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� TOWN()F YARMOUTH BOARD�F HEALTfI c��c�e�Z,t-7g I
APPLICATION FUR LiCENSElPERI�iIT-2Q16 '� �`��''+ ��' ��� ` �"'� C
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""' *PIease complet�f�rm and attach all necessarr}�dncuments by December 1S.�'it15 ,';���i i I
Failare to do so�vzll result in the return of your applicatian paeket. 3 , , �
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ESTEIBLISHMENT NAIVIE: Caoe Manaqement Team LLC DBA Dunkin'Donuts TAX ID• t _ l�
LOCATION AI3DRESS; 464 Rt.28 West Yarmouth MA 02673 T`EL.#:�a�-z�s-o2so r
MAILING ADDRESS:�69 Main Street Stoneham,nnA o21so � ;,� �
E-I��it�IL A.DDRESS;office coutomana4ement com ���' �
OWNER NAME: �a� o�to . 0 5:z �`� `
CORPORATION NA1V1E(IF APPLICAEiLE):���nkin'Don�ts '� � • �
MANAGER'S NAME;Denise Cook TEL.#:�ai-z�s-ozso �
1V1AILIN('.�ADDRF,SS:169 Main Street Stoneham MA 02180 �
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POOL GERTIFICATIONS. ? -. (
The pool supervisar must be certified as a Pool Operator,as required by State taw. Please list fhe designated *��- �` '-"-
Paot Operator(s)and attach a copy of the certificatian to this form. '
l.N/A 2. '
Paol operators must list a minimum af twa employees currently certified in standard First Aid and Community ,
Gardiopulmanary Resuscitatian(CPR),having one certified employee on premises at all times. Please list the
employees belaw and attach cogies af their certifications ta this form.The Health Department will not use past
years'records. You must provide new copies and maintain a file at your place of business.
1. N/A �.
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FOOD PROTEGTI(7N MANAGHRS-CERTIFICATIONS:
All food service establislunen�ts are required to have at least one full-time employee wl�o is certified as a Faad
Protection Manager,as dafined in the State Sanitary Code for F'ood Service Establishrnents, l Q5�MR 594.000.
Please attach copies of certification to this application. The Health Department will not use past years'records. '
You must pra��ide new copies and maintain a fi[e at your estabtishment. I
l. Fd�ardo •orr-ia �, Mynneka Holmes f
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PERSON IN CHARGE; �
Each food establishin�nf must have at least one Person In Charge(PIC)an site during hours af caperation. �
1. Karen O'Connor �• P
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ALLERGEN CERTIFIGA"TTONS: �
All food service establishments are required to have at least one fu}l-time employee who has Allergen certificatian, �
as defined in the State Sanitary Gode far Food Service Establ'tshments,l OS CMR 590.009{G)(3)(a). Please attach �
copies of certification to this application. The Health Department will not use�ast years'recards. You must f
provide new capies and mautt�in a file at your establishinent. (
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1. Denise Cook 2. Karen O'Connor �
HEIMLICH CERTIFICATIONS: �
Ail food service establishments with 25 seats or more must have at leasi ane employee traineB in the Heimliet� i
h3aneuver an the premises at a1i times. Please list your employees trained in anti-chokmg proceduzes betow and
attach copies af employee certificarions ta this form. The Heatth Department}vill not use past years'records, i
You must provide new copies and maintain a file at your piace of business.
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RESTAURANT SEATING: TQTAI,# �a
OFFICE USE ONL�' '
LODGING:
L[CENS6 REQiIlR,�D FEE PERR4II'# L(CENSE R£QUIFtF.D FEE PERTv1IT� LIGENSF REQGIREl7 FEE PERMIT# ��
6&B S55 CABiN $>5 MOTEL $114
—INN $55 CA�1P $SS S1u1�14MfNG POOL$��flea
_L04GE $55 �T'RAILER PAKK �105 _WHIRLP001, $110ea
FOOP SER4ICE:
LICENSE RE UIRED FEE PE �41t +� LTCENSE RFQU112FD FEE PC2M1T i! LI�F?JSG REQUII2ED FEB PERMIT� C
�„d-1�0 SEA�`S $IZS�f�;�b�'{ CONTINENTAL $35 NUN-PROFTT 33q ,
>t00 SBATS S?40 �CQR4M4N V[C. S60 �SZ �WiiULESAL,C S80 !
