HomeMy WebLinkAboutApplication and WC i
puN�ciW'i�oNUTS
d TOWN U�'�'.�RiVIOUTFi BOARD OF HEALTH �8� ���-�
� � APPLICA'1'ION FOR LICENSEl1'ER11�1IT-20I6 r--. ��'�. ,
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*Please complete farm and attach atl necessar�dacuments by ember 15 2(113. r"+"�""""""�""'�'�
Failure to do so will result zn the return af your applicauon pac e�.I�—���' � __ � i
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BSTABLISHMENT NAME: Caoe Manaqement Team.LLC DBA Dunkin'Donuts TA.X ID: ! ,;�; � ' i
LOCATIQN�DDRESS:�as�Rt 2s south Yarmouth nna ozssa T�L.##: 508-394-1161 � �
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MAILING ADDRESS: �69 Main Street stoneham MA o21so k --= ' +
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E-Rf1AIL ADDRESS: officeC�Dcoutomanapement com � _ �.
OWNER NAME; Sa�Couto Ceo � � _,;� i
CORPORA.TION NAME(IF APPLICABLE):Dunkin'Donuts � -i �' i i
MANAGER'S NAME: Denise Cook TEI.#: 781-279-0290 � '
MAILING ADI��ZE$S: 169 Main Street Stoneham,MA 02180 �� _�__.__, I
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PO4L CER'FIFICATI(}NS: '
The pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ,
Poai Operator(s)and attach a eopy of the certi�ieation to this form.
I. N/A � '
Pool operators must list a nainimum of two emptoyees currentivi certified in standald First Aid and Gommunity ,
Cazdiopulmanary Resuscitation(CPR.),havin�one certified employee on premises at all times. Please tist the '�
employees below and attach copies of their certifications to this form.The Health Department will not nse past
years'records, You must provide new cogies and maintain a�le at yaur place of business. ,
1.N/A i '
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FQOD PROTECTION MANAGERS-CERTIFICATIONS: '
All food seryice establishments are required ta have at Ieast one full-time employee who is certified as a Food
Protection Manager,as defined in the�tate Sanitary Code for Fond Serviee Establishments, 105 CMR 59Q.dOQ.
Please attach capies of certification to this application. The Health Deparhnent will nat use pastyears'records.
You must provide ne�v capies and maintain a fite at your establishmen� j
l. Eduardo Correia 2. Daniella Pereira
PERSON IN GHARGE:
Each food estabIishment must have at least one Person In Charge(PIC)on site durin�1laurs of operarion. i
J, Gauri Patel 2. Robert Bach �
ALLERCrEN GEIZTIFICATIdNS: i
All food service estabiishmznts are required to haV e at least one full-time emplayee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.QQ9�G){3)(a). Please attacl�
capies of certification to tivs application. TheHealth Department will not use past years'records. You must �
pravide new copies and maintsin a�]e at your establishment. i
1. Deni�e Cook �. Eddie orreia �
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HEIMLICH CERTIFICATIONS: i
Ail food service establishments with 2�seats or more must have at least ane emplopee trained in the Heimlich `
Maneuver on the premises at a11 times. Please list yaur employees Crained in anti-chaking pracedures below and .
attach copres of employee certificatians to this forrn. The Health Department will nat use past years'records.
You must provide new cogies and maintain a'�le at your place af business.
1. N/A 2.
3. �.
RESTAURt�NT SEATING: TOTAL# �Z
�FFICE USE��V�.� I
LODGtNG:
GICENSEREQUFREQ FF� PERMiT# LICEN&EREQU[R�D FF_.E PEftt�i11'# LICENSERfiQUIRED FGE P8RN71T#
B&B S55 CAB1N $55 MOTEL $110
vINN $53 GAMA $SS SWIMM1NGPt}()L$114ea
_LOI7CE �55 �TRAILGRPARK $105 �WHlRLPOOL $IIQea.
