Application and WC TOWN OF XARMOII7CH BOARD OF HICALTH
APPLICATION FOlt LiCE1V8F✓PERMIT- 2014
"'Please complets form and attach all necessary documvnts b
Feiture to do so will result in the rerturn of your appli�tton p��014 � fp'' � '
NAME OF ESTABLISHMENT: Dunkin'Donuts TEL.# �' �In�t
LOCATIONADDRESS: _,1.� F�_�ain Street � �' '-"
MRILINGADDRESS:__�R9 Main St_ renY ton ,j�m MA n�1$0 � c �
OWNER NAM$: Sa�vi Ceu4n TAx ID(F�IN or 4SNY ,Q9 �7Ro�da 1 � �
CORPORATION NAME(IF APPLICABLE):Ca�e Manapp.ment Team" �,LG.
MANA(3ER'S NAME: TEL. # 7R1_97A_09g0
MAILING ADDREss: 769 Main Stree Stqneham. MA 02780
POOL CER'1'IFICATIONS: -
The pool aupervisor mast be certified as a Pool Operator,as required by State law, Please list t6e designated
Pool Operator(s)and attach a copy of the certificallon to t6is form.
t. 2. f �,�� �I�
Pool operators must 1'ut a minimum oftwo employe�es currendy certified in basic water sefety,standard First Aid anci �/1'✓p �
Commwiity Cardio�pulmonary Resuscitadon(CP1t,L1'lease list these employees below and ettach copies ofemployee -��0 i
certiRcations to thts form.The Health Department wi11 not nae past years' records. You must provide new ��1�J
copies and msdntain p tile at your place o£bnsiness. v,
� i
1. 2. �
3. _4. �Ci /'
POOD PROTECTION MANAGERS-CERTTFICATIONS: �`s
All food servioe establishments are required to have st leastone full-time employce who is certified as a Food V
Protecdott Manager,as defined in tha State Sanitary Code for Food Service Estabifshments, ]OS CMR 590.000.
Please attach copies of certification to thu applicatiou. The Heak6 Depnrtment will not use past years'records. n
You mast provide new copies and maintain n Me at yoar establishment. �,
I�Yt �
1, Denise Russell Cook z, �� �
PERSON IN CHARGE: �
, Each fuod estab]ishment miut have at least one Persou fu Charge(PIC)on site dwing hours of operadon. �
1 Denise Russell Cook Z
HEIMLICH CBRTIFICATIONS: �
All food service establishmenta witli 2S seats or more must have at least one employee tralued in the Heimlic6 �`��
Maneuver on the premises at all dmea. Please list youremp loyees u�ined in anti-choking procedures below and !
attech copies of employee certi6cariops to this form..The Health Department will not use past yesrs'records.
You must provide pew copies and maintaln e Hle at your place of business, ���
1. ' 2.
3, 4. Q�
RE�TRURANT SBATINCi: TOTAL# 0 ^i `��i l �
LODGINa� OFFICC USE ONI.X
� LIC@NSBREQUIRED FEB P�1tA9T# LICENSEREQUIR£D FE6 PERAUi'8 LICEC7SENEQUIRF,D FEE PERMITfl
_B&B S55 _CABA1 S55 � _MOI'A. - 555 -
. 1NN, S55 _CP.MP S55 , _SWIMMINOPOOL SBOea
_LODtlE $55 �,_„_, _TRAILGRPARK S105 _WE�IRLPOOL SSOee.___
800D BERVICEi � '
� UC6N3�REQIIIRED FCE PQtMtl'# -L[CENSEREQURtED T�C P&RMITN LICG!]SEREQURtED FEE" PFRT�(fITR - -
Laaoos�nnTs S85 _CONfWENfAL S35 y _,NON-PROF17 530
- �>I00913ATS 5160 �COMMONVIC. $GO ' �.�WtiOLESALE S60 . . � �
- ,� RETAIL BERVICE: � _...RESID.KiTCHEN S80 �
. � T.ICfiNSBREQUIRED fLE PGRM17'B LICENSCRBQUR2SD FEE PERM17'fl LICENSEREQUIRED F6E . PFRMI'1'H �
� , � . �,a50sq8 SSO _>25,OOOaq.B. $235 �_ _VENDINO•FOOD S25 �� � �
. _Q5,000-sq.R. S80 _FROZENAG&SBRT 940 �;TOIIACCO S53 . �
x.�e egaivice: a�s AMOUNT DiJ� _ $ SF nn:—
- . . "•^«'RLBASE TURN OV6R AND COMPLETB OTRER 31DE OF NY1RM'"••" ,p_G� .$QV S �. .
