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Home My WebLink AboutApplication and WC d TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 *Please complete form and attach all necessary documents by December 15.2017. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: ceoe Meoeoaroaot Taero.��c oeA o�okio�000�t: TAX ID: LOCATION ADDRESS:1353 Rt.28 South Yarmouth.MA 02664 TEL.#: 781-279-0290 MAILING ADDRESS: 1RA Main SfraaT Stnnaham Ma m�an E-MAIL ADDRESS: office@coutomanagement.com OWNERNAME: Salr��itn [:Fn CORPORATION NAME(IF APPLICABLE): Dunkin'Donuts MANAGER'S NAME:Michelle Dankers TEL.#: 508-889-2sos MAILINGADDRESS: tssn�ainstreetstonenam,Maoz�so POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. S O � 1. N/A 2. � �, m f" n Pool operators must list a minimum of two employees cunently certified in standard First Aid and Community � � m Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the -�- � employees below and attach copies of their certifications to this form.The Health Department will not use past 0 N � years'records. You must provide new copies and maintain a file at your place of business. � � O � 1. N/A 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: 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, Eddie Correia 2, �s � ! �;:: ..'� PERSON IN CHARGE: . ` Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ` � 1. Rosalia Richard 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. 1. Michelle Dankers 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 ail times. Please list your employees trained in anti-choking procedures below and attach copies of employee 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. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: I ENSE REQUIRED FEE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $125 ,�i v�3 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 _<25,OOOsq.ft. $150 _FROZENDESSERT $40 TOBACCO $ll0 NAME CHANGE: $IS AMOLTNT DUE _ $ $125.00 ****xpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 6o�1-F-15-6s78-43 � 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVTI'SIGNED AND ATTACAED 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 limitations 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 principai place of residence elsewhere.Transient occupancy shail 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 shall not be considered transient. Occupancy that is subject to the 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 Deparhnent prior to opening. Contact the Health Department to schedule 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: Ali 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 opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department 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 Deparhnent, 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE AN. DATE: 10/25/17 SIGNATU PRINT NAME&TITLE: Salvi Couto,President Rev.]0/12/17 ' I �;_ The Commonwe�clth ofMrrsscrchusetts � ;� � � Departhzent of Industrial Accidents ,� Of�ce of Invest�gatBorrs . {� dDD Washington Street t� Bostan,MA 021I1 t�; www.mass.gov/dia Workers' Compensation Insuramce Affidavxt: General Businesses � Aat�licant Informatio� . P�es�se 1'r�nt Lc�.ib1Y Bus�nessior�an��.�onrr��ape Management Team, LLC DBA Dunkin' Donuts Address: 1353 Rte. 28 . c��yis��izi�:S. YarmQuth� MA 02664 Phone#; 781-279-0290 Are yau au employor?Checic the appronriate box: Business Type{reguired): 1,� I am a employer with 7 employees(full and/ 5• ❑Retai[ ar part-tii�te).* 6. �Restaprant/Bar/�ating�sCablishment 2.❑ I am a sole proprietor or partnership and have no �, �p�ce and/or Sales(incl,real estate,auto,etc.) einployees working for me in any capacity. [No workers' comp,insurance required] 8• ❑Non-pro�t 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right o£exeax�ption per c. 152, 1 4),and we have § { 10.❑Manufacturing iio employees. [No workers'comp,insurance required]* 11.[]�Iealth CaR•e 4.