FdOD SERVIGE:
LIGENS6 REQUIRED F'E� P RMIT LICENSE REt�UIRED F�E PERhiCI'il LICENSE RE UIRED FEE PERMtIT� �
�U-IOOSEAI'S $t25 ���o�j C(?NTINENTAL S35 NON-PE20�IT $3Q
>100 S�A"CS 5204 �C4htR10N VIG. $GQ ��j� =WHOLGSA[,E $90 i
i —RES[A KITCF(EN$SQ
RETAtL SERVICE: �
[,TCBNSERGQtJt2FD �EE P�RMIT# 4ICENSEFiEQUIKGp FEE P�7ZIvil1"it LICGNStiREQUfRED FEE PERh77T#
<SO sq.ft. S50 >25;OQQ cq�� , $2$5 V ENI?ING-FOOD $25
<2>,OOQ sq:R. $iSQ �'RqZBN llESSER'C $46 =TqBACG4 5110
NA�tECNANGE: $IS AMOUNT DLT� = � i85,t3b '
*****PLEASE TURIY OVER AND GOMPLETE OTHEl2 SIDE OF FORM*x**"
ADMI1�fISTRATI4N w � �
Under Cha�ter 152,Section 25C,Subsection 6,the TQwn of Yarmouth is now required to hold issuance or renewal �
of any license or permit ta aperate a business if a person or company does not have a Certificate Qf Worker's
Compensation Insurance. THE ATTACHEl? STATE WORKER'S COiVIPENSATION INSURANCE
AFFIDAVTT MUST BE COMPLETEI}AND SIGNED,OR
GERT.OF INSURANGE ATTACHED
OR '
WORKER'S C�MP.AFFIDAVIT SIGNED AND ATTAGHED�
Town af Yarmouth t�xes and liens must be paid priar to renewal or issuance of yaur permits. PLEASE CHECK ;
APPROPRIATELY IF PAID:
YES_�� NO
MQTELS AND OTHER LODGING ESTASLISfIMENTS '
TRANSIENT OCCUPANCY: For purposes of the lisnitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and sh�rt term occupancy,ardinarily and customarily assaciated with motel and hotel use.
Transient occugants must have and be able to demonstrate that they maintain a principal place of residence ,
elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of nflt more than thirty(3Q)days,and
an ag�regate of not mora than ninety(90)days�vithin any six(6}month period. Use of a guest unit as a residence or '
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room dccupancy ,
Excise,as defined in M.G.L.c.6�G ar 830 eMR 64G,as amended,shall generaIly be considered Transient.
POOLS �
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POOL OPENING:Ali swimming,wading and whirlpaals which have been closed for the season must be inspected �
by the Health i7epartment prior to opening. Cantact#he Heatth Department ta schedule the inspectian three(3}
days�rior to opening.PLEASE NOTEs Peaple are NQT allowed to sit in the pool area unril the paol has been ,
inspeeted and opened. � j
POOL�VATER TESTING; The water must be tested for pseudomonas,tatal coliform and standard plate count M
by a State certified lab,and subrnitted to the Health Department three(3)days prior to opening,and quarterly f
thereafter. �
POOL CLOSINGs Every outdoar in ground swimrning paol must be drained or covered within seven(7)days af �
closing. �
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FOOD SERVICE �
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SEASONAL Ft}OD SERYICE OPENING: E
All food seruice establish�nents must be inspected by the Health Department prior ta opening. Please cantact the
Health Department ta schedule the inspection three(3}days priar to opening.
CATERING P�LICY: (
Anyone wha caters within the Town of Yarmauth must notify the Yarrnouth Health Department by filing the
required Temporary Food Service Application forrn 72 hours prior to the catered event. These forms can he
obtamed at the Health Department,or from the Town's website at wcuvv.yarmouth.ma.us under Health Department,
Dowuloadable Farms, i
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FROZEN DESSERTS: (
Frozen desserts must be tested by a State certified lab prior to opening and monthfy thereafter,with sample results i
submitted to the Health Depariment. Failure to do so will result in the suspensian ar revocation of your Frozen
Dessert Permit until the abave terms have been met. ;
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OUTSIDE CAFES: ;
Outside cafes{i.e.,outdoar seating with waiterhvaitress service),must have prior approval from the Board af Health. ;
OUTDOOR COOKING: '
Outdaar caoking,prepararion,or display of any food product by a retail or food service establishment is prahibited. ;
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMI'LETED RENEWAL APFLICATION(S)AND REQUIRED FEE(S)BY DECBMBER 15,201�.
ALL RENOVATIONS TO ANY FOOD $STABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i
EQUIPMEN'I`,ETC.),MUST BE REPORTED TO AND AFPROVED BY THE BC3ARD OF HEALTH PRTQR
TO COMMENCEMENT. RENOVATIONS MAY RE � LAN.
DATE: �0�22�20�5 SIGNATURE.
