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Home My WebLink AboutApplication and WC T}oNticteS' �acav� , � <. TOWN OF YARM(}UT'H BQE�RD OF HEALTH l353 f�:�$ �; APPLICATIQN FOR LICENSElPERMIT-?QI+7 '` � *Please camplete form and attach a(t nec:essan documents by�Decem�& r xs•�or$ Failure to do so wi[l result in tlie return of your applicatia' n packet. �STt113LISFP.4IENT NAA•4E:Cape Manageme�Team LLG DBA Dunkin'Donuts '['�}�jj}; 01-0769146 LOCATION ADDRESS: 1353 RL 28 South Yartnoufh MA Q2f�4 TEL.#:508-384-1220 h3AILiNG ADDRESS:�69 Main Streetstaneham,r�noziao E-MF1IL ADBRESS_office�coutoman eme�tq pWNER NAME: va�Couto CEo COR.PORAfitON NAMF r�dT't'T lCABLE): Dun�in'Donuts n�v�rrA�ER°s NAM�:�V11tf��1e t�C�fl rs r�L.�: 7s�-2�s-a2so � ..� 143AILING ADDRE�S:169 Main Street Stoneham MA 02180 � � '�t F<' PQt�L CERTIFICr1TtC>NS: � ---� � iF Tha poat sunennisor must be certificd as a Pool Operafor,as requirecl by State law. Please list the designat�d -�� V '� i'ool Operator(s)and attach a copy of the certification to this form. � ,.� 1, N�a �, `v� � ' `t � � .. Paol o�serators must list a minimuin of nvo eniployees currently certiF�d in st�ndard First Aid and Gommunity Cardiopnlmonary Resuscitation(GPR},having one certitied emptoyee on premises at alt times. Please list the employees�elow and attach copies of their cerfirficntions to this form.The Health Departmenf w itl not use past years'recnrds. You must nro��de netiv copies and maintain a file at,your�rtace of business. i. Nr� 2. 3. �• FO()D PR(?TE�TION AiANAGERS-CERTIFICATit7NS: All faod sercnce establishments are required ta hate af Ieast one fidl-tin�e employee�uho is certified as a I'aod t'rate�tion Mana�er,as defin�d i�i the State Sanitarr Cac1e fnr Pooci Servzc�Estalalishn�ents,105 CMR a90A0D. Please attach capies�f certificatian to this applica#ion. The Heatth De�artment witl not use�astyexrs'records, ?` � You musE nrovide na�v copies and n�aintain a file at;�our establishmen� C�=--� 1.Gauri Patei � � � _ ,. , P�R.SON 1N�H�RGE: `� �"�� E�ch food establishment must have at l�nst one Person In Char�e(PIC)on site durina haurs of aperati.on. ]. Debbie Fleminq �• ALLERGEN CERTIFt�ATiO�(S: A!1 food servicc est�tt�lislunc�nts are required ta hat-e at least Ane full-time employee�vhc�has AUergen certification, as defined in the State Sanitar}r Gode for Food Service Establi.shments,l q5 CIt�1R 590.OQ9(G)(3)(a). F'Izasz attach cepies ofcertification ta this a�plicati�n. The Flealth Dep�rtmettt��ill nat use past years'reeaeds. You must prnviae nes��copies and maintain a fite at your estabiisl►ment. 1. Micheite Dankers 2. Deb6ie Flemi� HEIT3LIC'H CERTIIaICA"fIQNS: All fnod sen�ice establishments��ith 25 seats ar more must have at le�st one emplayee train�d in the I-Ieimiich Maneuver on t(�e premises at all tu�jes. Please list your emgloyees trninezl in anti-claokin�;proceduces below and attach copies ofemplayee certillcations ta this form. The Healtlt Department wiIl nat use past years'recards. �au must provide nejv copies and maintain a file at yonr place of business. �. NlA 1 J. �• RESTAU[2ANT SEATiNG: TOTAL# o t}L+F1CI:TiSC ONLY LODCIhGi [.IC[i�St:REQtiI{ZEp FLE E'E[th1[`T� I.IC�tVSE FE.QUtRi:D I�EF Pk;Rh[t"I'u LiCENSF RG��UIRFb PEE P£R?vtlT l! HcF�t3 S55 CAl31N S55 Mt)TEL Sll{) —IN�t S55 _. .