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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTA BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 ` *Please complete form and attach all necessary documents byDecember IS.2017. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: ceoe Meoe�r�ot Team.uc oen o��k��Donuts TAX ID: LOCATION ADDRESS:16 East Main Street West Yarmouth.MA 02673 TEL.#: 7s1_279_0290 MAIL,ING ADDRESS: 169 Main StraP4 Sfnnaham MA 091A0 E-MAIL ADDRESS: office@coutomanagement.com OWNERNAME: Salc:n�rtn,_{:F[) CORPORATION NAME(IF APPLICABLE): Dunkin'Donuts MANAGER'S NAME:Michelle Dankers TEL.#: 508-889-2909 MAILING ADDRESS: 169 Main SVeet Stoneham,MA 02180 = � .� POOL CERTIFICATIONS: � n � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � m Pool Operator(s)and attach a copy of the certification to this form. � .p, 1. N/A 2. � � m Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � � � 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 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-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, Eduardo Correia 2. � 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. Eddie Correia 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. 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 REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: I ENSE RE UIRED FEE P RMIT LICENSE REQLTIRED FEE PERMIT# LICENSE RE LTIRED FEE PERMIT# 0-100 SEA�TS $125 �� _CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $I50 _FROZENDESSERT $40 _TOBACCO $110 NAME CHADIGE: $15 AMOUNT DLTE _ $ $125.00 **'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** Bo�f��-(S�6�- 0.3 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.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 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 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 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 Heaith Department 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: All 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 Deparhnent 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 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 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 IRE PLAN. DATE: 10/25/17 SIGNATURE: �--- PRINT NAME&TITLE: Salvi Couto,President Rev.10/12/17 _.,_ The Commonwe�clth ofMassachusetts � � '� Depa�tment of Industrittl Accidents Off�ce of Investig�tioras �� 600 Washington Street � Bostan,MA 421.i.1 r-�6 www.mass.gov/di�c Workars' Compensation Insurance Affidavit: General Businesses Aaulicant Information Piease Print Lc�ibly Business/4rganizatianN�me: Cape Managem°ent Team, LLC DBA Dunkin Donuts Address: 16 East Main Street . City/State/7ip:W.. Yarmouth, MA 02673 Phone#: 781-279-0290 � Are you ap employor?C�eck thc appropriate box: l3usiness Type(required): 1,� I am a employer with 5 employees(full and/ 5. ❑Retai[ or part-tinne).* 6. �Restaaran�/Bar/Eating�stablishmeilt 2.❑ I am a sole proprietor or partnership and have no 7, �OfFice and/or Sales(�tcl,real estate,auto,etc.) employees working for me ia any capacity. � [No worI<ers' comp.insurance required] 8• ❑Non-pro�it 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right o£exe�ption per a 152, §1(4),and we hlve 10.[]Manufacturiug iio employees. [No workers'comp.insurance reguired�* 1 I.❑Ilealth Cace 4.❑ We 1re a noa-profit organixation,staffed by volunteers, with no employees. [No workers' comp.insura�ice req.] �2,� Other � '�Any appllcant that cltecks box#1 mtist r�so fill out the section below showing tl�elr�vorkers'com�ensation po!icy inform�Eion, s�'Tf thc coi7>oratc officers have ex�mpted d�emselves,but ihe corpornt[on.has oUicr cmployees,a workcrs'compensation policy is requt►�etl and such an organization sliould.check box#1. " 1 nrrt�tn e�nployer tliat�S providtng�vorkers'corripertsatton insurnnce for n:y em�loyees. Below rs ifte policy infor�rrrrtion. 