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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF AEALTH � APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December l6 2016. Failure to do so will result in the return of your application pac zet. ESTABLISHMENT NAME: cape Management 7eam,��c oBn ounkin'oonuts TAX ID:o�-o�ss�as LOCATION ADDRESS: �05o Rt 2a South Yarmouth,Ma,o2ssa ��„#; �si_z�s-o2so MAILING ADDRESS: 169 Main Stree Stoneham,MA 02180 E-MAIL ADDRESS:office@coutomanagement.com OWNER NAME: Sal Couto,CEO CORPORATION NAME(�APPLICABLE): Dunkin'Donuts MANAGER'S NANIE: Michelle Dankers TEL.#: 781-279-0290 MAILING ADDRESS:�69 Main Street Sroneham,MA o2180 POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi Pool Operator(s)and attach a eopy of the certification to this form. -� 0 �� ? f`�t f'r1 � 1.N/A 2. D C� ' i Pool operators must list a minimum of two employees currendy certified in standard First Aid aad Communi :� N '! Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the �� employees below and attach copies of their certifications to this form.The Health Department wiU not use past�:r� � ,„ years'records. You must provide new copies and maintain a file at your place of business. - -� �._� ; � � �'�` 1. N/A �' � '----- ------� 3. 4. FOOD PROTECTION MANAGERS-CERTIF'ICATIONS: � All food service establishments are required to have at least one full-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 establishment. 1, Robert_Bach 2. , � � PERSON IN CHARGE: " � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operarion. l, Chellsea Hontr 2, ALLERGEN CERTIFICATIONS: 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 must provide new copies and maintain a file at your establishment. ], Chellsea Hontr 2, Donna Snarsky 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-cholang procedures below and attach copies of employee certifications to this form. The Health Department will not ase past years'records. , You must provide new copies and maiatain a file at your place of business. ' 1. N/A 2. 3. 4. RESTAURANT SEATING: TOTAL# �2 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B SSS CABIN S55 MOTEL 5110 �NN S55 —CAMP S55 —SWIMMINGPOOLSIlOea �,ODGE a55 7'RAILERPARK 5105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE RMIT LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0.t00 SEATS 5125 �� CONTINENTAI, S35 NON-PROFIT S36 >100 SEATS $200 �COMMON VIC. S60 �(p� —WHOLESALE S80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 , >25,000sq ft 5285 VENDING-FOOD S25 —<25,Oo0sq.ft. E150 �ROZENDESSERT S40 �I'OBACCO $I10 NAME CHANGE: S15 AMOUNT DUE _ $ I$5.OO "•"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*t+"" W4}�-f 5-E)C�� O2� r ADNIINISTRATION Under Chapter 152,Section 25C,Subsecrion 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 WORKER'S COMPENSATION INSURANCE , AFF'IDAVIT MUST BE COMPLETED AND SIGNED,OR j 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 petmits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with mote!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 withit►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 tlie collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,sha11 generally be considered Transient. POOLS POOL OPEIVING:All swimming,wading and whirlpools wluch have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health�p artment to schedule the insp��on three(3) days prior to opemng.PLEASE NOTE:People are NOT allowed to sit in the pool area until tlie pool has been inspected aad opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count thyelea�ft�e e certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7}days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPE1�iING: All food service estabiishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred 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.varnnouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified Lab prior to opening and monttily thereafter,with sample results suhmitted to the Health Department. Failure to do so will result in the suspension or revocadon of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approvai from the Board of Heaith. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NO'I'ICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., P?,IlVTING, NEW ' EQUIPMENT,ETC.),NNST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COTRVIENCEMENT. RENOVATIONS MAY REQUIREA SITE PLAN. � DATE: 11/23/16 SIGNATURE: z � � 1� r ~ � PRINT NAME&TITLE:Salvi Couto,President x�.iaivi6 ' ,��_ The Commonwealth ofMassachusetts � Department of Industrial Accidents J � Of�ce of Investigat�oris 600 Washington Street � Boston,MA 42XX.X t-� � www.mass.gov/d�a Workers' Compensation Insurance Affidavit: General Businesses Apl�lic�nt Information Please Print Le�ib1Y Busi�rxess/�rganiza.tionName: Cape Managem°ent Team, LLC DBA Dunkin Donuts Address: 1050 Rte. 28 . City/State/Zip:S. Yarmouth�MA 02664 Phone#: 781-279-0290 Are yaa an employor7 Check thc appro�riate box: Business Type(reguired): 1.