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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 *Please complete form and attach all necessary documents by December IS 2017. Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: caoe Manaaement 7eam.��c oen ounkin'Donuts TAX ID: LOCATION ADDRESS:464 Rt.28 West Yarmouth.MA 02673 TEL.#: 781-279-0290 MAILING ADDRESS: ��s nna��sr��r sr��Pnam nna o2�ao E-MAIL ADDRESS: office@coutomanagement.com OWNER NAME: Sal c:nuto,CFn CORPORATION NAME(�APPLICABLE): �unkin'oonuts MANAGER'S NAME:Michelle Dankers TEL.#: 508-889-2909 MAILING ADDRESS: �69 Main Street Stoneham,MA 02180 POOL CERTIFICATIONS: L=T1 � ('�n 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. � � � .,� m 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 Cle at your place of business. 1. N/A 2, ,� 3. 4. r�; ,.� 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 Healt6 Department will not use past years'records. ^ You must provide new copies and maintain a file at your establishment. ; � i, 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. Marcia DePaula 2. � ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fuli-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 Hea(th Department will not use past years'recoeds. You must provide new copies and maintain a file at your estabtishment. 1. Marcia DePaula 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 tile at your place of business. 1. N/A 2. 3. 4. RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED 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 REQUIRED FEE T LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-100 SEATS $125 � q,j CONTINENTAL $35 NON-PRO IT $30 >100 SEATS $200 gCOMMON VIC. $60 � _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 �ROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ $185.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*x**• �01�F-��-b869' -03 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 ta�ces 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 wkuch 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,totai 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 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 Deparhnent,or from the Town's website at www.yarmouth.ma.us under Health Department, 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 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 TE PLAN. DATE: 10/25/17 SIGNATURE• s PRINT NAME&TITLE: Salvi Couto,President Rev.]0/12/17 .� The Commonwenith of 1Vlassacht�setts � ;� � � Depa�tment of Industrtal Accidents � �N Of�ce of Investigations � � G00 Washington Street u,� - Boston,MA 021I1 ��5 www.mass.gov/dia Workors' Compensation Insurance Affidavxt: General Businesses � ApUlicant Informatlon . Please Print Lcgibly Business/OrganizationName: Cape Managem°ent Team, LLC DBA Dunkin Donuts Address: 464 Rte. 28 � City/State/Zip:W.:,Yarmouth, MA 02673 Phone#; 781-279-0290 Are you an employer?Check thc appropriate box: Business'Type(reguired): 1.[X� I am a employer with 20 employees(full and/ S. ❑Retail - Or part-time).* 6. �Restaarant/Bar/Eating Establishmant 2.❑ I am a sole proprietor or partnership and have no �, �Office 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 corporatiaa and lts o�cers have exercised 9. ❑EntertAuunent their right of exemption per c. 152, §1{4),and we have �p,[�ManufActuring no employees. [No workers'conlp,insurance required]* 1 I.�Tlealth Ca�•e 4,❑ We are a non-profit organization,staffed by voIunteezs, with no employees. [No workers' comp.insurance req.] 12,0 Other � *Aciy applicant tliat checks box t�1 must fllso fill ouf the section Uelow showlug d�elr wor[cers'compensation pof icy intormation. **Tf thc corpornte oflicars have exempted U�emselves,but llie oorporntion.hos othcr cmployees,a workcrs'compe�tsation policy is require<I aud sudi an organization should.check box#1. `` I rtrri nn erriployer�leat�S ptovl�ltng ivorkers'compensativn insurnnce for my e�nX�loyees, Below is tke pollcy�nfornrntlon. Insurance Compa�y Name; MA Retail Merchants WC Group, Inc. Ir►surer's Address: P.O Box 859222-9222 � City/state/zip: Braintree MA 02185 Poticy#or Self•ins,Lic.