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PRINT NAME&TITLE: Salvi Couto President
ae�.iaiov�s '
_� The Commonwe�Cth of Massachusetts
K Department of Industrial Accidents
� Of�ce of Investagatio�rs
600 Washington Street
� Boston,MA Q2X 11 �
t-� www.mass.gov/dia ;
Workors' Compensation Insuranee Affidavit: General Businesses
Ap»�icant Information Please Print Lc�iblv
Business/Organization N�me: Cape Management Team, LLC DBA Dunkin Donuts
Address: 1050 Rte. 28 � i
City/State/Zip:S. Yarmouth� MA 02664 Phone#: 508-394-1161 � ';
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Are you�n employer?Check thc appronriate box: Business Type{reguired):
1,(� I am a employer with �6 employees(fall and/ 5. ❑Retai[ ;
or part-tirne).* 6. �]Resta[trant/Bar/Eating Establishnient i
2.❑ I am a sole proprietor or partnership and have no 7, �p��and/or Sales(incl.real estate,auto,etc.) ;
employees working for me in any capacity.
[No workers' comp,insurance z�equired] �• ❑Non-pro�it �
3.❑ We are a corporation and lts off'icers have exercised 9. ❑EntertAinment
their right of exemption per c. 152, §1(4),and we hlve 10.[�Manufacturing
no employees. [No workers'comp.insurance required]* 11.[]Ilealth Care
4.❑ We are a non-profit organization,staffed by volunteeis,
with no employees. [1Vo workers' comp.insurance req.] 12,[� Other
� '�Any appllcant tliat checks box#1 must�lso fdl ouf the section befow showlug dieir workers'compensation pol icy in1'ormation.
*'�Tf thc corporate officers have exempted themselves,but ihe corporntion.hos othcr cmployees,a workcrs'compensation policy is requtred and such an
organization should.check box#1. "
I am an emnloyer�liat�S provf�ling workers'compensatton insurnnce for my em�uloyees. 13e6ow is tfie policy infornzntlon.
InsuranceCompa�yName: AM Guard Insurance Co.
Insurer's Address: 16 South River Street PO Box A-H
City/stat�/zip: Wilkes-Barre PA 18703-002Q
Policy#or Self ins,Lic.# R2WC632118 Expiration Date: 4/22/16
Attacli a copy of the warkers'compensatio��policy declaration page(shawing tlae policy number atid expiration date).
I'ailure to secure coverage as requirad under Section 25A of MGL c, 152 can lead tQ the impositian of criminal penalties of a
�ne up to$1,500.00 and/or one-year imprisonment,as well as civil pe�iaities In the forin of a STOP WORIC ORD�R and�fi.ne
of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverag�varification.
�
I�lo kereby cert , n� t a penalttes of perjury tltrtt tlie infurmatlort I�roviderl above ls true nrt�l co�rect. I
i nature: �--� D�te: 10/14/15 '',
Phone#� 78�-279-�290 �
O�cial use only. Da not wrile tn tli�s area,to be completed by ctty or tuwn nfjic�al. '
City or Townc Perinit/License# I
Issuing At�fhorlty{circle one):
1.Board of Hcalth 2.Buildiag Dc���rtmeut 3.City/Town Clerk 4.Licensing Boarc� 5.Selectmen's Office
6.Other
Contact Persan: Phone#:
www.mflss:gov/dia
� BERKSHIRE HATHAWAY Worker's Comoengakion and Emalover's Liabili�y olicv
INSURANCE AmGUARD Insurance Compdny -A S#ock Company
����� COMPANIES Policy Numbe�R2WC632118 ,
Renewal of R2WC595758
NCCI No. [21873].
