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Home My WebLink AboutApplication and WCTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2019 r * Please complete form and attach all necessary documents by December 15 2018. NOTE. ALL BUSINESSES WITHLIOUORLICENSESMUSTRETURNFORMS BYN V MBER15`h Failure to do so will result Int e return of your application packet. ESTABLISHMENT NAME: Cape Management Team, LLC dba Dunkin' Donuts TAX ID: LOCATION ADDRESS:464 Route 28, Yarmouth MA 02673 TEL.#: 781-279-0290 MAILING ADDRESS: 169 Main St, Stoneham, MA 02180 E-MAIL ADDRESS: office@coutomanagement.com OWNER NAME: Salvi Couto CORPORATION NAME (IF APPLICABLE): Cape Management Team, LLC MANAGER'S NAME: Michelle Dankers TELN: 781-279-0290 MAILING ADDRESS: 169 Main st. Stoneham. MA. 02180 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. 1. N/A 2. 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. N/A 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. Marcia Depaula 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 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 Marcia DePaula 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. 2. 3. 4. RESTAURANT SEATING: TOTAL # 24 NAME CHANGE: $15 AMOUNT DUE = $185.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Id 0 b L OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # $55 $55 $110 _B&B $55 _CABIN CAMP $55 _MOTEL SWIMMING POOL $110ea. _INN LODGE $55 —TRAILER PARK $105 _ WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P IT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # �0-100 SEATS $125 CONTINENTAL $35NON-PROFIT $30 SEATS $200 X COMMON VIC. $60 '17 =WHOLESALE $80 _>I00 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # <50 sq ft. $50 >25,000 sq ft. $285 VENDING - FOOD $25 —TOBACCO =<25,000 sq.ft. $150 =FROZEN DESSERT $40 $110 NAME CHANGE: $15 AMOUNT DUE = $185.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Id 0 b L 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 COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. 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, 2018. 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 E PLAN. DATE: 12/1/2018 Rev. 10/23/18 SIGNATURE: PRINT NAME & TITLE: Salvi Couto, President The Commonwealth of Massachusetts Department of Industrial Accidents 0 1 Congress Street, Suite 100 Boston, MA 02114-2017 `t www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Cape Management Team, LLC DBA Dunkin' Donuts Address: 464 Rte 28 City/State/Zip: Yarmouth, MA 02673 Are you an employer? Check the appropriate box: I. ® I am a employer with 13 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.] Phone #: 781-279-0290 Business Type (required): 5. ❑ Retail 6. ®Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11. E] Health Care 12.❑ Other *Any applicant that checks box 41 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 insurance for my employees. Below is the policy information. Insurance Company Name: 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. # 014005034027118 Expiration Date: 01/01/2019 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, ,un tqr fly pains and penalties of perjury that the information provided above is true and correct. 12/1/2018 Phone #: 781-279-0290 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 #: INFORMATION PAGE Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-922'2 Braintree,'MA 02185 (Carrier Code: 34355) 1. The Insured: Cape Management Team LLC Dunkin Donuts Mailing Address: 169 Main Street Stoneham, MA 02180 .Other workplaces not shown above: SEE SCHEDULE OF OPERATIONS RENEWAL AGREEMENT PRODUCER: Agent# 1042 Eastern Insurance Group LLC 233 West Central Street Natick, MA 01760 Carrier Policy #: 014005034027118 Carrier Prior Policy #: 014005034027117 Fein: Type of Business: Limited Liability Co Risk`ID: 2. The policy period is from 12:01 a.m.. on _1/01/2018. to 12:01 a.m. on 1 01 2019 at the_insured's mailing address. 