# 014005034027117 Expiration Data: 1/1/18 Attact►a copy of the workers'comp�nsation policy declaration page(showing the policy number and expiration date). I'ailure ta secure coverage as requira�under Section 25A of MGL c, 152 can lead to the imposition of criininal penaities of a flne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fortn af a STOP WORK.O.RD�R and a fine of up to$250.00 a day against ttie violator. Be advisecE tl�at a copy o�this statement may be forwarded to the Of�ce of Investigations of the DIA for insurance coverage verificAtion. I rlo liereby cert ,t�n�l � airrs«nrl penattles of perjury thnt t)te ir�'ormat�on lirovided above ts true�n�l correct. i natur : Date: 10/26/17 Phone#� 781-279-0290 Ofjtcial use onXy. Do not write tn tli�s area,to be completert by cdty or totvn nffic�nl. City or Towni Permit/License# Tssui�ag At�thority(circle one): 1.13o�rd of�Icaltli 2.Building Departmetit 3.City/Town Clerk 4,Licensing Board 5.Selectmen's Office d.Othcr Contaet Persan: Phone#: www.iruiss:gov/di1 � INEORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent�� 1042 � MA Retail Merchants WC Group Inc. Eastern Insurance Group LLC � PO Box 859222-9222 233 West Central Street � Braintree, MA 42185 Natick. MA Q1760 ; (Carrier Code: 34355) Carrier Policy ��: 014005034027117 � Garrier Prior Policy �: Oi40050340271I6 1. The Insured: Cape Management Team LLC � Dunkin Donuts � Ma.iling Address: 169 Main Street � Stoneham, MA 02180 Fe3n: � � Other workplaees not shawn above: Type o£ Business: Limited Liability Co SEE SCHEDULE OF OFERATIONS Risk ID: 2. The policy period is from 12:01 a.m, on 1/Q1l2017 to 12:01 a.m. on 1/Ol/2018 at the insured's mailing addrass. 3. A. Warkers Compensation 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 policy applies to work in eaeh ; state listed in Item 3.A. The lim3.ts of our liability under Part �aa are: ' Bodily In�ury by Accident $ l.QOQ,000 each accident Bodily In�ury by Disease $ 1 000 d00 policy limit Badily Injury by Disease $ 1.000.000 each employee C. Other States Tnsurance: i D. This policy includes these endorsements and sc'hedules: WCOOa000C(01J15) WC0003Q8(04/84) WC000406(08184) WCOOQ414(07190) WCQ00422B(O1j15� WC200301(04/84} WC200302(05/86) WG200303B(�7/49) WG2Q0306B(�6/13) WC200405(06/Ol) � WC20f}601A(Q7l08) � 4. The premium for this policy will be daterminad by our Manuals of Rules, Classificatians, Rates and Ra.ting Plans. All informatian required below is subject to verification and change by audit. Classificat3ons Code Premium Basis Rate Per Estimated No. Total. Estimated $100 of Annual Annual Remuneratian Remuneration Premium ' SEE SCHEDULE OF OPERATIONS Tatal Estimated Annual Premium $ 29,912.00 ' Min3mum Premium $ 292.00 Expense Constant $ .0� Deposit Premium $ .00 , I � � � ; � i i ; SCHEDULE OF OPERATIONS FOR: PAGE: 2 Dunkin Donuts Carrier Policy #: Q1400503402711? Cape Management Team LLC Fein: 169 Main Street Stoneham, MA �2180 DIV #: OOOOQ E/L Number: OQ00000401 QTHER W�RKPL�CES: i Cape Management Team LLC Dunkin Danuts 792 Main Street State Risk ID#: 000456527 �sterville, MA 02655 Eff date: 01/01/17 NAICS: 722513 ' �zv #; o�aao E/L Number: aa000aaoo� Cape Management Team LLC � Dunkin Donuts 1450 Route 28 St�te Risk ID#: OQ0456527 South Yarmauth, MA 02664 Eff date: 01/01J17 NAICS: 722513 DIV #: OOOQO E/L Number: OOOOOOOQ02 Cape Management Team LLC Dunkin Donuts 1353 Raute 28 State Risk ID#: 000456527 South Yarmouth, MA 02664 Eff date: Q1/Q1/17 NAICS: 722513 DIV #: 40000 E/L Number: Q�00000003 Cape Management Team LLC Dunkin Donuts 14-16 East Main Street State Risk ID#: 000456527 West Yarmouth, MA 02673 Eff date: os/os/1� i NAICS: 722513 ' DIV #. 00000 ; E/L Number; OOOOOOOOQ4 i Cape Management Team LLC � Dunkin Donuts � 464 Raute 28 Main �treet State Risk ID#: 00045&527 � west Yarmouth, MA 02673 Eff date: 01J01/17 NAICS: 722513 ; DIv #: 40000 � E/L Number: OOOQ000011 � WC QO 00 01 B � � � I � �