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HomeMy WebLinkAboutApplication and WC�7 � o~ W �U V a .cl � 0 O Cd PLO Z �N � O cd 4�� 3 Wo PLO � o rn aNr� h °z N m o� C's 0 n i. W ��„ O Oyu v)i Ute° 7� 6f°' on WD WD < vii~ o v)CA s �41. En rA c I t8 kn Q 0 4.0 o IiQbbos,o a C6 Z°?�,�o icn oo �UF"� �WA� Qo o °oH U Up � Cd 0 Cd e5 .. cd on Z W ani s-- COO o U o cc's ;� '' W co M v .o `� 003 W�00Ute, Uo�4+� woo CZS cd 40, rS.�aa� V, ° a .� x� d --4 M il kn c,9 It - a T � W�O w asssss w sss9 W��� W000 Wino A wsss9;,� wrtssc w�� a O WW a�w� WW rx0 aw �a 0QOw �zu aa�I al wwr� wa; aQ czxox� w�¢ as ZO wa�ln� a zl3 I a'I� 4� Cid O Wv �n wQS�� Weno wr,� Wo�o� � 4.�� h W�U [Wr� x w w z zo �• hoz O z � f 7 z'9 50 tool zNa nl aUIUIF� aU�� a kn c,9 a kn nn Wknkti �n o WAN W�O w asssss w sss9 w ss r. 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O o �;tiZ > �o ocs --' ° CD CD 0 CD ° `ti p aCD `° qo CDn � o � c �R, CD , CD CD oy�CC o CD CD � EF O : CD °O cl, °am y Z O O yCi �j O n LS' .O .� fD 0 CD CD o > d CD CL 0 CD x O o O ° CD fD CD p (14 �� i• i CD 0 o =R "Cl CD qa o o er o 5'' � � (DD o `D ��'�, °, y op t r. 0 CD CD O p� O o. A. C� r� a y 0 n Ia O . fD W CD CD CD 0 0 0 f' O N g o O P� o n~ O CD O� 0C b 09 R M0 O �� 'OO � -'51 o n O �C�y•ri ° Cd d O CD CD cCD p, .0 C1 0 Y' ry- r� O CD o d a� CAD W '"+ O CD x O °¢ CA cz Q. C+.0 C•: K o CD O CD o. o �� CD O `� o'tiQ. Q\ �n n O N CD v� UQ P CD R+cw CD 5 N O. 9 CD O 0 The Commonwealth of Massachusetts Fee /001� Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-0923-04 Issue Date: 01/01/2019 Mailing Address: STATION AVENUE DONUTS, LLC DUNKIN' DONUTS P.O. BOX 485 SOUTH DENNIS, MA 02660 Location: 436 STATION AVENUE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2019 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2019 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 36 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, R.S., CHO / Amy L. von Hone, R.S., CHO Health Director / Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information (� 1uI�I y� Please Print Legibly Business/Organization Name: ',DhS Db Cmu n a A-6 Address: City/State/Zip: �,Vw( i (�^�. P�,D� Phone #: �O `�Q4 -1 N 1 Are you an employer? Chec the appropriate box: I. V I am a employer with JD employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. DRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) S. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11. ❑ Health Care 12. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. * *If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurange for my employees Below is the policy information. Insurance Company Name: Insurer's Address: &D S l o 0 { o rPft9xLA,-L—VEt City/State/Zip: CU M m i 04 q `f l 1 'rl Policy # or Self -ins. Lic. #WC✓ (>22,9) ID Expiration Date: I I Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER 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 Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: www.mass.gov/dia Phone #: 0 N m C? Z .NOTICE O TO EMPLOYEES EMPL The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENT 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.massgov/dia As required by Massachusetts Genera Law, Chapter 152, Sections 21, 22, 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Wesco Insurance Company NAME OF INSURANCE COMPANY Avenue WWC3322810 POLICY NUMBER N 21st Floor, Cleveland, OH 44114 ADDRESS OF INSURANCE Insurance Agency, Inc - [E [E OF INSURANCE AGENT Station LLC 'ANY 1/1/2018 to 1/1/2019 EFFECTIVE DATES 1468 Pleasant Street, Fall River, MA (5C 02723 DU RESS 436A Station Ave, S Yarmouth, MA 02664 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT n the course of The above named insurer is required in cases of personal injuries arising out of and i employment to furnish adequate and reasonable hospital and medical eer t of Injury ces n ac must be givence with the the