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.# 014005034027117 Expiration Date: 1/1/18 Attncif a copy o#'tlie�orl�ers'eomp�nsation policy declArAtion page(shawing the policy number�nd expiration date}, I'ailure to secure coverage as requ�rad under Section 25A of MGL c, 152 carx fead to the impositioii af criminal penalties of a fine up to$1,500.00 and/or one-year imprisomnent,as weli as civil penatties in the form of a STOP WORK ORD�R and a fine of up to$250.00 n day against the violator. Be advised that a copy of this statement may be forwarded to the OtTce of . Invasti atians of the DIA for insurancs coverage varification. I do ltereby cerd n tIt airrs«ntlpenultles of,�erJtary that tlte informat�on provtded nhove ls traae�trtrt correct. i nature. Date: 10/25/17 Phone#: 78�-279-�29� O�ci�rl use only. Do not wrile tn ili�s area,to be completed 6y clty or town offictr�l. City or Town: Permit/License# Issuing At�thority(circle one): 1.Board of Hcalth 2.Building Departmeut 3.City/Town Clerk 4.Licensing Boarc� 5.Selectmen's Office 6.Othcr Contact Person: �'lione#: www.mnss:gov/di� � � INFORMATION PAGE RENEWAL AGREEMENT � � Insurer: PRODUCER: Agent�F 1042 � MA Retail Merchants WC Group Inc. Eastern Insurance Group LLC ! PO Box 859222-9222 233 West Central Street 3 Braintree, MA 02185 Natick, MA Q1760 � (Carrier Code: 34355) Carrier Policy �t 014045034027117 Carrier Prior Policy �6c 014005034027116 ; 1. The Insured: Cape Management Team LLC � Dunkin Donuts Mailing Address: 169 Main Street f Stoneham, MA 02180 Fein: 3 Other workplaces not shown above: Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATION5 Risk ID: 2. The policy period is from 12:01 a.m. on l/Ql/2d17 to 12:01 a.m. on 1/Ol/2018 at the insured's mailing address. I 3. A. Workers Compensation Insurance: Part Qne 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 In�ury by Accident $ I.O�Q.000 each accident Bodily In�ury by Disease $ 1 QQ0.000 policy limit Bodily Injury by Disease $ 1.Q00.000 each employee C. Other States Insurance; D. This policy includes these endorsements and schedules: WCOOOOOOC(Ol/15) WC000308(04/84) WCOQ04Q6(08/84) WC000414(0J190) WC000422B(O1/15) WC200301(04f84) WC20d302(05/86) WC200303B(07/94} WC200306B(06f13) WC200405(06/Ol) WC200601A(07/08) 4. The premium for this palicy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required belAw is subjeet � to verificatian 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 � � Total Estimated Annual Premium $ 29,912.Q0 � Minimum Premium $ 292.00 F�pense Constant $ .00 Deposit P�emium $ .00 � I � 5 SCHEDULE OF OPERATIONS FOR: PAGE: 2 Dunkin Donuts Carrier Policy #: 014005Q34027117 Cape Management Team LLC Fein: 169 Main Street Stoneham, MA 02180 DIV #: 00000 E/L Number: 0000000001 OTHER WORKPLACES: Cape Management Team LLC � Dunkin Donuts ` 792 Main Street State Risk ID#: 000456527 Osterville, MA 02655 Eff date: 01/01/17 NAICS: 722�13 � DIV #: 00000 � E/L Number: OOOOOQ0007 Cape Management Team LLC Dunkin Donuts 1050 Route 28 State Risk ID#: 000456527 South Yarmouth, MA �2664 Eff date: 01j01/17 { NAICS: 722513 � DIV #: 00000 E/L Number: 0000000002 Cape Management Team LLC Dunkin Donuts � 1353 Route 28 State Risk ID#: 000456527 South Yarmouth, MA 02664 Eff date: 01j01/17 NAICS: 722513 DIV #: 00000 � E/L Number: OOOOOOOOQ3 Cape Management Team LLC Dunkin Donuts � 14-16 East Main Street State Risk ID#: 000456527 ' West Yarmouth, MA 02673 Eff date: 01f01j17 NAICS: 722513 ' DIV #: 00000 � E/L Number: Od00000004 ; Cape Management Team LLC Dunkin Donuts � 464 Route 28 Main Street State Risk ID#: 000456527 � West Yarmouth, MA 02673 Eff date: 01/01/17 NAICS: 722513 # DIV #: Q0000 E/L Number: 0000000011 WC 00 00 01 B i I �