— —2ESID.KITCHEN $80 +
RETAIL SERYICE>
LICGNSE REQU1REi7 FEE PERhi1T# LICENSBREQ[IIRGI? FEE PERINIT# LICFNSE REQUIRED FEE PERhtIT# I
e5�:�q.ft. $54 �25,000 sq ft. $285 VEIvD1NC`r-FOOR S25
—<25,000 sq.ft. $130 —FRC?ZGN DESSERT $�0 _—'TC76A�C0 $I I0
tv;ahiE cH�Nc�: �is AMOUNT DUE = � 185,ot�
****+PLEASE TURN O�'ER AND GO�iPLET�OTHER SIDE OF FORht*****
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ADMINISTRATION
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Under Chapter 152,Section 25C,Subsection 6,the Tovvc�af Yannouth3s naw required to hold issuance or renewal !
of any license or permit ta operate a business if a person or company does not have a Certificate of Warker's
Compensation Insurance. THE ATTACHED STAT'E WORKER'S C�MPENSATION INStIRANCE
AFFIDAYIT MUST BE COMPLETED AND SIGNED,OR �
CERT.O�INSURANCE ATTAGHED �
OR j
WQRKER'S COMP.RFFIDAVIT SIGNED AND ATTAGHED�_ 4
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Town of Yartnauth ta}ces and tiens must be paid prior to r�newal or issuance of your permits. PLE.�SE CHECK
APPROPRIATELY IF PAID;
YES__a� Nd �
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MaTEL3 AND OTHERLODGING ESTABLISHMENTS ,
TRANSIENT OCCiIPANCY: Far purposes ofthe limitations af Motel or Hotel use,Transient occupancy shalt be �
limited to the temporary and short term occupancy,ordinariiy and customarily associated with motel and hotel use. �
Transient occupants must have and be able to demonstrate that they maintain a principal piaca of residence
eIsewhere.Transient occupancy shall generally refer to continuous occupancyof nat more than thirty(30)days,and I;
an agge�ate of nat more than ninety(90)da;s within any six(6)month geriod. Use of a guest unit as a residence or ;
dwelling unit shali not be considered transient. Occupancy that is subject to the cnllection of Room Occupancy �
Excise,as defined in M.G.L.c.64G ar 830 CMR 64G,as amended,shall generally be considered Transient.
PC?C)LS
POOL OPENING;All swimming,wading and whulpoals whieh have been closed for the season must be inspected
by the Health Department prior ta apening. Contact the Health Department to schedule the inspection three(3)
days prior to opening.PLEASE NOTEa People are NQT allawed to sit in the pool area until the pool has been
inspected and opened.
POOL�'VATER TESTING: The water must be tested for pseudomanas,total caliform and standard plate count
by a State certified lab, and submitted to the Health Department three(3) days prior to opening,and quarterly
thereafter.
POQL GLOSING.Every outdoor in groand swimming pool must be drained or covered within seven(7}days of
closing.
FdOD SERVICE
SEASQNAL FOOD SERVICE OPENING:
All faod service establishments must be inspected by the Health Department prior to opening. Please cantact the
Health Department ta schedule the inspection three(3)days prior to opening.
CATERING POLICY-
Anyone tivho caters within the Town of Yarmouth must notify the Yarmouth H�alth Department by f ling the
requ�red Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health I}eparmlent,or from the Towr►'s website at ww;w.varmonth.ma.us under Health Department,
Downloadable Forms.
FRUZEN DESSERTS: i
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results ,
submitted ta the HeaIth Department. Failure to do so will result in the suspension or revacatian af your Frozen
Dessert Perniit untit the above terms have been met.
OUTSIDE GAFES.
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must hava prior approval from the Board of Health.
OUTDOOR CCIOKING;
Outdoar cooking,preparation,or display of any food product by a retail or food service establishmenc is prohibited. ,
NQTICE:Perrnits run annually from January 1 to December 31. IT IS YOiJR I2ESPONSIBILI'I'Y TO RETURN
THE COMPLETED RENEWAL APPLICAT`ION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2015.
ALL REN�VATIONS TO ANY FOOD ESTABLISHMEN'I', MOTEL OR T'OOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED Tt?AND APPRdVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MA j
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DATE:10��20�s SIGNATURE: �
PRINT NAME&TITLE: Sa�vi Couto Pr �ident
Rev.J Ott3 U I S
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_� The eommonwealth ofMassachusetts
� Depa�tment of Industrial Accidents ;
� Of�ce of Investigations
� 60D Washington St�eet
� - Boston,MA Q2X.1.1 4
t-�6 www.mass.gov/dia . �
Workers' Compensation Insuranee Affidavit: General Businesses
Annticant Informat�oa� Please Print Lc�.iblv
Business/Organization.Name: Cape Management Team, LLC DBA Dunkin Donuts
464 Rte. 28 �
Address: �
City/State/Zip:W. Yarmouth, MA 02673 Phone#: 508-862-9062 �
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Are you an employer?Check the appropriate box: Business Type(required): �
1.� I am a employer with �5 employees(full and/ 5. ❑Rettiit
or part-time).* 6. �]RestarirandBar/�ating�stablishment
2.❑ I Am a sole proprietor or partnership and have no 7, �p�ce and/or Sales(incl,real estate,auto,etc.)
