HomeMy WebLinkAboutApplication and WC�
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� � TOWN O�XARMOCTTH BQARD OF HEALTH ts. �.r�q Kn� �r;
� APPLICATIQN FOR LICEI�'SE/PEI2MIT-28 « �-�; .3 �,� �.."`��"`"�".'M`�`
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'`°' *Plesse complete form and attach all necessary documents y�p� ` TS 1� . ' ' ;
� Failure to do so will result in the retum of your appi',a1�on p et '• � � � � �:� i
� � �
F.:_°.� a,._ra. ': :3 �
ESTA$LISH11�tENT NAME: Cape Management Team,LLC DBA Dunkin'Donuts TAX ID: � �
LOCATION ADDRESS: �s east Main street west Yarmoutn,MA 02673 TEL.#: 7s1-27s-o2so F � '
Mr1ILING ADDRESS: �ss Main street stoneham,MA oz�so ' ' '
� �, :�� i
E-MAIL ADDRESS: office(a�coutomanagement.com p �
� UWNER NAME` sal Couto,CEo � ' -�-- -� �
GORPORt�TION NAh�1E(IF AFPLIGABLE): Dunkin'Donuts � ;
IvLANAGER'S NAME:Denise Cook TEI„#; 781-279-0290 ��-•-T--�--_--.-----,.......�
MAIX.ING AD���S: 169 Main Street Stoneham,MA 02180
� POOL CERTIFICATIONS:
� The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the desi�nated
Pool Operator(s)and attach a capy of the ceriificatinn to this form.
i 1. N/A �.
Poal operators must list a minimum of two employees currently certified in standard Firsi Aid and Gommunity
Cardiopulmonary Resuscitatian(CPR),havu3g one certified employee on premises at all times. Please list the
employees below and attach copies of their eertifications to this form.The Heaith Department will not use past
years'records. You mnst provide new copies and maintain a�le at vour plaee of 6usiness.
1. N/A �.
3. �.
FQOD PROTE(;TIQN MANt1G�RS-CERTIFIGATTONS:
All food service establishments are required to have at least ane full-time employea�vho is certified as a�ood
Protection Manager,as defined in the State Sanit�ry Code for Food Service Establishments, 1fl5 GMR 590.000.
Please attach copies af certificatian to this appiication, The Health llep»rtment will not use past years'records.
Yau mustpra«de new copies and maintain a fiile at your establishment.
�
; ], Eduardo Correia e,
i
� PERSON IN CHARGE:
Eaeh food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1, Dawn Lopes ?
ALLERGEN CERTIFIGATIQNS:
All food ser��iee establishrnents are required to t►ave at least one full-time employee c�ho has Aller�en certificativn,
as defined in the State Sanitary Gode far Food Service Establishments,105 CMR 590A09(G)(�)(a). Please attach
cogies of certification to this application. The Heal#h Department wiil not use past years'records. You must
provide new copies and maintain a file at your establishment.
l, Denise Cook 2, Dawn Lopes
HEIh1LIGii CERTIFICATIONS:
All food service establishments with 2� seats or more must have at least one employee trained in the Heimlich
1�Ianeuver on the premises at all titnes. Please list your employees trained in anti-choking procedures below and
attach copies of emplayee certifications to this form. The Health Department will not use past years'reeords.
You must provide new copies and maintain a�le at�=our place of business.
l, N/A �,
3. 4.
' RESTALTRANT SEATING: TQTAL# �
QFFICE USE ONLY
�,a�c�Nc:
i t,IC61tiS�REQL'1R�D PfiE PERh1fI# LICEiNSF RE(2L7R�D FEE P�,RAAIT# LiGEt+1SF..REQC.ARED FE� FERA9I`I'#
6&.B $SS GABIN SS5 MO"I'EL $Ild
—INN $SS �CANiP $55 —S�k7MMTNGPQl7L$ItOea.
��LODGE $55 TRAiLERPARK $10'� WHIRLPOOL $IlOea.
