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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMTT-2017 *Please complete form and attach all necessary documents by December 16.2016. , Failure to do so will result in the retum of your application pac et. " ESTABLISHMENT NAME: Cape Managament Team,LLC DBA Dunkin'Donuts 'T'AX ID:OtA789146 LOCATION ADDRESS: 464 Rt.28 West Yarmouth,MA 02673 TEL.#:781-279-0290 MAILING ADDRESS: E-MAIL ADDRESS: 169 Main Street Stoneham,MA o2180 OWNERNAME: SalCouto,CEo CORPORATION NAME(IF APPLICABLE): Dunkin'Donuts ' MANAGER'S NANIE:Michelle Dankers '1'gI„#.781-279-0290 � � �.�°� MAILING ADDRESS: 169 Main Street Staneham,MA 02180 �' n' �. 'i :.-i ._. �.,,� POOL CERTIFICATIONS: `�` N � 'i The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated €� rv Pool Operator(s)and attach a eopy of the certification to this form. r ;. � i�..; 1. N/A � � v 2. , ; �� Pool operators must list a minimum of two empioyees currenfly certified in standard First Aid and Community ` Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the v employees below and attach copies of their certifications to 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 2, 3. 4. :._�.. � FOOD PROTECTION MANAGERS-CERTIF'ICATIONS: -- -� All food service establishments are required to have at least one fWl-time employee who is certified as a Food � Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establ'eshment. 1.Jennifer Peters 2. , PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operarion. ' 1, Jennifer Peters 2, ALLERGEN CERTff�'ICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years'records. You mast provide new copies and maintain a file at your establishment. 1,Jennifer Peters 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. T6e 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 2 3. 4. RESTAURANT SEATING: TOTAL# 24 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# _BBcB S55 CABIN $55 MOT'EL 5110 [1dN S55 —CAMP $55 _SWIMMING POOL SIlOea =LODGE a55 =7'RAILERPARK $105 _WI-IIRLPOOL S110ea. FOOD SERVICE: LICENSE REQUII2ED FEE RMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQ UIRED FEE PERMIT# �0-100SEATS 5125 , 1?��I CONTINENTAL S35 NON-PROfiIT S30 >100 SEATS 5200 �COMMON VIC. S60 �� =VVHOLESAI,E S80 RETAIL SERVICE: —RESID.KITCHEN a80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,000sq ft. $285 VENDING-FOOD S25 =<25,OOOsq.ft. 5150 =FROZENDESSERT $40 =TOBACCO $110 NAMECHANGE: a15 AMOUNTDUE _ $_�$5.00 •«.«•p�pSE TURN OVER AND COMPLETE OTHER SIDE OF FORM**+'• ao+��-15-ba6q-62 � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED X Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the lunitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants 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 not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shali not be considered transient. Occupancy that is subject to ttie collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedu(e the inspection three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter. ' POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Hea1th Department prior to opening. Please contact the Hea1th Department to schedule the inspection three(3)days prior to opening. CATERING POLICY• Anyone who caters within the Town of Yannouth must notify the Yannouth Health Depactment by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior 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 until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEN'T, MOTEL OR POOL (i.e., PAINT'ING, NEW F.QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUI SITE AN. ' DATE: 11/23/16 SIGNATURE: , PRINT NAME&TITLE:Salvi Couto,President Rev.10/12/16 _� The CommonweaCth ofMassachusetts � Depaptment of Industrlal Accidents � � Offdce of Investtgatiorrs ; 600 Washington Street �1- Boston,MA Q21X.1 ,c-�b www,mass.gov/daa Workers' Compensation Tnsurance Affidavit: General Businesses Agplicant Information . Ple�se Print Lcgiblv Business/OrganizationNtune: Cape Management Team, LLC DBA Dunkin Donuts Address: 464 Rte. 28 - City/Sta.te/Zip:W.. YarmQu�h, MA 02673 Phone#; 781-279-0290 � Are you an employer?Check the appro�riAte box: Business Type{required): 1.� I am a employer wittz �7 employees(full and/ 5• ❑R��iE or part-time).�` 6. �Restapran�/Bar/�ating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) empfoyees working for me in any capacity. � [No workers' comp,insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment tl�►ei.r right o£exemption per a �52, §1{4),and we have 10.