einpfoyees working for me in any capacity. �
[No workers' comp,insurance required] 8• ❑Non-pro�t
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1{4),and we have lp.[�]Manufactueing
no employees. [No workers'comp,insurance required]* �� ����alth Ca�•e
4.❑ We are a non-profit or�anixation,staffed by voiunteeis,
with rro employees. [No workers' comp.insurance req.] 12,[] Other
*Any applicaot that cheeks box#1 mt�st�Iso f3ll out the section below showlug d�eir workers'compensntion pol icy InformaEion.
"*Tf thc corporate officers hava exeiupted tl�emselves,but 1he corporationlias oUicr employees,a workers'eo�npensation policy is reqaired and sud�an
or�aiilzatton should.check box#1. "
I am nn em,�loyer t/i�t is��rovlrll�g workers'con�pensation iMsurarlce for my emrrloyees. I�C�OW!S ftt@�O�Cy�11fOYH7lllJ0it.
Insurance Company Name: AM Guard Insurance Co.
Insurer's Address: 16 South River Street PO Box A-H
city/sta�e/zip: Wilkes-Barre, PA 18703-4020
Palicy#or Self-ins,Lic.#� R2WC632118 Expir�tion Date: 4/22/16 '
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Attacli a copy o�'the warkers'compensation holicy declaration page(showing the policy number n��d expiration date). j
P'ailure to secure coverage as requireii under Section 25A of MGJ.c, 152 can lead to the imposition of criminal penalties of a
�ne up to$1,500,00 a�id/or one-year imprisonment,as well as cIvil penalties in tx►e forin of a STOP W�RK.ORD�R and a fine
of up to$250.00 a day against t�Ze violator, Be advised tl�at a copy of this statement may be forwarded to the Of�ce of .
Investigations of the DIf1 far insurance coverage verificAtion, '
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X rlo hereby certt utei «n[l penadtles af perjury titnt tfte!t{fbtniatlon provuled above fs true nrt�l correcL '
Si nature• Date: 10/14/15 '
Ph e#: 78�-279-�29� ,
Offtcial use only. Da not write ltt tli�s nrea,to be completerl by city or totvn of,fic�al. '
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City or Town� Permit/License# ,
Issairxg AYithority(circle one):
1.Board of�Icaltlx 2.Building Departmei�t 3.City/Town Clerk 4.Licensing Board 5.Selectmeu's Office ,,
d.Othcr
Coutact Person: Phone#:
www.mnss:gov/dia
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BERKSHIRE HATHAWAY �Norker's Comnen�ation and�mniover's Liabilitv Policv I
INSURANCE AmGUARD Insurance Compdny -A Stock Company �
�� ��� COMPANIES Ralicy Number R2WC632118 �
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Renewaf of R2WC595755 �
NCCI No. [21873]. 4
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Rolicy I�formation Page(AR) �
[i]Nam�d Insured and Mailing Address Agency !
Cape Management Team LLC EASTERN INSURANGE GROUP j
lb4 Main Street 233 West Centrat Street �
Stoneham, MA Q2180 Natick, MA Oi760
Agency Code: MAEAINIO
Federa) Employer's ID I�sured is �imited Uability Co. (LLC}
Risk ID Number 456527
Additional Names of insured k
(N2) Dunkin Donuts
LocatiOns an Policy -See Extensian of Information Page - Schedule of Lacations
�Z] Policy Pe�iod
From Ap�i! 22, ZO15 to April 22, 2016, 12:01 AM,standard t(me at the insured's maiifng address.
