town Clerk 4,Lieensing Board 5.Selectmen's Office
d.Other
Contact Person: Phone#:
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www.mass:gov/dia
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� BERKSHIRE HATHAWAY H►o�rcer's ComQensation and Emalover's Liabili�y Policv
GUARDINSURANCE AmGUARD insurance Compd�y -A Stock Company `
COMPANIES Policy Numbe� R2WC632118
Renewai of R2WC595758
NCCI No. [21873],
Rolicy Information Page(AR)
[i]Named Insured and Mailing Address Agency
Cape Management Team LLC EA5TERN INSURANCE GROUP
169 Mafn Street 233 West Centrai Street
Stoneham, MA 02180 Natick, MA Q1760
Agency Code: MAEAINSO
Federal Emp{oyer`s ID Insured is Limited Liability Co. (LLC}
Risk ID Number 456527
Additional Names of Insured
(N2} Dunkin Donuts
Locatio�s on Policy - See Extension of Information Page - Schedule oF Lacations
[2] Policy Period
From Aprii 22, 2015 to April 22, 2016, 12:01 AM,standard time at the insured's maNing address. ',
[3l Coverage ',
A. Workers'Compensation Insurance- Part One of this poticy applies to the Workers`Compensation
Law of the followfng states: Massachusetts ;
B. Emp(oyer's Lfability Insurance- Part Two oF this poifcy applies to work in each of the states listed
in item [3JA. The limlts of our liabil+ty under Part Twa are:
Bodily Injury by Accident-each accident $1,000,000 I
Bodily Injury by Disease- each empioyee $1,OQO,Q00
Bodily Injury by Disease- policy limit $1,000,000 ; I
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�, Refer ta Residual Market Limited Qther States Insurance Endorsement-WC2003066 i
D. 'F'his policy inciudes these endarsements and schedules (
See Extension of Information Page-Schedule of Forms �
[4J Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates,and Rating Plans. Ail required information is subject to verification and change by
audit. (Continued on another page)
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Total Estimated Policy Premium � 39,557 '
Totai Surcharges/Assessments $ 1,765.00
7'otal Estimated Cost � 41,322.Q0
trZrERNa�u5E c� Page- 1- Information Page
MGA :R24VC632118
Date : Q4j02/2Q15 WC OOOOOlA
MANOTE
Issuing Office:P,p,Box A-H, ifi S. River Street,Wilkes-Barre, PA 18703-Q020�www.guard.com
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BERKSHIRE HATHAWAY Worker's Comoensatlon and Emnlover's Liabilitv Policv
G U A R D INSURANCE AmGUARD Insurance Company-A Stock Company
COMPANIES Policy Number R2WC632118
Renewat of R2WC595758
NCCI No. [21873�,
Poticy Information Page(AR)
Extension of Information Page
Schedule of Locations
(L2) 1050 Route 28, South Yarmvuth, MA 02664(Q4/22/2015- 04J22/2016j
(L3) 526 Route 28,West Yarmouth, MA 02673 (04/22J2015 -04/22f2Q16)
(L4) 1353 Route 28, South Yarmouth, MA 0�664(04/22J2415- 04/22/2016)
(LS) 14 16 East Main Street,West Yarmouth, MA U2673(04j22/2QiS - 04/22/2016)
(L6} 39 Nathan Ellis Nighway, Mashpee, MA 02649 (04J22/2015 - 04/22/2016)
(U} 156 Iyannough Road, Hyannis, MA 02601 (04/22l2015- 04/22/2016)
(L8) 792 Main Street, Ostervilte, MA 02655(04j22/2015- 04/22J20i6)
(L9} 40 South Street, Mashpee, MA 02649 (04/22J2015-04/22/2016)
(L10)_ 343 Scenic Highway, Buzzards Bay, MA 02532 (04/22J2015- D4j22/2016)
(Lii) 702 Iyannough Raad, Hyannis, MA 02601(Q4j22J2015 -04/22j2016)
(L12) 464 Route 28 Main Street,West Yarmouth, MA Q2673(04/22/2015-04/22/2016)
E�ctension of Information Page '
Schedute of Forms
" WCOOOOOQC-STANDARD POLICY
* WCQOQOOIA- INFQRMATION PAGE
* WCOa0414- NOTIFICATIQN OF CHANGE IN OWNERSHIP ENDT
* WC2Q0101 - MA TERR. RISK INS. PROG REAUTHORIZATION
' WC2001Q2 -MA NOTICE OF PEND LAW CHANGE TO TRIPRA
* WC240301 - MA LIMITS OF LIABILI'fY ENDORSEMENT
* WC200302A- MA ASSESSMENT CHARGE
* WC200303R- MA NOTICE TO POLICYHOLDER ENDORSEMENT
x WC2Q0306B- MA LIMITED OTHER STATES BENEFIT ENDT.
* WC200307 - MA ASSIGNED RISK POOL ELIGIBIIITY ENQL
* WC200405 - MA PREMIUM DUE DATE ENDQRSEMENT
' WC20Qb01A- MA CANCELLATION ENDORSEMENT '
• WC2Q0604 - MA POLICY�EFINITION ENDORSEMENT
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* As part af our ongaing commitment to environmentai responsibitity throughout our operations, we have f
chose�not to reprint those forms(marked with an asteriskj that have not changed and were previously �
sent to you. You can obtain a new copy of any af these Eorms by accessing your account information at
our Poilcyho/der Servlce Center(a selection availabte via our website at www.guard.com). Please be
aware that you wilf be asked to enter your policy number, policy inception date, and federal ID number in
order to log on to this secure portion of our site. ,
Alternatively, you can contact us via phone at 800-673-2465; our Customer Service Representatives wili
either be abfe to help you locate a document yourself ar can send a copy to you. As always, we thank you '
for selecting us as your insurer. We look forward to serving you!
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Remember, we make a variety of loss control services available to you at no �
additional charge, including educational resources accessible fram our Poticyholder '
Service Center at Policyholder Service Genter.
LNTERNAL USE xx Page-2- Information Page
MGA :R2N10632128 WC 000061A
Date :dQ/02j2p15
MAN4TE
Issuing Office:P.O,Box A-H, 16 S.River Street,Wilkes-Barre, PA 28703-002Q •www.guard.com
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