HomeMy WebLinkAboutApplication and WC l�u^f��s`Aa�3�rt�' �
� TOWN OF I'ARMOUTH BflAi2D OF IiEALTH «�.+'�a�n�Sr. �
� APPLICATIUN 1�OR LtCENSEIPEIZMIT-20l 7 ;
'"' *PIease complete form and attaeh all necessary dncw»ants by Decernher 13 lfJ £
Failure to dn so wiil resutt in the return of your applicat�on pac et.
I;S7��1F3LISHMENT IVt1h4�: �Pg Mar�gement Team,LLC DBA Dunkin'Donuts 'j'�jp;p1-p7gg148
LOCATION A]7DRESS: ��East Main streetwest varmouth.MA o2s�a T�I�.#: 7a�-zTg-o2so
MAILING ADDFiESS: �se Main Street Szoneham,Ma o2�80
�-?v1AIL ADDRESS: office�caut4managemenGcom
UW'NER N�.ME: Sa�Couta CEo
T � -�,-�,i
GORPQRATIQN NA11�E(IF APFLICABLE): Dunkin'Danuts !`�i r-r� �' :`�
MANAGER'S Nt11l�IE:Michelei Rankers T�L.#:T81-279-0290 � n �",� ,
IY1t�1LINCr ADI3Ft$SS: 169 Main Strest Stonehsm.MA U2180 � --► � ,,,�
N
PC}OL�ERTTFTCATt{?NS: � �v �:, :
The pool supervisor must be certified as a Pool Operator,as rcquired by State t��v. Pleas�list the designated U o M;
Pool Qperatc�r(s}and attach a copy of the cei�i.fication to this form. --i � 5�'�
j, N/A �
Poal operators must list a niinimtun of tw�a em}�loyees currentli certitied in standazc(First Aid and Cummunetv
Cardic�pu[manary Ttesuscitation(GPR),having onz certikied ernplayee on pramises at all tiznes. Please list ihe
emp(oyees belaw and attach copies of their certzfieations to this form.The Fiealth Department w•ill aat use past
years'records. You mast praviae ne�v capies ttnd maintain a file at your�tuce of business.
I. N!A '� . .
3. �.
FQOn PROTECTION�iANr�GERS-CERTIFICATIONS:
All food service.establishments are rc�uired to ha�•e at least one fu11-time employee�vho is ceriified as a FooJ �""
Protectian l�lanager,�s defined in i4�Sfiace Sanitary Code for Faod Service Est�blishments, 165 CMR 59d.�dp. , �
Please�ttacl�capies ofcertifieation to tlus a�plicatioi�. The Iiealth De�artment�vill aot use�s�st years'reeorcls. v"
You mast prot ide netv copies s�nd mttintain a f[le at}�anr establishmene. , � ,
�.1
1. Rosalia RichaM 2 �
P�,ItS4i�!iN CI-IARGE:
Es�ch ft�od establishment must have at leasi onc Person lai Charge(PIC)on site during hours of�peration.
j, Ros�iia RichBrci �,
��.�:�c.G��r c��ra�tc�-rlorrs:
AU food service establishments sre required ta have at least ane full-titne emplopee who has Allergen certifiefftion,
�s define�in the SCate Sanitary Code for Food Setviae Establishments,I(}5�IvtR Sit�.OQ9(G}(3}(a), Please attach
co�?ies of certif cation to tliis applieatidn. 'I'he He�l[h Departmeat��itl nnt usc past years'recnrds. You musE
pro4=[rte new cupics and maintain a file at your estabiisunte�lt.
], Rosalia Richard ?, Donna Snarsky
HEIIvtLICH CGRTII�IGATIQNS:
All food service establishments�uith 2�szats ar more must l�a�°e fl2least one empinye�trained in d�e Heimlich
Aganeuver oii#11e premises at alI Eimes. Please list your emplo��ees trained in anti-cholsn�prc�cedures belo«aiid
attaci�copies of emplovee cerEifieatioiu ta this f�rm. The Heaitt�De arfiuenf��ill not use past y�ears'reeards.
Yau must pravidc nerv copies and mainYain a fite at}?our place o�business.
1. WA �
.i. �.