FOOD SERti ICE:
UCL-'NSG ItEQUIRED FEL- M1T# i,TCENSG REQUIRED FEE PERR9I7# LICENSE RE UIRED FEE PERAAIT#
�0-IOOSEATS fiI2S %���8 —CONTINENT'AL $35 NUN-PRO�)T 53d
>1DOSEA'CS $2Q0 G4I�iM(1NVIC. 360 "�WHOLESILE S84
� —RESID.K[TGHEN$84
RETAIL SERV IC�:
L,ICENSt,Rf;QUIREC? I�$E P�RMI'T# LICENSE t2EQU1RGD FEE Pt;Rh91`I'� LICENSE RE(jUIRLD P�E t'EIL•'v11T#
<SO sq.ft. S50 >2S,�QtI sq.ft. 5285 VCNDIN'G-FpOD 525
=<25.DD0 sq.ft. $15Q _FROZEN DESSER7' $4Q _TOBACCO St 14
1�AhtECHANGE: $15 AMOUNT DUE _ $ I2S•�C?
. ,:. ���`��
`****PLEASE'NA�Q�'ER AND C01NPl.ETE OTHER SIDE OF FORM***4" '6� �-�* �'���
r
AD11�tINISTRATION '
Under Chapter 1�2,Section 25C,Subsection 6,the Town af Yannauth is now required to haid issuance or renewal
of any license ar permit to aperate a business if a person or company does not have a Certificate of Worker's
Compensation Inswance. THF ATTACHEI} STAT'E WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMP'LETED AND 3IGNED,OR
CERT.t7F INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED X
To��vn of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE GHEGK
APPROPRIATELY IF PAID:
YES x NO
MOTELS AND OTHER LODGING ESTABLISHIYIENTS
TRANSIENT OGCUPANGY: For purposes of the limitations of Motel or Hotel use,Tzanszent occupancy shall be
limited to the temporary and short term accupancy,ordinarily and customarily assaciated with matel and hotel use.
Transient accupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of nat more than ninety(94)days within any six(6)month period. Use of a guest unit as a residence or
dwellin�unit shall not be considered transien� Qccupancy that is subject to the callectian ofRoam Qecupancy
Excise,as defined'zn M.G.L.c.b4G or 830 CMR 64G,as amended,shall generally be considered Transient.
POQLS
PO4L OPENING:A11 swimming,wading and whirlpools which have been clased for the season must be inspected
by the Health Department prior ta opening. Contactthe Health Deparkneat to schedule the inspectian three(3}
days prior fo opening.PLEASE NOTE:People are NOT allowed to sit in the paol area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested far pseudornonas,tatal cotiform and standard plate counf
by a Stat�certified lab,and submitted ta the Health Department three(3)days prior to opening,and qeaarterly '
thereaiter. '
POOL�LdSING:Every outdoor in ground swimming pool must be drained or cavered within seven(7)days oF
closing.
FC}OD SERVICG '
SEASONAL FO!QD SERVICE dPEi�TING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three{3}days prior to apening.
CATERING P�LIGY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Heaith Department by filing the
required Temporary Fnod Service Application form 7Z hours prior ta the catered event. These forms can be
obtained at the Health Depar[inent,or from the To�m's website at www.varmouth.ma.us under Health Department,
DownIoadable Forms.
FROZEN DESSERTS:
Frazen desserts mnst be tested by a State certified lab prior to apenin�and monthly thereafter,with sample results
submitted to the Health Department. Failure ta do so will result in the suspension or revocatian of yaur Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outde�or seating with waiterlw�aitress service),must have prior approval from the Board of Health.
QUTDOOR COOKING:
Outdoor cookin�,preparatian,or display of any faod product bya retail or foad service establishment is prnhibited.
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE"TURN
THE COMPLETED RENEWAL APPLIGATION(S)AND REQUIRED FEE(S)BY DEGEMBER I5,201�.
ALL RENOVATIONS TO ANY FOOD ESTABLISF-TMENT, MQTEL OR POOL (i.e., PAINTING, NEW
EQUIPIv1ENT,ETC,),MUST BE REPORTED TO AND APPRQV BY THE BQARD OF HEALTH PRTOR
TO COMMENGEM�NT. RENOVATIONS MAY RE �RLAN. �
D.L1TE. ioiz2i2o�5 SIGNATURE:
PRINT'NAME 8c TITZE: galvi Couto.President
�v.iotavts � �
T
_� The Commonwe�clth ofMassachusetts
� Department of Industrial Accidents �
J � Of�ce of Investdgatior�.r
600 Washington Street
��� - Boston,MA 42X11
t-�• www.mass.gov/dia
Workars' Campensation Insurance Affidavit: General Businesses �
Apulicant Information Please Print Lc�ib�
Business/(�rganizationNttme; Cape Management Team, LLC DBA Dunkin Donuts
Address: 16 East Main Street .