[�Manufacturing no employees. [No workers'comp.insurance required��` 1 I.�]Ilealth Ca►•e �4.❑ We are a non-profit organixation,staffed by volunteex•s, with rro employees. [No workers' comp.insurance req.] 12,� Other � *Any appticant tliat checks box#1 Enust also fill out the section Uelow showing tl�eir wor[cers'compensation pol icy inPormafion. **TFthc co�porate oflicers hava exempted tliemselves,Uut U�e corporatlon.hsu othcr employees,a workcrs'co�npensation policy is reqaired and such an organizHtton shoiild.check box#1. � I�tni�n employer tJiat is�roviding ivorkers'con:pensatto�:insurnnce for my e»y�loyees. BeCow�S tlie poC�cy�nfornzatlon. Insurance Compa$y Name: MA Retail Merchants WC Group, Inc. I�isurer's Address: P.O Box 859222-9222 City/state/zip: Braintree� MA 02185 Policy#or Self-ins,Lic.# 014005034027116 Expiration Data: 1/1/16 Attach a copy o�'tlie worl�ers'campensatimi policy declaration page(showing tlae�olicy number ax�d expiration date). railure to secure coverage as r�quired under Section 25A of MGL c, 152 can lead tQ the impositian af criinin�.l panalties of a fine up to$1,500.04 and/or one-year imprisoninent,as weli as civil penalties in the forin of a STOP WORIC.ORD�R r�nd a fine of up to$250.00 a day against tl�e violator, Be advised tkiat 1 copy of fihis statement may be forwarded to fhe Of�cs of . Investi ations of tl�e DIA far insurance coveraga veritication. Itlo ltereby certi ,un�ler air�s�in[lpe�endtle,s nfperjury tltat t/te lrtformatdon liruvtderl�bove ls trite�rtrl correcl. i nature: Date: 11/23/16 I'l�one#� 781-279-0290 , � Offlcial use only. Do nOt Wtite tn thJs[�relt,to be completed by city or town of,ftctal. City or Town: PermitlLicense# Jssuing AYithority(circle one): 1.Board of Healtla 2.Building Departme�it 3. City/Town Clerk 4.Lieensing Boarc� 5.Selectmen's Office G.Other Contact Person: 1'lione#: www.mass:gnv/dia ' INFORMA.TIQN PAGE Insurer: PRODUCER: Agent# 1042 MA Retail Merchants WC Group Inc. Eastern Insurance Group LLG PO Box 859222-9222 233 West Central Street Braintree, MA 421&5 Natick, MA 01760 (Carrier Code: 34355} Carrier Policy #: Q14005034027116 Carrier Prior Policy #: NEW 1. The Insured. Cape Management Team LLC Dunkin Donuts Mailing Address: 169 Main Street Stoneham, MA 02180 Fein: O1Q769146 Other warkplaces not shown above: . Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATIONS • Risk ID: 2. The palicy period is from 12:01 a.m. on 4J22/2o16 to 12:oi a.m. on lJOlJ2o17 at the insured�s mailing address. 3. �. Warkers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Snjury by Accident $ 1,000,004 each accident Badily Injury by Disease $ 1,0�0 000 policy limit Badily Injury by Disease $ 1,0�0,000 each employee C. Other States Inaurance: D. This policy includes these endorsements and schedules: , WCOd04�OC(01/15) WCOQ0348{04j84) WC040406(08j84) WC000414 (07J90) WC000422B(O1j15} WC200301{04j84) WG200342(05/86) WC2443035(07/99} WC20Q346B(06j13) WC2Q0405{06j01} WC2QQ601A(Q7j08� 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Ratas and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Sasis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated �lnnual Premium $ 31,480.00 Prorateci Premium $ 21,910.00 Minimum Premium $ 294.00 Expense Constant $ .Q4 Deposit Premium $ .00 SCHEDULE OF OPER�TIQNS F�R: PAGE: 2 Dunkin Donuts Carrier Policy #: OZ4Q05034027116 Cape Management Team LLC Fein: d1Q769146 169 Main Street Stoneham, MA 02180 DIV �c 00000 EjL Number: QQOQOOOa01 OTHER WQRKPI�A�ES: Cape Management Team LLC Dunkin Donuts 792 Main Street State Risk ID#: 000456527 Qsterville, MA 02655 Eff date; 04j22j16 NATCS: ?22513 DIV # : 04Q00 , EjL Number: 0040000007 Cape Management Team LLC Dunkin Donuts 1050 Route 28 State Risk ID#= 000456527 South Yarmouth, MA 02664 Eff date: 04j22/16 NAICS: 722513 DIV #: OOQ00 EjL Number: QOQOOOOOQ2 Cape Management Team LLC Dunkin Donuts 1353 Route 28 State Risk ZD#: 000456527 Sauth Yarmouth, MA 02664 Eff date: 04/22j16 NAICS: 722513 DIV # : 00000 EjL Number: QOOOOOQOQ3 Cape Management Team LLC Dunkin Donuts 14-16 East Main Street State Risk ID#: 000456527 West Yarmouth, MA Q2673 Eff date: 04j22/16 NAICSs 722513 DIV # : 00000 EjL Number: OOQOOQ0004 Cape Management Team LLC Dunkin Donuts 464 Route 28 Main Street State Risk ID#: 000456527 West Yarmouth, MA 02673 Eff date: 04/22f16 NAICS: 722513 DIV #: 00000 EjL Number; 0000000011 WC 40 00 Ol B