RESTAUR.AN1"SEATING: 'rt}TAL.'-�` Q
OFFIC�USE O;YLY
�or�c.��t,:
l..ICIrNSE R(QU(REt) ['!iE PERM17'N !_ICENSF KI?QUiRED FCSB PER�itl'# LICFNSr RFQUIRER f'GF.. PFR!�tiT tt
E�S[i 5{5 CAHiM $i5 I�AOT'EL Sl ip
=ITJN S55 —CA,41P 5S5 `—S!1'MMINCP�OL$IIi7�a
LODGG 35� �`IR�itl.[RPARK 5105 —�� -,tuII1Rt.N001. 511{}�.
FqOp S�RNICE:
LiCLTiSI RI�t�U[R[Oi I'I:£ ''RMITN (.IC[.NSk:RF(}UIRGD FEE PEI2,�Ii`I�ir t.ICEtvSCREQUIRE[� FGE PER411T�
_�4-It}QbEAi'S SI3{ ���� ._CONTINEM"At, $35 NC)N-PROP("C S3{�
>IQ6SF.ATS �21)4 �f'Of�1Att)NVIC. Sfi0 \4'HC)[.E:S1I.E S80
—RE51[?.KITGHGN$30
RET 1f t,SERY ICE:
l.(CENSE Rt:QUtREp FC:E PERhtI'f� LICENSE REQl11RGD F[�F AGRSil7'; I,1CF.,NSE REQtIIRGD PGG PEAMIT�
<50.�y ft. SSiI >25.OU0yy ft. �'_$� 4't;Nt)IN(i-FOUD 52�
�23;fHtisq,R. $154 V FRC)ZGTf[IESSERT S4p �"i'C3k3ACC() 5t tt?
na�i�ce��r.e: srs ANTOUN'I'l)UE = � /.25'.00
`�*"**PL�ASE TURN QVER AND Cp�1PLETE 07H�R SIDE OF FnR!4t'�"*•"
_ _ _ __ �Q�F- is--o��g-oZ
AI?M�NIS'i'Rr1TiON �
Under Chapter 152,Section 25C,Subsectian 6,the Town af Yarmouth is nowrequired to hald issusnce orrenewal
crf any license or�ermit ta t��rate a business if a person�r campany does not have a Certificate of Worker's
Compensation Insuzance. TH� ATTACHED STAT� WORKER'S C4MPENSATTON INSLjI2A1KCE
AF�IDA\�IT M[!ST BE CQM'PLETED AND SIGNED,Ol2
CBItI".QF INSUF�AIVCE ATTACHED
UR
WORI:ER'S CC�h4F.AFI'IL?AVIT S1GN�D AI��D ATTA�HED X
Tawn of Yarmouth taxes and liens must t�e paid priar to ren�cval ar issuance of}rour germits, PL�ASE CH�CK
AFPROPR7ATELY IF PAID.
YES " �O
Mf�TELS AND t}TIiER Lt}DGING FSTABLTSI-IMENTS
TItANSIENT OGCUPANCYc For purpases of d2e li�nitations ofMoteI or Hotel use,Transient occupancy shall be
limited to the tetnporaryand short term occupancy,ordinurily and customarily associated with motet and hotel use.
Transient ac�upxnts must have and be able ta demonstrate that they maintain a parincipal place of residence
elsewhere.Transi�nt occupancy shall generully refer to continuous occupanc}�of not more than Ehirty(30)days,and
an a�regate af nat more than ninety(90)days witl�in any six(6}month period. Use oCa guest unit as aresid�nce�r
dwellin�unit shall not be considered tr�nsient. Occiipaney that is subject to the coltection of Roam 4ecupancy
�xcise,as defined in M.G,Z.c.6�t'i or 83Q CMR 64G,as amended,shalt benerally be considered Transient.
POOI,S
POOL 4PENTNG;,�ll swinirnin�,wadin�and whirlpools which haFe been closed for the season must be inspecteci
by the Health Depurtment prior to opening. Gantact the fiealth Deparhnent ta schedule the inspection three{3}
days priar#o apeneng.PLEASE N4TB:People are 1vrOT allawed to sit in the paol araa until the poal h�s been
inspected and opened.
POQL WA1'ER TESTING: 'The water�nust be tesfed Tcrr pseudomonas,total calift�rn�anci standard plate count
by u State certified lab,and submitted to the H�altli Departn��nt three{3)c�ys prior to opening,and quarteriy
ihereai�er.
PQOL CLOSING:Every outdoor in€nound swimming pool must be drained or covered wittzin seven(7)days of
ciosing.