City/State/Zip:W.. Yarmouth. MA 02673 Phoiie#: 508-862-0124 �
Are you nn employer?Clieck thc app►•oprinte box: l3usiness`Type(required):
1.� I am a employer with 5 employees(full and/ 5. ❑Retail
Or pa�-time).* 6. �RestacYrant/Bar/Eating�stablishnient
2.❑ I am a sole proprietor or partnershin and have no �, �pffice and/or Sales(incl,real estate,auto,etc.) '
amptoyees working for me in any capacity. �
[No workers' comp.insurance required� g• ❑Non-pro�it ,
3.❑ We are a corporation and Its officers hava exercised 9. ❑Entertauunent
their right of exeanption per c. 152, §1(4),and we have 10.❑ManufActuriug
iio employees. (No workers'comp,insurance required]* �� �k�ealth Care
4.❑ We are a non-profit organization,staffed by volunteeis,
with rro employees. [No workers' comp.insurance req.] �Z.� Other
� *Any applicant tliat cttecks bax#�1 must xlso fili out the section below showing d�elr workers'compensation poiicy information. ;
*+If the co�orate of�icers have exempted tl�emselves,but ihe corporAtionhos other employees,a workcrs'compe��sation policy is requtre<I and sudl an '
or�aulzation shoi�ld.check box�1. �.
� ..,.w :
I a�n�an e�rrployer t/�crt�S providing workers'compensatinn tnsurarrce for my em��loyees. �elow ls tfe�pultcy informrrtion. ''
Insurance Compaay Name; AM Guard Insurance Co. '
u�surer's Address: 16 South River Street PO Box A-H
city/state/Zip: Wilkes-Barre, PA 18703-0020
Po2icy#or Self ins Lic.# R2WC632118 Expiration Date: 4/22/16
Attach a copy o#'the workers'compensat�on palicy declaration page(showing the policy number t�nd expiration date).
railure to secUre coverage as required undec Section 25A of MGL c, 152 can lead to the impositia»af criminal penalties of a
fine up to$1,500.04 and/or one-year imprisomnent,As well as civil penaities In the form of a STOP WORK O.RD�R and a fi.ne
of up to$250.00 a day against the violator, Be advis�d tl�at a copy of this statement may be fonvarded to the Of�ce of
Investi ations of the DIA for insurance coveraga verification.
,T do i:ereLy cert rrs rtn[l pena/ttes c�f,�erjury thnt tlte�2furmat�on pruvlded nGove ls trite�trtrl correcl.
Si n�ture: � Date: 10/14/15
I'hone#: 781-279-0290
Official use onty. Da not write ln th�s�rea,to Ge conrpleterl by clty ot tvwrt offic�nl.
City or Town: Perinit/License#
Jssuing Autl�orlty(eircle one): �
1.Board of��calth 2.Building Depflrtment 3.City/Town Clerk 4,Licensing Boarc� 5.Selectmen's Office
G.Other '
Contact Person: Plione#: :
wHw.mnss:gov/di�
i
BERKSHIRE HATHAWAY �Norker's Comner�,�ation a„�}d Emalover',��iabili�y Policv
G UA RD INSURANCE AmGUARD Insurance Company -A Stock Company
� COMPANIES Policy Number R2WC632118
Renewai of R2WC595758
NCCI No. [21873].
� Rolicy Information Page (AR)
[i]Named Insured and Mailing Address Agency
Cape Management Team �LC EASTERN INSURANCE GROUP
169 Main Street 233 West Central 5treet
Stoneham, MA 02180 Natick, MA 01760
Agency Code: MAEAINIO
Federal Employer`s ID Insured is Limited Uabflity Co. (LLC)
Risk ID Number 456527
Additianal Names of Insured
(N2) Dunkin Donuts
Locatio�s on Poticy - See Extension of InformatiQn Page- Schedule of Lacations
[2) Policy Period
From Ap�il 2Z, 2Q15 to April 22, 2016, 12:Q1 AM, standard time at the insured's maifing address.