❑ We are a non-profit organixation,staffed by voIunteei�s, with no employees. �No workers' comp.insurance req.] 12,� Other � *Any applicaat Hiat chccks box#1 must nlso fill out the seotion Uelow showiug d�eIr wor[cers'compensntion pof Icy inPoimaEion. *�`If thc corporatc ofticers hlva ex�inpted tl�emselves,but Uie corparAtion.hm�odicr employees,a workers'compensAtion policy is required and such an orgai�izatlon shonld.check box#1. ^ I n»t nn e�nrployer tlrat is provlding workers'compertaatiun insurance for n:y em�loyees. Below ls tfee policy�nform�rtton. Insurance Compa$y Name: MA Retail Merchanges WC Group, Inc Insurer's Address: P.O Box 859222-9222 city/state/zip: Braintree,�._,MA Q2185 Pv�icy#or Self-ins,Lic.# 014005034027117 Expiration Date: 1/1/18 Attacli a copy o�'the wort�ers'campensation policy declaration page(showfng the policy number and expiratian date). railure to secure coverage as required under Section 25A of MGL c, 152 car�lead to the impasitioli of criminal psn�lties of a fine up to$1,500.04 and/or one-year imprisonment,as well as civil penalties in the forin of a STOP W�RK ORD�R and a fine of up to$250.00 a dAy against tl�e violator. Be advised that a copy of this statement may be forvc�arded to the Office of Investigations of the DIA far insuranc$coverage verification, I do liereby cett � �rs ttrttl penalt+ies of perjury tltrtt tFte�rtformatlon�rovkled abave ls trcre nnd correcl. i nature. --- Date: 10/25/2017 Phone#; 78�-279-�290 Offlcial use vnly. Do nat write ln th�s area,to be completerl by city or town official. City or Towne PermitJLicense# issuitxg Author�ty(circle one): 1.Board of Hcaltli 2.Building Dc��artment 3.City/Town Clerk 4.Licensing Boarc� 5.Selectmen's Office 6.Othcr Contact Persan: Plione#: www.mtiss:gov/dia � � INFORMATION PAGE RENEWAL AGREEMENT � Insurer: PRODUCER: Agent�� 1Q42 MA Retail Merchants WC Graup Inc. Eastern Insurance Group LLC PO Box 859222-9222 233 West Central �treet Braintree, MA 02185 Natick, MA Q1760 (Carrier Code: 34355) Carrier Policy ��: 014005Q34027117 � Carrier Prior Pol.icy ��: 014t�05034027116 1. The Insured: Cape Management Team LLC � Dunkin Danuts � Mailing Address: 169 Main Street � Stoneham, MA Q2180 Fein: j � i Other workplaces not shown above: Type af Business: Limited Liability Co ' SEE SCHEDULE OF OFERATIONS Risk ID: ; 2. The policy period is from 12:01 a.m. on 1/Q1lZQl7 to 12:01 a.m. on 1101/2018 : a�e the insured's mailing address. � 3. A. Workers Compensation Insurance: Part One of the policy apglies to the Workers Compensation Law of the states listed here: MA B. Emplayers Liability Insurance: Fart Two of the policy applies ta wark in each state listed in Ttem 3.A. The limits of our liability under Part Two are: Bodily In�ury by Accident $ I.000.000 each accident Badily Injury by Disease $ 1.00Q.000 policy limit i Bodily Injury by Disease $ l,OdQ.000 each employee ; C. Other States Insurance: D. This policy includes these endorsements and schedules: WGOOOOOQC(O1J15) WG0003Q${Q4184) WC0004Q6(08/84) WCOQQ414(07/90) WCOOQ422B(O1/15} WG200301(04/84} WC200302(05/86} WC200303B(O7/99} WC200306B{06113} WC20p405(06101) WC200601A(07/08} 4. The premivm for this policy wi].I be determined by our Manuals of Rules. � Classifications, Rates and Rating Plans. Al1 information required belaw is subjeet 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 OE OPERATIONS ; Tatal Estimated Annual Premium $ 24,912.OQ Minimum Premium $ 292.00 F.�cpense Canstant $ .00 Deposit Premitun $ .00 , � , i � i � � � i 1 SCHEDULE QF OPER.ATIQNS FOR: PAGE: 2 Dunkin Donuts Carrier Policy #: 014005034027117 Cape Management Team LLC Fein: 169 Main Street Stoneham, MA 02180 DIV #: OQ000 E/L Number: OOQOOOQQd1 QTHER WORKPLACES: Gape Management Team LLC Dunkin Dpnuts 792 Main Street State Risk ID#: 000456527 ; �sterville, MA 02655 Eff date. 01/01/17 £ NAICS: ?22513 � �=v #: oaoaa E/L Nurnber: oaaooaoao� Cape Management Team LLC � Dunkin Donuts 1050 Route 28 State Risk ID#: Q4Q45652? South �armouth, MA 02664 Eff date: Q1/Q1/17 NAICS: 722513 ; DIV #: QOOQO ` E/L Number: 0000000002 Cape Management Team LLC Dunkin Danuts 1353 Route 28 State Risk ID#: OOa456527 South Xarmouth, MA 02664 Eff date: Q1f01f17 NAICS: 722513 DIV #: OQ000 E/L Number: 000a00000� Cape Management Team LLC Dunkin Donuts 14-16 East Main Streat State Risk ID#: OOQ456527 ; West Yarmouth, MA 02673 Eff date: 01/01/17 NAICS: 722513 ; Dzv #: aoaao ; E/L Number: OOOOOQ0004 � � Cape Management Team LLC � Dunkin Donuts � 464 Raute 28 Main Street State Risk ID#: 000456527 � West Yarmouth, MA Q2673 Eff date: 01/01j17 ; NAICS; 722513 ' DIV #: 00000 � EjL Number: OQ00000011 WC �0 00 D1 H ; i i � I I