� I am a employer with �4 employees(full and/ 5. ❑Retail or part-time).* 6. Q Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietoar or partnership and have no �7, �Office and/or Sales(incl,real estate,auto,etc.} empfoyees working for me in any capacity. � [No worlcers' comp.insurance required] 8• ❑Non-pro�t 3.❑ We are a corporatian and its officers have exercised 9. ❑Entertairunent tl�►eir right of exemption per c. 152, §1(4},and we have 10.�ManufActuring no employees. [No workers'comp,insurance required]* �� Iealth Ca�•e 4.❑ We flre a noa-profit organization,sta�fed by voIunteeis, with no e�nployees. [No workers' comp.insurance req.] 12,❑ Other � *Any applicant tliat checks boxl�l ent�st nlso fill out the section Uelow showlug d�elr workers'compensation poilcy intormation. °'�If thc corporata officers have exempted 8iemsetves,but 1he corporation.hnv othcr cmployees,a workcrs'compensation policy is required and snc1�an organization shoiild.check box#1. " I nrri nn em�Yoyer t/eat�S��rovtding workers'compensatlon insurance fnr my employees. 73elow is tf:e,�olicy�nfornzr�tion. Insurance Compat�yName: MA Retail Merchants WC Group, Inc. v�surer's Address: P.O Box 859222-9222 City/state/zip: Braintree MA Q2185 Pvlicy#or Self-ins,Lic.# 014005034027113 Expiratioi�Date: 1/1/17 Attach a copy o�'the vvorkers'compensation policy declaration p�ge(showing the policy number and expiration date). I'ailure to secure covet�age as requireci under Section 25A of MGL c, 1 S2 can lead to fhe imposition of criminal penalties of a fne up to$1,500.00 and/or one-year imprisonment,as well as cIvil penalties in the form of a STOP WORK.�RD�R and a fine of up to$250.00 a day against ttxe violator, Be advised that a copy of this statement may be forwardad to the Off ce of . Investigations of the DIA for insurance coverage verificAtion. I rlo l�ereby certi «ncl pena�ties of perjury thnt t/te irtformat�on riruvlrCed rrGove fs true�rt�l correet i nature: Date: 11/23/16 Pt}o�e#� 781-279-0290 , Offcial use only. Do not write ln tlils area,to be completed by clty or town nfjictnl. City or Town: Permit/License# Tssuiug Authorlty(circle one): 1.Board of Ficaltli 2.Building Depflrtmerit 3.City/Town Clerlc 4,Lieensing Boflrd 5.Selectmen's Office 6.Other Cantact Person: Phone#: www,mass:gov/di� � INFQRMATION PAGE Insurer: FRODUCER: Agent# 1Q92 £ MA Retail Merchants WC Graup Inc. Eastern Insurance Group LLC PO Box 859222-9222 233 West CentraZ 8treet Braintree, MA 02185 Natick, ARA 01764 (Carrier Code: 34355) Carrier Policy #: 014045034027116 Carrier Prior Policy #: NEw , 1. The Insured: Cape Management Team LLC Dunkin Danuts Mailing Address: 169 Main Street Stoneham, MA Q2280 Fein: 010769146 Other warkplaces not shown above: , Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATIdAiS • R.isk ID: 2. The policy period is frotn 12:OI a.m. on 4/22/2016 to 12:01 a.m. an 1jOlJ2d17 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the palicy applies to the Workers Compensation Law af the states listed here: MA B. Employers Liability Znsurance: Part Two of the pol.icy applies to work in each state listed in Item 3.A. 'Tha limits of our liability under Part Two are: Bodily Injury by Accident $ 1,o00,OQ0 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,d00,000 each employee C. Other States Znsurance: D. This policy includes these endorsements and schedules: WCOOAOaOC{O1fI.5} Tn7C000308{04/84} WCOd0406(Q$/$4) WCQQ0414 (07/9Q) WC000422B{O1f15) WC2003a1{04J84} WC200302{05JSb} WC20�343B(07I99j WC2003068(06J13} WC200405(06j01) WC2006fl1.A(07jd6) 4. The premium for thzs policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. AI1 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 Annual Fremium $ 31,480.00 Prorated Premium $ 21,910.Q0 Minimum Premium $ 294.00 Expense Constant $ .Q4 Deposit Premium $ .40 SCHEDULE OF OPERATIONS FaR: PAGE: 2 Dunkin Donuts Carrier Policy #: 014005Q34027116 Cape Management Team LLC Fein: O1d769146 169 Main Street Stoneham, MA Q218Q DIV #: 00000 EjL Number: OOOa00Q001 OTHER WORKPLACES: Cape Management Team LLC Dunkin Dgnuts 792 Main Street State Risk ID#: OQ0456527 Osterville, MA 02655 Eff date: 04j22j16 NAICS: 722513 DIV #: OOOQO EfL Number: 0000000007 Cape Management Team LLC Dunkin Donuts 1050 Route 28 State Risk ID#= 000456527 South Yarmouth, MA 02664 Eff date: Q4j22fZ6 NAICS: 72251.3 DIV #: �aQa� EjL Numbex: 0000000002 Cape Management Team LLC Dunkin Donuts 1353 Route 28 State Risk ID#: QOQ456527 Sauth Yaxmouth, MA Q2664 Eff date: 04j22j1& NAICS: 7�2513 DIV #: 00000 EjL Number: OOOOOOOOQ3 Cape Management Team LLC Dunkin Donuts 14-16 East Main Street State Risk ID#: 000455527 West Yarmouth, MA 02673 Eff date: 04j22/16 NAICS: 722513 DIV #: 00000 EfL Number: 0000000004 Cape Management Team LLC Dunkin Donuts 464 Route 28 Main Street State Risk ID#= 000456527 West Yarmouth, MA 02673 Eff date: 04j22j16 NAICS: 722513 DIV #: Q0000 EfL Number: OOOOOOQOII WC 0� 00 01 B