provisions of the Workers' Compensation Act. A copy of the First R _p injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,n f the treatmenis attentit employees necessary and reasonably connected to the work related injury. In cases requiring hospital _ are hereby notified that the insurer has arranged for such attention at the r � NAM OF HOSPITAL ADD' SS TO BE POSTED BY EMPLOYER ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE I) TYPE OF INSURANCE 11/19/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Stephen Neto NAME: Neto Insurance Agency Inc PHONE (508) 678-9068 FAX (508) 672-9265 03/24/2019 AIC No Ext): AIC, No 1470 Pleasant Street E-MAIL ADDRESS: p ste hen netoinsurance_com INSURER(S) AFFORDING COVERAGE NAIC # GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑ JECTPRO PRO- LOC OTHER: Fall River MA 02723 INSURER A: Safety INSURED INSURER B. Wesco Insurance 25011 Station Ave Donuts LLC INSURER C 436A Stattion Ave INSURER D INSURER E: S Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: UL18111905435 RF'VIRInN NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADULSUBR INSD WVD POLICY NUMBER POLICY EFF MWDD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR BMA0026475 03/24/2018 03/24/2019 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑ JECTPRO PRO- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS $ 2,000,000 Employee Benefits $ AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ er accident A X UMBRELLALIABOCCUR EXCESS LIAR 4CLAIMS-MADE CM00005953 01/01/2018 01/01/2019 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ DED I X1 RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERIEXECUTNE OFFICERIMEMBEREXCLUDED? � (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WWC3322810 01/01/2018 01/01/2019 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GANGELLAIIUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of South Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ��// MA A4� 97/. V ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD R O O c O m Z 0 Q 1 c 0 E a m LL X v W C� 0 O f6 U v_ o d a U O L O O 00 L, G U C O d C d � O N 0 d o Zit U. _ 0 N 3 u s � c W VI O ^j MOM Z t s W O wya f O WV U T C 0 a U IA U uj to In J c O m Z 0 Q 1 r.. O X V Lu c o d 0 0 0 _ a U LL. a o LLJ O_ u� • ��. d z O a U � d x S a N L" N z 0 o w Q 0 0 LL N '• a ILOw N X Q > = N Ln o (n N LLJ D -$ z � � W CD m r d ` 44, �lcl� a � L N LU v l 0 d 0 0 0 L O G t u� a _ J• v t; s a e o R J C ^ N •H' y O� N ,t p' r q �g o Q v w z; a e •H' y O� N ,t p' z; 1 t 4i � v y a The Education Center, below, verifies that Karen Jones has successfully completed the knowledge and skill evaluations for the Adult, Child, Infant CPR &AED Emergency Care & Safety Institute Course. August 24, 2017 August 24, 2019 3NN14P7FIWMC Course Name Course Completion Date Recommended Renewal Date Student Authorization Number Cape Cod CPR & first Aid Training 508-364-4750 Lindsey Brown FHC8OV9ICPM6 Education Center Education Center Phone Number Instructor Name Instructor ID Number info@CapeCPR.com' This certificate does not guarantee any future performance or suggest any form of licensure. Skills deteriorate rapidly when not Education Center Email used. Periodic retraining is strongly recommended. Cut along the dotted line at the bottom of StudentAuthorization #: 3NN14P7FIWMC the certificate and along the dotted lines around Education Center: Cape Cod CPR& First Aid Training the course completion card. Fold the card in half. Education Center Email: mfo@CapeCPR.com e Education Center Phone #: 508-364-4750 Instructor Name: Lindsey Brown Instructor ID #: FHC8OV91CPMB The Education Center verifies that the above has successfully f completed the knowledge and skill evaluations for the Emergency Care & Safety Institute Course.dh August24,2017 August24,2019 Course Completion Date Recommended Renewal Date LC I Numb— 1,8(XI) 71 ORAIICE