�AA1P S;j �`"'SWIMt�1Ii�1CrPC�I..S1I0ea. �LUDGE �33 � A'TRAILER PARIi �1i75 -� �, _1k111RLPCIC?L $1IOeR: FOUp SERV ICE: LtG�A356 REQt1tRED P�E6 PL��'R.�IT n Qp LlC�:iVSG;R4QUlRFQ rEF I��RhiIT� LICFNSE REQtiTRFD FEC P[K,tiiC'C�l LO-I�SEATS SI?i Oy-\ .._CONTI+lE'�7AL 535 NO�t.PRQFtT S_0 _�,�„�. >�oo s�:n�rs s�oa �'F— coA�n��r vic, s�a Guxo�.�snr,r_ ssn '—" —' —RkiSTD.t{f7CFlEh $8�f ftETAIt,SERV ICE: LIC[iNSf RE:(1UIRCU FG� P[=12�i1t� LICGAISGR[:QtJIRft7 Pf:F'. PL-:IiM1i17'# t,ICENSr REt1t11RGD FEC I'ERMil"k <j�,sc�fl. S�0 >25,OOO:A.ft. $2A5 VEAiDf1�Ci-F�C)D $2$ �<2S.�O�sy.ft. 5150 iPRt)ZFS�I�ESSFRT"SAO _I'tT[1AC(�Ca $IIO � tva��cttn�vice: sis t111�OL�NT llUE = � IZS.00 °***'PLEASE TURY Q�'BR AM1D CO�i PLET�OT'NEIZ SIDE OF FQR11'**h° aol�F-Is-b��E-by ;. _ __ ADMIi�iISTRAfiIQt+t �' Under Chapter 152,3eetion 25C,Subsectipn b,ih�Tov�n af Xarmouth is now reqaired to hold issuance or renewa( of any license ar pe.rmit to operate a business if a person or company does not have a Gertif cate of Worker's Campensatic�n Insurance. THE ATTACHED STATE WOl2KER'S COMPENSATTUtY IMSL�RA7YCE AFFIDAVIT MUST SE COhiPLETED AIVD SIGNED,OR CERT.OF tNSURANCE ATI`ACHED DR WORKER'S CQMP,A£FII}AVIT SIGNGI3�NNI�ATTACF3ED� Tawn of Yarn�nuth t�xes and liens must be paid paor to r�newal or issuance afyour pzrmits. FGEASE GHECk AFPKOPRIATELY IF AAID: YES� Nt} M4TTL3 ANTI OTHER LQDGING ESTABLISHMENTS TRANSIENT OCCtIFANCY: Far purposes of the limitations of Motel or Hatei use,Transicat accupancy shall be limited to the temporary and short term accupancy,ordinarily and custcrmarily associatec[with motet and hotel use. Transient occupants must have and be able to deinonstrate tlyat they maintain a prinaipal place of residenee els�where.Transient occupancy shalt generally refer ta continuous occupancy of not more than thirty(30)days,and an aggeegate of nai more ihan ninety(9Q)days v��ithin any six(b}month period. Use of fl guest unit as a resid�nce or dwelling unit shall not be considered transient. Occupancy that is subj�et to the ca]lactinn o�Raam Oceupancy Excise,as deiined in M.G.L.c.64G or$3Q CAiR b�G,as�tmende�,shall aenerally be considered Transi�nt. FdOLS PQOL OPF.,NING:Al l swin�ming,wading and whirlpaols w�iich have been closed far the season must be inspected �y the Health De�artment grior ta opening. Contact tl�e He�alth Depsrttnent td schcdule the inspection three{3) days priar to opening.PLEASE NOTE:Peaple ar�NOT alSawed to sit in the�ool aren until the pool has been inspecteti and c�pened. POOL WA`CER TESTING: The«•ater must be tested far pseudomonas,total cofiform and standard piate cnunt by s State certifieti lab,and submitted tc�the Health 13epartmznt three(3)days prior to openine,ancl quart�rly tlaereaf�er. POOL CLOSIl�'G:Every outdoor in ground swzmcning pool must be drained or covered within seven(7)days or �lasin�, FOOD S�RVIC� SEASUNAi:FOdD SERVIC�OFENING: Al I Food service es#ablishments must be inspected by the I3�aith L?epartment priar ta o�ening. Please contxzet the Health Department to schedule th�inspection three{3)days priar to openin�. GAT�RING POLiCY: tlnyone tivho oaters within the Tow»of Yarmauth must natify the Yarmouth Health Depattment by�lin�the required Temporar} Faod Service Application form 72 hours pri�r tn the cat�red event. These forAt�s can be t�btained at the Health Departinent,or fi•om the Town's tvebsite at«�rv�.varrnouth.ma.us under Health I}eparhneir4 I?ownlaadable Farms. FROZF:N UESSERTS: Frozen desserts must be tested by a State certifi�d lab pri�r to bpening and monthly theresfter,w�th s�ng[e resulis submitted to th�Healih I?epartmznt. E�ailure to do sa will resu(t in the suspension or revocation of p�ur Frozen Dessert Permit until th�above terms have been inet t)UTSIDE CAF�S: Qutside cafes(i.e.,outdaor se�tinp�vith waiter/wtutress service),must have prior appro�al from the Board of Heaith. OUTDOQR COOKING: Outdoor coakine,preparation,or display of any f'o�d product by a retail or foad service estabtishment is prohibited. NOTiCE:Permiis run annually fiom Januarp 1 to C}ecemt�er 31. IT IS 1'OLJR RESPONSIBILITY TU RETUF2N THE CQ1�IPLETTD RENE�h1AL APPLICATI9N{S)AND I�QtJIREt?fE�(S)BI'D�CEMBER 1�,2015. ALL RENOVATIONS TO tANI FOOD CSTATiL15HMENT, b40TEL OR POOt< (i.e., PARVTING, NE�V EQUIPM�N`f,�TC.),NIUST BE REPORTED TO:�tl}A ROVED BY THE BOARD OF HEALTH PRIOR TO COMI�iEI`TCEARENT. RENOVt'1TIUNS MAY t2EQ Dt'�TE: �»z��s SIGNATURE: _.__ PRINT'NAME c2,TI`t'LE:__Salvi Couto,President Rec.I W61i15 ,,;_ The Commonwer�Cth ofMassachtusetts ;,� � Depa�tment of Industrial Accidents � �� Offdce of Investigations E1 600 LVashington Street t� Boston,MA Q2XXX - r. www.mass.gov/d��c . Workers' Compensation Ynsurance Affidavxt: General Businesses � At�ulicRnt Informatlon Please Print Lc�ibly Bu��ssio�gan��.tionrr��!�ape Management Team, LLC DBA Dunkin' Donuts Address: 1353 Rte. 28 . City/State/Zip:S. Yarmouth, MA 02664 Phone#: 781-279-0290 � Are yau nn employer?Check thc appropriate box: Business Type{rec�uired): 1,(� I am a employer with 7 employees(full and/ 5• ❑R��i[ or part-tinne).* 6. �RestactrantlBar/Eating Establishnient 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 worI<ers' comp,insurance required] 8• ❑Non-profit 3.❑ We are a corporation and Its officers have exercised 9. ❑Entertaitunent tltieir right of exemption per c. 152, 1 4 ,and we have 10.[�Manufacturing no employees. [No workers'comp,insurance required]* 11.[]Ilealth Care 4,❑ We are a non-profit organization,staffed by voIunteexs, with no e�nployees. �No workers' comp.insurance req.� 12,�] Other � *Any applicant tliac chccks hoxl�l must also ffiI out the section trelo�v showing dteir workers'compenst�fion policy infoemaEion. *"Tf thc coiporate officers have exempted themselves,Uut ihe corporAtion.hmv othcr cmEaloyees,a workers'coinpensation po(icy is requlre<I aud snch an arganization shoi�ld.check box#1. ^ I nrri nn em�loyer tli�t rs provtdJng�vorkers'conzpensatlon insurrurce for n:y emj�loyees, aelow is tlee poltcy inforFnrrtion. Tnsurance Compa$y Name; MA Retail Merchanges 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 Date: 1/1/17 Attach a copy o�'tl�e workers'compensation nolicy declarntion page(showing the policy nttmber and expiration date). railure ta secure coverage as required under Section 25�1 of MGL