Policy I�formation Page (AR)
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[i]Named Insured and Mailing AddreSs Agency
Cape Management Team lLC EASTERN INSURANCE GROUP
ib9 Main Street 233 West Cent�al Street
Stoneham, MA 0218Q Natick, MA 01760
Agency Code: MAEAINIO
Federa) Emp{oyer's ID Ynsured is Limited uability Co. (LLC)
Risk ID Number 456527
Additional Names af Insured
(N2) Dunkin Donuts ,
Locatians on Poticy - See Extensian af Infarmation Page -Schedule of Lacations I
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[2] Policy Pe�iod 4
From Apri! 22, 2015 to April 22, 20l6, 12:01 AM,standard time at the fnsured's mailing address. �
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[3] Coverage �C
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A. Workers'Compensation Insurance- PaK One of this po(icy app(ies ta the Warkers'Compensation �
Law of the folfowing states; Massathusetts
B. Employer`s Liabtlity Insurance- Part Two oF this policy applies to work in each of the states listed
in item [3�A. The limits of our liability under Part Twa are: �
Bodily Injury by Accident-each accident $1,OOQ,000 ; �
Bodily Injury by Disease- each emptoyee $1,000,400
Bodily Injury by Disease- policy limit $1,00O,OOQ
�, Refe�to Residual Market Limited Other States Insurance Endorsement WC2003068
D. This policy includes these endorsements and schedules: ;
See Extensbn oP Information Page-Schedule af Forms �
[4] Premium �
The Premium Basis and,therefore, the premium will be determined by our Manual of Rules,
Classifications, RaCes,and Ratmg Plans. All required information is subject to verification and change by
audit. (Ca�tinued on anather page)
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Total Estimated Policy Premium $ 39,557
Tatal Surcharges/Assessments $ 1,T65.OQ
Total Estimated Cost $ 41,322.00
tNrERNAL usE xx Page- 1- Informatian Page
MGA :R2WC632118 WC OOOO�lA
Date :Q4/02/2015
MANOTE
Issufng Office:P.O.Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-OQ20�www.guard.com
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BERKSHIRE HATHAWAY WQrker's ComDensation and Emplover's Liabilitv Policv
G U A R D INSURANCE AmGUARD Insurance Company-A Stock Company
GOMPANIES Policy Number R2WC6321i8
Renewal of R2WC5957S8
NCCI No. [21$73],
Policy Information Page(AR}
E�ctension of Information Page
Schedule of Locations
(L2} 1050 Route 28, South Yarmouth, MA 02664(04/22J2015- 04/22/2016)
(L3) 526 Route 28,West Yarmouth, MA Q2673(04/22/2015 -04/22/2Q16}
(L4) 1353 Route 28, South Yarmouth, MA Q2664(04/22/2015- 04/22/2016)
(LS) 14 16 East Main Street,West Yarmouth, MA�2673(04/22/2015 - 04/22/2016) :
(L6} 39 Nathan Ellis Highway, Mashpee,MA 02649 (04/22/2015-04/22(2Q26)
(lT} 156 Iyannough Road, Hyannis, MA 02601 (04J22/2015- 04/22/2016)
(L8) 792 Main Street, Osterville, MA 02655(04/22/2015 - 04J22/2016)
(L9} 40 5outh Street, Mashpee, MA 02649 (04(22/2015-04/22/2016)
(L10) 343 Scenic Highway, Buzzards Bay, MA 02532(04/22(2015- 04/22/2026)
(Lii) 702 Iyannough Road, Hyannis, MA 02601{04/22J2015 -Q4/22J2U36}
(L12) 464 Route 28 Main Street,West Yarmouth, MA 02673(Q4/22/2015-04l�2/2016)
Extension of Information Page
Schedute of Forms
* WC000040C-STANDARD POLICY
* WCOOOOOlA-INFORMATION PAGE
* WC000414- NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
* WC2001Q1 - MA TERR. RISK INS. PROG REAUTHORIZATION
" WC2001Q2 -MA NOTICE OF PEND LAW CHANGE TO TRIPRA
* WC2Q0301 - MA LIMTfS OF LIABILIfY ENDORSEMENT
* WC2003Q2A-MA ASSESSMENT CHARGE ���'
` WC200303D- MA NOTICE TO POL.ICYHOLDER ENDORSEMENT i
* WC2003066- MA LIMITEQ OTHER STATES BENEFIT ENQT. �
* WC2Q0307 - MA ASSIGNED RISK PQQL ELIGIBII.TfY ENDT.
� WC200405 - MA PREMIUM DUE DATE ENDORSEMENT ;
* WC200601A- MA CANCELLATION ENDORSEMENT '
" WC2006Q4 - MA POLICY OEFINITION ENDORSEMENT
* As part of our ongoing commitment to environmental responsibility throughout our operations, we have
chosen not to reprint those forms(marked with an asterisk}that have not changed and were previausly I
sent to yau, You can obtain a new copy of any of these farms by accessing your account infarrnation at �
our Policyho/der Servlce Center(a selection available via our website at www.guard.com). Please be ;
aware that you wiif be asked ta enter your policy number, policy inception date, and federal ID number in ;
order to log on to this secure portion af our site. ' '
Alternatively, you can tontact us vfa phone at 804-673-2465; our Customer Service Representatives will i
either be abte to help you{ocate a dacument yaurself or can send a copy to you. As always,we thank you �
for selecting us as your insurer. We look forward ta serving you!
Remember, we make a variety of loss control services available ta you at na
additional charge, including educational resources accessible from our Policyholder
Service Cenrer at Polfcyho/der Service Center.
INTERNAL USE �cx Page-2- Information Pa e �
MGA :R2�YC632218 9
Date :04/02/2015 WC QOOOOlA
MANOTE
Issufng Office: P.O,Box A-H, i6 S.River Street,Wiikes-Barre, PA 18703-002Q •www.guard.com