�'OOD SERVICE
SEASOP�tAL FOUD SERVIGE UPENI1tiTG:
All food service establishments rnnst be inspected by the Health Deparunent pri��r to opeaing. Please cantact the
Health Deparhnent tn schzdule tt�e inspection ti�ree(3)days prior to opening.
CATERING POLTCY:
Anyone who caiers within the Towm of Yarmouth musi notify the I`armouth Healtli L}epartment by filin�the
reqmred T'emporary Food Service Applicatian f'orm 12 hours prior to tha catered event. These forrns catt be
obtamed nt the I�ietilth Department,or from the Ta��n's website at ur��-v+r.yarmouth.ma.us under FIealth Department,
I�ownloadabie Forrrts.
FROZEN DTSSEIiTS:
Frozen desserts must be tested by a Staie certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health i7egartment. Failnre to do so will result in the suspensian or revocatian of your Frozen
Dessert Permit untiI the aliave terms have been met.
OUTSIDE CAF�S:
Qutside cafes(i.e.,ontdoor seatin�with waiter/waitress service},must have prior approvai from the Baard of I�eslth.
OtITDOOR COOKII�'G:
Outdoor cooking,preparation,or display of any faod produci by a retaii or food service establishment is prohibited.
NQTICE:Permits run annuatly�fram January 1 to December 3l. IT IS YOLTR RESPONSIBILITY TO RETURN
TRG COA�iPLETED RENEWAL APPLICATION(S)t1ND REQ'CJIItED FEE(S)BY DECEI�IBER I5,2Q15.
ALL ttENOVATIONS `TQ ANY FUOD ESTABLISHt1�fENT, A�tOTEL OR POOL (i.e., PA1��iTING, NE�V
CQUIPMENT,E?C.},A�UST BE REPORTED TO ANI7 APPROVED BY THE BOARD OF HEAL"TH PRI4R
TO COh4M�NGEMLNT. RENOVATIONS A4AY RE ` �;'LAN.
DATE: 11/23/16 SI{;����
PRTNT NAME&171`LE: Sew�Gouto �residern
ftea.ItlrU1t15
_„ The Commonwe�lth of Massachusetts
� Department of Industrial Accidents
� Of,fice of Investtgations
�R 600 Washington Street
� Bosto�a,MA Q21X.1
t-� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
ApplicRnt Informat�on . Please 1'rint Lc�,ib�
Business/OrganizationN�me: Cape Management Team, LLC DBA Dunkin Donuts
Address: 16 East Main Street .
c�tyis�.t�iz�p:W. Yarmouth. MA 02673 Phone#; 781-279-0290
Are you an employer?Check the appropriate box: Business Type(required):
1.� I am a employer with 4 employees(full and/ 5. ❑Retai[
4r part-time).* 6. �]Restaarant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partuership and have no 7, �p�ce andlor Sales(incl,real estate,auto,etc,}
ampfoyees working for me in any capacity. �
[No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We are a corporation and!ts officers have exercised 9. ❑Entertainment
their right of exennption per c. 152, 1 4 ,and we have
§ { � 10.�]Manufttcturing
iio employees. [No workers'comp,insurance rec�uiredJ* 11.[]Xlealth Ca�•e
4.❑ We are a non-profit organixation,staffed by volunteez�s,
with no employees. [Na workers' comp.insurance req.] 12,�] Other
*Any appllcant tliat chccks box#1 must�lso fili out the section below showlug tlielr wor[cers'compensaf.ion pol icy intormation.
°*If the corporatc officers have axempted U�emselves,Uut 1he corporation.has other canE�loyees,a workers'compensation policy is reqnirecl and sttdl an
organizat[on should.checic bmt#1. �
I nrrt nn e»rployer tJiat�S provlding workers'com�ensatlun insurance fnr�:y employees. Below�S tfie��ultcy info�mrrtton.
Insurance CompatYyNarne; MA Retail Merchants WC Group, Inc
I�isurer's Address: P.O Box 859222-9222
City/stat�/zip: Braintree, MA 02185
Policy#or Self ins,Lic.# 014005034027116 Expiration Date: 1/1/17
Attacl�a copy of tlie vvorkers'compensatio�►�olicy declaration page(sliowing the policy numl�er and expiration date).
P'ailure to secure coverage as requ�rad under Section 25A of MGL c, 1 S2 can lead to the impositiou af crimin�l penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penaities in the fortn pf a STOP W�RIC ORD�R and a fine
of up to$250.00 a day against the violator, Be advised that�copy of�his statement may be forvvardad to the Office of .