[.�
��a,�t� C:�`f`�17
ADMIlVISTitATION . t'"".—"
Under Chapter 152,SecUon 25C,Subaection 6,tha Town of Yarmouth is now required to hold issuance or renwval
of aay licanse or permlt to operate a business if a person or company doea aot have a CertiBcate of Warka's
Compeasation Insurance. THE A7"PACH�D $TATE �40RKCR'S COMPFIV3ATION INSURANCE ,
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CSRT.OF INSU1tANC�ATTACHED� - � –
OR
WORKf3R'S COMP.APPIDAVIT SICiNSD AND ATTACkTED�_,
Town of Yatmouth ta�cea and liane must be paid prior to renewal a isauance of your permite. PLEASB CFiBCK
APPROPRIATELY IF PAID:
X&3 X NO
MOTELS AND OTHER LODGING$STABLISHA'II6NT5
'1'RANSIENTOCCUPANCI': ForpurposeaofthalimitationsofMotelorHoteluse,Transie�ocxUpancyshallbe
Gmited to tha temporary and ehort tarm occupsucy,ordinarity and a�stomarily associated with motd and hotel usc.
Transient occupants muat have snd ba sbleto damonstrate that t6ey maiMain a prinapd place ofresidence elaewhere•
Transient occupancy etastl ganerslty refer to continuous occupancy of not more than thirty (30) days, end an
aggregate of not more than pinety(90)daya within any ei�C(6)month period. Use of a gueat unit as a rasidence or
dwelling unit shall not ba considered transiant. Occupancy tl�at is subjoct to the oolfeotion oERoom Occupancy
Excise,as definad in M,G.L.c.64G or 830 CMR 64G, ss amanded,ehall genara]ly be considared Trmtsient.
POOLS
POOL OPI�NING:All swimming,wad'n�g and wLirlpools wbich have bean cloged forthe aeason must be' �
bythaHealthDaperdnont riortoopening. ContacttheHealthDeparUnenttoacheduletheinepeotionthra��( )days
pnor to opemng.pb�QT�:P�P1e are NOT allowed to sit�n the pool aren unU7 the pool has been lnspacted
and opened.
POOL WATER 7'ES'CIlVCr. Tha watar muet be tasted for paeudomonas total coliform and atandard plate count
by ar�� cerdfied lab, aud submitted to the Aeakii Depaztmeat tivee(�!)days prior to opaning, end qusrtedy
ths
POOL CLOSING:Every outdoor in ground awimming pool mustba drained or covered within sevea(�days of
closing.
FOOD SERVICE
CATERINI;PQLICY:
AnyonewhocaterswitbinthaTownofYarmouthmustnotitythaYarmouthHealthD�e+rtby�fl�rsquired
Temporary Food Servica Applicatlon form 72 hours prior to the catered evant. 1'hese forms can ba obtained at the
Health Dapartment. ,
FROZEN AESSERTS:
Prozen desserta muat be tested on a mont6ly beats by a State cerdfled lab. Tast results must ba s�t to tha Health
Departmeeott. Bailure to do so will resuk iu tha s�ispension or cevocauon of your Prozan Dassert Astrnit untit flfa
above terms have been m�.
OUTSIDE CAF$S:
Outslda cafes(i.e,outdoor eeating wlth waiter/waitress servica),muet hava prior approval fromthe Soard ofHealth.
i
OUTDOOR COOIQNG:
Outdoor cooking,preparatioq or display ofany food product by a retail or food aervice oatablishment is protiibiteJ.
NOTICE:Permits ivn annually from Jenuary I to December 31. 1T LS YOUR RE$PONSIBIIfi1"Y TORflTURN
T[3E COMPLETED RENBWAL APPLICATION(S)AND RBQUIlLED FEH(S)BY DECEMBSR I5,'Z0�4 '
AI,L RBNOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIIdTING, NEW
EQUIPMENT,ETC J,MCJST BE REPOItTED TO ANU APPROVED BY 1T�BOARD OF HEALTH PRt01t
TO COMMENCEMENT. RENOVATIONS MAY REQCTIRE A SITE PLAN.