[3] Coverage
A. Workers'Compensation Insurance- Part One of this poticy appfies to the Workers'Compensation
Law of the follawing states: Massachusetts
B. Employer's Liability Insurance- Part Two of this poticy applies to work in each of the states Itsted
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident-each accident $1,0OO,OQO
Bodily Injury by Disease- each employee $1,000,000
Bodily Injury by Disease- policy limit $1,OQ0,000
�, Refer ta Residual Market Limited Other States Insurance Endorsement WC2003068
D. This policy inciudes these endorsements and schedules:
See Extension of Information Page- Schedule af Forms : f
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[a] Premium (
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, �
Classifications, Rates, and Rating Plans. Alt required information is subject to verificatian and change by �
audit. (Continued on anothe�page)
Total Estimated Policy Premium $ 39,557
Totai 5urcharges/Assessments $ 1,765A0
Total Estimated Cost � 41,322.00
If�TERNAL USE xx Page-1 - Information Page �
MGA :R2WC632118 WC 004001A ;
Date :Q4/02J2015
MANOTE
Issuing Office:P.O.Box A-H, 16 S. River Street,Wilkes-Barre, pA 18703-d020�www.guard.com
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BERKSHIRE HATHAWAY Warker's Comnensation and Emntover's Liabilitv Policv
� �U A R Q INSURANCE AmGUARD insurance Company -A Stock Company
GOMPANIES Policy Number R2WC6321i8
Renewal af R2WC595758
NCCI No. [218?3], ,
Rolicy Information Page(AR} '
Extension of Information Page
Schedule of Locations
(�2) 1050 Route 28, South Yarrnouth, MA 02664(Q4/22J2015- 04/22/2016) ,
(L3) 526 Route 28, West Yarmauth, MA 02673 (�4/22/2015 - 04/22/2016}
(L4) 1353 Route 28, South Yarmouth, MA 02664(04j22/2015- 04/22/2016} ,
(LS] 14 16 East Main Street,West Yarmouth, MA 02673(04/22/2015 - 04/22/2016)
(L6} 39 Nathan Ellis Highway, Mashpee, MA 02649 (04/22/2015 - 04(22/2016)
(L7) 156 Iyannough Road , Hyannis, MA 02601 (04/22/2Q15- 04/22/2016)
(L8) 792 Main Street, Osterville, MA 02655(04/22/2015 -04J22/2416) '
(L9} 40 South Street, Mashpee, MA Q2649(04/22/2Q15-04/22/2016} '
(L10) 343 Scenic Highway, Buzzards Bay, MA 02532 (04/22/2Q15- 04j22/2016) '
(lli) 702 Iyannough Road , Hyannis, MA 026�1(04J22/2015 -04/22/2016}
(L12) 464 Route 28 Main Street,West Yarmouth, MA 02673(Q4/22/2d15-04/22/2016�
Extension of Information Page : .
Schedute of Forms
' WCQOOOOOC-STANDARD POLICY ,
* WCQOOOOlA-INFORMATION PAGE i
* WCOa0414- NQTIFICATION OF CHANGE IN OWNERSHIP ENDT �
* WC200101 - MA TERR. RISK INS. PROG REAUTHORIZATION �
" WC2001Q2 - MA NOTICE OF PENO LAW CHANGE TO TRIPRA
* WC200301 -MA LIMITS OF LIABILITY ENDORSEMENT �
* WC204302A-MA ASSESSMENT CHARGE
* WC200303D- MA NOTICE TO POLICYHOLDER ENDORSENIENT
* WG2003068- MA LIMITEQ OTHER STATES BENEFIT ENDT.
* WC2Q0307 -MA ASSIGNED RISK POOL ELIGIBII.TtY ENDT. (
* WC204405 - MA PREMIUM DUE DATE ENDORSEMENT i
* WC200601A- MA CANCELLATION ENDORSEMENT . f
* WC20a604 - MA POLIGY DEFINITIQN ENDORSEMENT �
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* As part oP our ongaing commitment to environmental responsEbility throughout aur operations, we have �
chose�not to reprint those forms(marked with an asterisk}that have not changed and were previously
sent to you. You can obCain a new copy of any of these forms by accessing your account information at
our Policyholder Servlce Center(a sefection available via our website at www.guard.com). Please be
aware that you will be asked to enter your pniicy number, policy inception date, and federal ID number tn
order to log on to this secure portion of our site. i
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Alternatively, you can contact us v(a phone at 800-673-2465; our Customer Service Representatives wili ;
either be abte to help you locate a document yourself or can send a copy to you. As always,we thank you
for selecting us as your insurer. We took forward to serving you!
� Remember, we make a variety of loss control services available to you at no
additional charge, including educational resources accessible from aur Policyho/der
� Service CenCer at Poticyho/der Service Center.
INTERNAL USE xx Page-2- Information Page
MGA :R2WC632118 WC 000061A
Date :04102/2Q15 '
MANOTE
Tssuing Office:P.O.Box A-H, i6 S.River Street,Wilkes-Barre, PA 18703-002Q •www.guard.com
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