HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee
Town of Yarmouth $185.00
Food Establishment License
Number: BOHF-15-1268-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
KC PIZZA INC. 484 STATION AVE
DOMINO'S PIZZA SOUTH YARMOUTH, MA 02664
65 THORNBERRY CIRCLE
MASHPEE, MA 02649
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Food Service; Common Victualler
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
SEATING: 9
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
Of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
4
1144
Bruce G. Murphy,I PH, R.S., CHO
Health Director
The Commonwealth of Massachusetts
Department of Industrial Accidents
FFFL•...: ,� Office of Investigations OEC 13 2021
=MO 1 Congress Street,Suite 100 HEALTH D
1.0 SIPP—Cr Boston MA 02114-2017wsoimmir
EpT
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: KC Pizza Inc. d/b/a Domino's Pizza
Address:65 Thornberry Circle
City/State/Zip: Mashpee, MA 02649 Phone #:508-561-1484
Are you an employer? Check the appropriate box: Business Type(required):
1.0 I am a employer with 125 employees(full and/ 5. El Retail
or part-time).* 6. 17 Restaurant/Bar/Eating Establishment
2. I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 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 prow workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: N &Dedham Mutual Fire Insurance Company
Insurer's Address:649 High Street
Dedham, MA 02026
City/State/Zip: _..._.__
Policy#or Self-ins. Lic. # WE115956A Expiration Date:09/12/2022
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. 1:52 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. - advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA "nsurance co/-rage verification.
Ido hereby certify,under ' •pains and'• , •s of pedury that the information provided above is true and correct.
Signature: . Date:
11/22/2022
'
Phone#:508-561t1481 / —!
Official use only. Do not write in this ar=,,to be completed by city or town official.
City or Town: Pernik/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: _ Phone#:
www.mass.gov/dia
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY--INFORMATION PAGE
INSURER: POLICY NO: WE115956A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026
-� NCCI Company No: 21059
`' DEC 1 3 202.1 Account No: $63006110
�T FEIN: 45-2586927
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
KC PIZZA INCORPORATED DBA DOMINO`S PIZZA A. DAVID RISMAN INSURANCE
65 THORNBLRRY CIRCLE AGCY
MASHPEE, MA 02649 689 FELLSWAY
MEDFORD, MPS 02155
AGENT NO.: 20722
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See VVorkers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 09/12/2021 To: 09/12/2022
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 500,,000 each accident
Bodily Injury by Disease: $ 500,,000 policy limit
Bodily Injury by Disease: $ 500 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms arid Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 456 Annual Premium: $ 56,505
Audit Period: NNuA,I, Additional/Return Premium:
Comments:
Issued At
Date: 08/03/2021 Countersigned by
WC 00 00 01A Copyright 1987 national Council an compensation Insurance
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