[3] Caverage
A. Warkers'Compensation Insurance- Part One of this poficy appiies ta the Workers'Compensation
Law of the folfowing states; Massachusetts
B. Emplayer's Liability 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 Tnjury by Accident-each accident $1,QOO,OOQ
Bodily Injury by Disease- each employee $1,OOQ,Q00
Bodily Injury by Disease- policy limit $1,000,000
�, Refer to Residual Market Limited other States Insurance Endorsement WC200306B
D. This policy includes these endorsements and schedules:
5ee Extensiun of Information Page- Schedule of Forms
[4] Premium
The Premium Basis and,therefore, the premium will be determ(ned by our Manuai of Rules,
Classifications, Rates, and Rati�g Plans. All required information is subject to verification and change by
audit. (Continued on anather page} :
i
Tatal Estimated Palicy Premium $ 39,557
Total Surcharges/Assessments $ 1,765.00
Total Estimated Cost � 41�322.00
(f�'ERNAL USE xx Page- 1 - Information Page
MGA :R21MC632116 WC OOOOOlA
Date c Q4(02/Z015 j
MANOTE '
Issui�g Qffice:P.Q. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-Q020�www.guard.com
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� BERKSHIRE HATHAWAY Worker's Comnensation and Emnlover's Liabili P„glicv
� � A D INSURANCE AmGUARD Insurance Company-A Stock Company
' �� � COMPANIES Policy Number R2WC632118
� Renewai of R2WC595758
NCCI No. [218T3�.
Policy Information Page(AR}
Extension of Information Page
Schedule of Locations
(l2) 1050 Route 28, South Yarmouth, MA 02664{Q4/22/2015- 04J22/2Q16) ,
(L3) 526 Route 28,West Yarmauth, MA 02673 (04/22/2015 -04/22/2616j
(L4) 1353 Route 28, South Yarmouth, MA 02664(04/22/2015- 04j22/2016)
(LS} 14 16 East Main Street,West Yarmouth, MA 02673(04/22J2015- 04J22J2016}
(L6) 39 Nathan Ellis Highway, Mashpee, MA 02649 (04/22/2Q15- 04/22/2016)
(L7} 156 Iyannough Raad, Hyannis, MA 02601 (04/22/2015- 04J22/20I6}
(LB) 792 Main Street, Osterviile, MA Q2655(04/22J2015-04/22/2016) '
(L9} 40 5outh Street, Mashpee, MA 02649(04/22/ZQ15-Q4/22/2016)
(l10)_ 343 Scenic Nighway, Buzzards Bay, MA 02532 (04/22/2015- 04/22/Z016)
(Lii) 702 Iyannough Road , Hyannis, MA 02601 (04/22/2015 -04/22/2016}
(L12} 464 Route 28 Main Street,West Yarmouth, MA 02673(04j22/2015-04/22/2016)
Extension of Information Page
Scheduie of Forms
* WCOOOOOOC-STANDARD POLICY
" WCQOOOOlA-INFORMATION pAGE
* WCOOQ414- NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
* WC2Q0101 - MA TERR. RISK INS. PROG REAUTHORIZATIQN
• WC200102 - MA NOTICE OF PEND LAW CHANGE TO TRIPRA
* WC20�301 - MA LIMITS OF LIABILITY ENDORSEMENT
* WC200302A- MA ASSESSMENT CHARGE
* WC200303D- MA NOTICE TO PaLICYHOLDER ENDORSEMENT
" WC2003066- MA LIMTTED OTHER STATES BENEFIT ENQT.
* WC2003Q7 -MA ASSIGNED RISK POOL ELIGIBILTfY ENDT.
* WC2d0405 - MA PREMIUM DUE DATE ENDORSEMENT
* WC24Q601A- MA CANCELLATION ENDORSEMENT
" WC2Q0604 - MA POLICY DEFINITION ENDORSEMENT
* As part of our o�going commitment to envi�onmental respansibility throughout our operations, we have
chosen not to reprint those forms(marked with an asterisk)that have not changed and were previausly
sent to you. You can obtain a new copy of any of these forms by accessing your account infarmation at
our Poilcyholder Service Center(a selectlon available via our website at www.guard,com). Please be
aware that you wifl be asked to enter yaur policy number, policy inception date, and federai ID number in
order to log on to this secure portion oP our site.
Alternatively, you can contact us via phone at 800-673-2465; our Customer Service Representatives wili
either be able to help you focate a document yourself or can send a copy to you. As always, we thank you
for selecting us as your insurer. We look forward to serving you!
Remember, we make a variety of loss control services available to yau at na
additional charge, including educational resources accessible from aur Policyholder
Service Cenrer at Polfcyho/der Service Center.
INTERNAL USE xx Page- 2- Information Page
MGA :R2vVC632116 WC OOOOd1A
Oate :04/02/2015
MAN4TE
Tssuing Office:P.O,Box A-H, 16 S.River Street,Wilkes-Barre, PA 16703-0020 •www.quard.com