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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 1 S 2017. Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: Caoe Manaaement 7eam.��c oen ounkin'oanuts TAX ID: LOCATION ADDRESS:1050 Rt 9R Snuth Yarmn ith_MA 02664 TEL.#: 781-279-0290 MAILING ADDRESS: 1R9 Main StrPat StonPham�MA 02180 E-MAIL ADDRESS: office@coutomanagement.com OWNER NAME: Sa�rnuto,CFn CORPORATION NAME(IF APPLICABLE): Dunkin'Donuts MANAGER'S NAME:Michelle Dankers TEL.#: 508-889-2909 MAILING ADDRESS: tss enain Street Stoneham,MA 02180 = J � POOL CERTIFICATIONS: � � C7 The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � � �f1 Pool Operator(s)and attach a copy of the certification to this form. � -J � 1. N/A 2. � � v 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. : . 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 Health Department will not use past years'records. - —" You must provide new copies and maintain a file at your establishment. 1. Gary Simpson 2. �;' '� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Mallory Nelson 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, t 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. Chelisea Hontr 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 REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiTIRED FEE PERMIT# B&B $55 CABIN $55 MOT'EL $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 REQUIRED FEE PERMIT# 0-100 SEATS $125 #��p CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 gCOMMON VIC. $60 ��p� _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# <50sq ft. $50 >25,000 sy.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ $185.00 '****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* �0.��-t5-68�0'� 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 Health 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 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 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 U E PLAN. DATE: 10/25/17 SIGNA PRINT NAME&TITLE: Salvi Couto,President - Rev.10/12/17 ,,,_ The Commonwealth ofMass�tchusetts ;,� � Depa�tment of Inclustrial Accidents � p� Of,f�ce of Investlgcations . 600 Washington Street �� Boston,MA 02X.I.X c-� � www.mass.gov/d�� . Workors' Compens�tion Insurance Affidavit: General Businesses � ApplieAnt Inform�}t�on . Please 1'rint L,e�,ibly Business/�r�;anizatianName: Cape Management Team, LLC DBA Dunkin Donuts Address: 1050 Rte. 28 - City/State/7ip:S. Yarmouth, MA 02664 Phone#: 781-279-0290 Are you nn employer?Check thc appro�riate box: Business`l'ype(required): 1.� I am a employer with �0 employees(full and/ 5• ❑R��il - or part-time).* 6. ��testaurandBar/Eating�stablishnient 2.❑ I am a sole proprietor or partnership and have no 7, �p�ce and/or Sales(incl.real estate,auto,etc.} employees working for me ia any capacity. [No workers' comp.insurance required� 8• ❑Non-profit � 3.❑ We are a corporatiaa and its officers have exercised 9. ❑Entertainment their right of axemption per c. 152, 1 4 ,and we hlve 14.[]Manufacturing no employees. [No workers'comp.insurance required]�' 1 I.�klealth Care 4.❑ We tu�e a non-profit organixation,sta�£ed by voluntee�s, with no employees. [No workers' comp.insurance req.J 12.[] Other � *Any appllcant trint checks bax#1 must also fill auf the seation betow showlug tl�eir workers'compensation pof icy information. **Tf thc corpornte officers have exempted d�emselves>but the corporatlon.has othcr cmployees,a workers'compensation policy is rec�uire<f and sud�an arganlzatton should.check box#1. ^ I am ar�employer tliat�S 1�rovJrling�vorkers'compensatlun lnsurance for my eratployees, Below is tlie pol�cy informrrtlon. Insurance Company Alarne; MA Retail Merchants WC Group, Inc. Insurer's Address: P.O Box 859222-9222 City/state/zip: Braintree. MA 02185 Policy#or Self ins,Lic.