3. A. Workers 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 each state listed in item X.A. The limits of our liability under Part Two are: Bodily Injury by Accident $_ 1,000.000 each accident Bodily Injury by Disease $ 1.000.000 policy limit Bodily Injury by Disease $ 1Q"0-00— each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000308(04/84) WC000406 WC000414(07/90) WC000422B(01/15) WC200102(01/14) WC200301(04/84) WC200302A(09/08) W0200303D(08/10) WC200306B(06/1.3) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating 'Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis No. 'Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total; Estimated Annual Premium $ 26,825.00 Minimum Premium $ 292.00 Expense Constant $ Rate•Per Estimated $100 of Annual Remuneration Premium .00 Deposit Premium $ .00 SCHEDULE OF OPERATIONS FOR: Dunkin Donuts Cape Management Team LLC 169 Main Street Stoneham, MA 02180 OTHER WORKPLACES: Cape Management Team LLC Dunkin Donuts 343 Scenic Highway Buzzards Bay, MA 02532 Mailing: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin Donuts 156 Iyannough Road Hyannis, MA 02601 Mailing: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin -Donuts 702 Iyannough Road Hyannis, MA 02601 Mailing: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin Donuts 39 Nathan Ellis Highway Mashpee, MA 02649 Mailing: 169 Main Street Stoneham, MA 02180 PAGE.: 1 Carrier Policy #: 014005034027118 Fein: DIV #: 00000 E/L Number: 0000000001 State Risk ID#: 000456527 Eff date: 01/01/18 NAILS: 722513 DIV #: 00000 E/L Number: 0000000009 State Risk ID#: 000456527 Eff date: 01/01/18 NAICS: 722513 DIV #: 00000 E/L Number: 0000000006 State Risk ID#: 000456527- Eff date: 01/01./18 NAILS: 722513 DIV #: 00000 E/L Number: 0000000010 State Risk ID#: 000456527 Eff date: 01/01/18 NAILS: 722513 DIV #': 00000 E/L Number: 0000000005 SCHEDULE OF OPERATIONS FOR: Dunkin Donuts Cape Management Team LLC 169 Main Street. . Stoneham, MA 02180 OTHER WORKPLAC9S: Cape Management Team LLC .Dunkin Donuts 4.0 South Street Mashpee, MA 02649 Mailing: 1:69 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin Donuts 792 Main Street Osterville, MA 02655 Mailing: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin Donuts 1050 Route 28 South Yarmouth, MA 02664 Mailing: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC Dunkin Donuts 1353 Route 28 South Yarmouth, MA 02664 Mailing: 169 Main Street Stoneham, MA. 02180 PAGE: 2 Carrier Policy #: 014005034027118 Fein:. DIV ##: 00000 E/L Number: 0000000001 State Risk ID#: 000456527 Eff elate: 01/01/18 NAICS: 722513 DTV #: 00000 E/L Number: 0000000008 State Risk ID#: 000456527 Eff date: 01/01/1.8 NAZCS: 722513 DIV #: 00000 E/L Number: 0000000007 State Risk ID#: 000456527 Eff elate: 01./01/18 NAICS: 722513 DIV #: 00000 E/L Number: 0000000002 State Risk ZD#: 000456527 Eff date: 01/01/18 NAICS: 722513 DIV #• 00000 E/L Number: 0000000003 SCHEDULE OF OPERATIONS FOR: Dunkin, Donuts Cape Management Team LLC 169 Main Street Stoneham, MA 02180 OTHER WORKPLACES: Cape Management Team LLC Dunkin Donuts 14-16 East Main Street West Yarmouth, MA 02673 Mauling: 169 Main Street Stoneham, MA 02180 Cape Management Team LLC kin Donuts Rede 2 Nai'tr� ��" 26 Mailing: 169 Main Street Stoneham, MA 02180 WC 00 00 01 B PAGE: 3 Carrier Policy #: 014005034027118 Fein: DIV #: 00000 E/L Number: 0000000001 State Risk ID#: 000456527 Eff cute:: 01/01/18 NAICSs 722513 DIV # 00000 E/L Number: 0000000004 State Risk ID#: 000456527 Eff dates 01/01/18 NAILS: 722513 DIV ##: 00000 E/L Number: 0000000011