Investigations of the DIA far insurance coverags veritication.
I rlo liereby cert�,u � nd penudtles of,�erJrary lftnt tfte informatlon pruvlded n�iove 1s xrue nrt�l correcL
�__.._...
Si nature: Date: 11/23/16
Pl�one#: 781-279-0290
Offtc�al use onXy. Do not write ln tlt�s ttrea,to Ge cot�rpleter!by ctty or tuwrt nf,fictnl.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of T�Icaltli 2.Building Degartmeut 3. City/Town Clerk 4.Licensing Board 5.Selectmeu's Office
6.Other
Contact Person: Phone#:
www.iruiss:gov/dia
�
� INFQRMATION PAGE
;
Insurer: PRODUCER: Agent# 1042
MA Retail Merchants WC Group Inc. Eastern Insurance Group LLC
PO Box 859222-9222 233 West Central Street
Braintree, MA 02185 Natick, MA 01760
(Carrier Code: 34355} Carrier Policy #: 014005034027116
Carrier Prior Policy #: NEW
1. The Insured; Cape Management Team LLC
Dunkin Donuts
Mailing Address: 169 Main Street
Stoneham, MA 02284
Fein: 010769146
Other workplaces not shown above: , Type of Business: Limited Liability Co
SEE SCHEDULE QF dPERATI�NS Risk ID:
2. The policy periad is from 12:41 a.m, an 4j2z/2o16 to 22:d1 a.m. on 1141J2017
at the insured�s mailing address.
3. A. Workers Compensation Insurance: Part One of the palicy applies to the Warkers
Compensation Law af the states listed here:
MA
B. Employers Liability Insurance: Part Two af the policy applies to work in each
state listed in Item 3.A. The limits of aur liability under Part Two are:
Bodily Injury by Accident $ 1 000 000 each accident
Bodily Tnjury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,004,004 each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC4OOQa0C(Q1/15) WCOOQ308{p4/84) WC000406(0$I84} WC�00414(07j90) WC000422B(Q1/15)
WC2003a1{04j84} WC2Q0302(05j86} WC2043038{p7j99j WC20Q3d6B{06j13} WC2Q0405{06f41}
wcaoosaiACo�/os)
4. The premium for this policy will be determined by our Manuals af Rules,
Classifications, Rates and Rating Plans. AZl 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 QPERATIONS
Total Estimated Annual Premium $ 31,480.40 Prorated Premium $ 21,910.04
Minimum Premium $ , 294.Q0 Expense Constant $ .Od Deposit Premium $ .0�
s
SCHEDULE OF flPERATIDNS FOR: PAGE: 2
Dunkin Danuts Carrier Policy #: 014005034027116
Cape Management Team LLC Fein: 010769146
169 Main Street
Stoneham, MA Q2180
DIV #: 00000 EfL Number: OOQ0000401
OTHER WORKPI�ACES :
Cape Management Team LLC
Dunkin Donuts
792 Main Street State Risk ID#: OOQ456527
Ostervil.le, MA 02655 Eff date: 04j22/16
NAICS: 722513
DIV #: 04000
EjL Number: aoaoa0000�
Cape Management Team LLC ;
Dunkin Donuts
1050 Route 28 State Risk ID#= Od0456527
Sauth Yarmouth, NiA 02664 �ff date: o4/a2/�.�
NAICS: ?22513
DIV # : 04Q00
EfL Number: OQOOQQ0002
Cape Management Team LLC
Dunkin Donuts
1353 Route 28 State Risk ID#; 000456527
South Yarmouth, MA 02654 Eff date: 04/22j1&
NAICS; 722513
DIV #: OOQ00
E/L Number: OOOOOOOOQ3
Cape Management Team LLC
Dunkin Donuts
14-16 East Main Street State Risk ID#: 000455527
West Yarmouth, MA d2673 Eff date: 04j22j16
NAICS : ?22513
DIV #: 00000
E/L Number: OOQOQ00004
Cape Management Team LLC
Dunkin Donuts
464 Route 28 Main Street State Risk ID#: 000456527
West Yarmouth, MA 02673 Eff date: d4/22f16
NAICS: 722513
DIV ##: OOQ00
EjL Number: OOOOOOOQII
WC 00 00 O1 B