# 014005034027117 Expiratioa Date: 1/1/18 Attach a copy nf tlie worl�ers'compeusation palicy declaration page(showing the policy numher and expiration date}, I'ailure to secure coverage as requiraii under Section 25A of MGL c, 1 S2 can lead to the impqsition of criminal penalties of a fine up to$1,SOO.OU and/or one-year imprisonment,as well as civil penaities In the forin of a STOP WORK ORD�R and a fine of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investi ations of the DIA for insurance coverag�verification, X tlo fiere8y certt y, n ie 'ns«nd penaltles af perjury tfint tfie irzformatlon provlderd above ls true nn�l correcJ. Si natar . Dflte: 10/26/17 P�one#� 78�-279-�290 Offlcial use only. Do nnt write tn tlt�s area,to be completed 6y clty or town offic�rcl. City or Town: Permit/License# Issuing Aufhority(circte one): 1.I3oard of F�ealtli 2.Building Departmei�t 3.City/Town�Clerk 4.Licensing Boarc� 5.Selectmen's Office 6.Other Contact Persan: Phone#: www.mass:gov/dia i � , INFflRMATION PAGE RENEWAL AGREE�MENT � i Insurer; PRODUCER: Agent�� 1042 � MA Retail Merchants WC Group Inc. Eastern Insurance Graup LLG � PO Box 859222-9222 233 West Central Street � Braintree, MA 02185 Natick, MA 01760 ; (Carrier Gode; 34355) Carrier Policy ��: 0140�5034a27117 Garrier Prior Pai.icy ��: 014005034027116 � 1. The Insured: Gape Management Team LLC � Dunkin I�onuts � Mailing Address: 169 Main Street � Stoneham, MA Q2180 Fein: Other workplaces not shown above: Type of Business: Limited Liability Co � SEE SCHEDULE OF OPERATIONS Risk ID; i 2. The policy periad is from 12:�1 a.m. on 1[0112Q17 to 12;01 a.m. on 1I01/2018 a�e the insured's mailing address. 3. A. Workers Compensation Insurance: Part Qne af the policy applies to the Workers Compensation Law of the states listed here: MA , � B. Employers Liability Insurance: Fart Two of the policy applies ta wark in each state listed in Item 3.:A. The limits of our liability under Part �ro are: Bodily In�ury by Accident $ 1.OQQ.000 each accident Bodily Injury by Disease $ 1 000 000 palicy limit Bodily In�ury by Disease $ l.OQ0.000 each employee C. Other States Insurance: '; � D. This policy includes these endorsements and schedules: i WCOOOODOG(O1/15} WGOQ030$(Q4184) WCd00406(0$/84) WCOOQ414(07/9Q} WCQpp422B(C)1/15} WC204301(04184} WC200302(05/86) WG2003038{07/99} WC20p306B(a6/13} WC200405(06/dl) WC2Q(}601A(O7/08} 4. The premium for this policy wi11 be determined by our Manuals of Rulas, Classifications. Rates and Rating Plans. All in£ormation required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated ' No. Total Est3mated $100 of Annua� Annual Remuneration Remuneration Premium � SEE SCHEDULE OE OPII2ATIONS � [ Total Estimated Annual Premium $ 29,912.00 ; Mini.mum Premium $ 292.OQ Expense Constant $ .00 Deposit Premium $ ,00 � E � � � � � � � SCHEDULE OF OPERATIQNS FQR: PAGE: 2 Dunkin Donuts Carrier Policy #: p14005034027117 Cape Management Team LLC Fein: 169 Main Street Stoneham, MA 02180 DIV #: OQOQ� E/L Number: O�OOQ00001 OTHER WORKPLACES: I Cape Managernent Team LLC Dunkin Donuts � 792 Main Street State Risk ID#; 000456527 ` Osterville, MA 02655 Eff date: 01/�1/17 € NAICS: 722513 ` �zv #: oaoao EjL Number; OQ400QQ�07 Cape Management Team LLC � Dunkin Donuts 1450 Route 28 State Risk ID#: OQ0456527 South Yarmouth, MA. 02664 Eff date: Q1/01/17 NAICS: 722513 � Dzv #: 000aa E/L Number: Q000000002 Cape Management Team LLC Dunkin Donuts 1353 Raute 28 State Risk ID#: OQ0456527 South Yarmauth, MA 02664 Eff date: 01/01/17 NAICS: 722513 DIV #: a0000 E/L Number; O�OQOOU003 Cape Managemen.fi. Team LLC I Dunkin Donuts 14-16 East Main Street State Risk ID#: 000456527 West Yarmouth, MA 42673 Eff date: Q1/01/17 NAICS: 722513 DIV #: 00000 : E/L Number: oa000Qooa4 Cape Management Team LLC � Dunkin Donuts i 464 Route 28 Main Street State Risk ID#: OdQ456527 ` west Yarmouth, MA 02673 Eff date: 01/�1f17 ; NAICS: ?22513 , nzv #: 4Q000 ; EjL Number: 4000000011 � WC 00 00 U1 B ` € � � � �