c, 152 can lead to the impositian af criininal penalties of a �ne up to$1,500.00 and/or one-year imprisonment,as weli as civil penaities in the forin of a STOP WORK ORD�R and a fine af up to$250.00 a dAy agaiast tlae violator. Be advised that a copy of this statement may be fon�varded to the Off'ico of . Investigations of tt�e DIA for insurance coverage varification, _--�-- 1'do fiereby cer a � �s«nd�en�ltles of perfury lftnt tlte informnt�on rirovlderl above ls true�trt�l correct i nature. Date: 11/23/16 I'hone#� 781-279-0290 , Of,Jlcial use unXy. Da not wrile tn tlr�s area,to Ge completetl by etty or town offic�r�l. C3ty or Town: Permit/License# issuing Attthorlty(circle one): 1.Board of Hcaltti 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Of�ce G.Other Contact Persan: 1'hone#: www.tnass:gov/dia INF4RMATSON PAGE Insurer: FRODUCER: Agent# 1042 MA Retail Merchants WC Group Inc. Eastern Insurance Group LLC PO Box 859222-9222 233 West Gentral Street Braintree, MA 02185 Natick, MA 0176Q (Carrier Code: 34355} Carrier Policy #: 014005034d27116 Carrier Prior Policy #: NEW l. The Insured: Cape Management Team LLC Dunkin Donuts Mailing Address: 169 Main Street Stoneham, MA 02180 Fein: 010769146 Other workglaces not shown above: Type of Business: Limited Liability Co SEE SCHEDULE OF QPERATIONS • Risk ID: 2. The policy period is from 12:01 a.m. an 4/22J2016 to 12:a1 a:m. on 1/41/2017 at the insured's mailing address. 3. A. Workers �ompensation 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 po].icy applies ta work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 OOO,aQO each accident Badily Injury by Disease $ 1,d�d,000 policy limit Bodily Injurg by Disease $ 1,dQ0,000 each employee C. Other States Insurance: D. This policy ineludes these endorsements and schedules: WCOd0000C(Ol/15J WC000308{04j$4) WC000446{d8j84) WC404414 (07f90} WC600422B(O1/15} WC200301{04j84) WC200302tO5J86) WC20Q3Q3B(07J99} WC200306B(06j13} WC2Q0405{06j01? WC240601A(07/0$} 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Tatal Fsstimated Annual Premium $ 31,480.00 Prorated Premium $ 21,910.00 Minimum Premium $ 294.00 Expense Constant $ .00 Deposit Premium $ .Od , � i SCHEDULE OF QPERATIONS FOR: PAGE: 2 Dunkin Donuts Carrier Policy #: 014005034027116 Cape Management Team LLC Fein: 010769146 169 Main Street Stoneham, MA 0218Q DIV #$: OOb00 E/L Number: dOQ�Q000Q1 OTHER WQRKPLACES': Cape Management Team LLC Dunkin Danuts 792 Main Street State Risk ID#; d00456527 {�sterville, MA 02655 Eff date: Q4f22/I.6 NAICS: ?22513 DTV #: 00000 EjL Number: o00000000� Cape Management Team LLC Dunkin Donuts 1050 Route 28 State Risk ID#: OOQ45&527 South Yarmouth, MA 02664 Eff date: 04/22f16 NAICS : 722513 DIV #: 00000 EfL Number: OOQQQOQ002 Cape Management Team LLC Dunkin Donuts 1353 Raute 28 State Risk ID#c 000456527 South Yarmouth, MA 02664 Eff date: 04J22j16 NAICS: ?�2513 DIV #: 00000 E/L Number: OOQOOOOOQ3 Cape Management Team LLC Dunkin Danuts 14-16 East Main Street State Risk ID#: 000456527 West Yarmauth, MA 02673 Eff datee 04j22/I6 NAICS: ?22513 DIV #: OOQ00 EjL Number: Q0�0000004 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 #: QOd00 EjL Number: 4000QOd011 WC 00 00 Ol B