DATE: 11/25/74 SICiNATURE: ,
PRINTNAME&TiTLE: S81VI COutO
osnsro9
_� The Commonwealth ofMassachusetts
,;� � Department oflndustria[Accidents
� Office oflnvesttgations
4 600 Washington Street
�� Boston,MA 02111
r s www.massgov/dia
Worlcers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeiblv
Business/OrganizadonName:Cape Management Team LLC dba Dunkin Donuts
Aaaress: 16 East Main St.
c��yis�teiz�p:W. Yarmouth, MA 02673 1'hone#: 508-862-0124
Are you an employer7 Check thc approprinte box: Business Type(required): �
1,� 1 am a employer with 6 employees(full and/ 5. ❑Retai[
or part-time).* 6. � Restaurant/Baz/Eating�stablishment
2.❑ I am a sole proprietor or partnership and have no 7, �Office and/or Sales(incl.real estate,auto,etc J
employees working for me in any capacity.
[No workers' comp,insurance required] 8• ❑Non-pro5t
3.❑ We are a corporation and lts officars have exercised 9. ❑Entertainment
their right of exemption per a 152, §1(4),and we have l0.❑ Manufacturing
no employees. [No workers'comp,insurance required]* 11,0 Health Care
4.❑ We are a non-profit orgaztization, staffed by volunteeis,
with no employees. �No workers' comp.insurauce req.] 12.� Other
� •Any epplicant that cheeks box#1 must ntso fdl out the seotion below showing tlieir worhers'compensation policy intbrmatfon. -
. ••Tf the cdrpamte ofticers have exempted Giemselves,but Ihe corporaHon.has othcr cmployees,a workers'compensation polcy Is requircA and such an
. orgauizxtfon shoiild checic 6ox pl. . w.
I rsm an employer Ueat 1s providing workers'compensation insurruice for my emp/oyees, Relow Is the poltcy infoPmatlon.
Insurance CompaayName: AM Guard Insurance Co.
Insurer's nddress: 16 South River Street PO Box A-H
City/state/zip: Wilkes-Barre. PA 18703-0020
Policy#or Self•ins,Lic.# R2WC595758 Expiratiou Data: 4/22/15
Attach a copy of the workers'compensation policy declaration pnge(sliowing the policy m�mber nnd expiration date).
Pailure to secure coverage as raqulrad under Section 25A of MGL c. 152 can lead to fhe imposition of criminal penalties of a
fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties fn the form of a STOP WORK ORDER and u fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offce of
Invastigations of We DIA for insurance coverage veritieafion
I do/rereby cert�, � Aer t! � n[l penaltie,s ofperJury Iknt t/ie tr{/'i�rmntlon prnvkled rsLave is rrue rutd correcl.
�ignature: Date• 77/25/74
�Pe#: �8�-2�9-�29�
O�cia[use only. Do�int write!n tl�is nrea,to be completed by ciiy or tnivn officinl.
City or Towni PermiULicense#
Issuing AuthoNty(circle one):
1.13oard of Hcald� 2.Bullding Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Oftice
G.Other
Contact Person: Plione#:
www.mass:gov/dia
BERKSHIRE HATHAWAY woHcers' Comoensation and Emolover's Liabilitv Policv
GUARDINSURANCE AmGUARD Insurance Company - A Stock Company
COMPANIES BinderNumber456527
Policy Number R2WC595758
Renewal of NEW
NCCINo. [21873]
Policy Informatfon Page (AR)
'LlJ Named Insured and Mailing Address � pgency NY 4v u'�� - __ _ ._„v.____—.�_��
Cape Management Team LLC EASTERN INSURANCE
� 169 Main Street 233 West Central Street ,
Stoneham, MA 02180 Na[ick, MA 01760
Agency Code: MAEAINiO
� Federal Employer's ID 01-0769146 Insured is Limited Liability Co. (L�C)
i Risk ID Number 456527
I
i Additional Names of Insured �
(N2) Dunkin Donuts �
Location5 on Policy - See Extension of Informa[ion Page -Schedule of Locations
...._---_.--- --�---...__._---�--- .. _ . .. .. .. .__.. __. . ..._ _ ._._. ..._ ._._. ._.i
._.____.. .__.____._.....___ Y. _ . _.. .. ._._ .._....
_.__. .. ... .. _... _..... _.___._..7
� [Z] Policy Period ;
. From April 22, 2014 to April 22, 2015, 12:01 AM, standard time at the insured's mailing address. '
i
_..._ ._..___ . .._. . ___. . ....._ . . .
� L37 Coverege _ _ _i
� A. Workers' Compensation Insurance - Part One of this polity applies to the Workers' Compensation �
� law of the fotlowing states: Massachusetts
B. Employers Liability Insurance -Part Two of this poiicy applies to work in each of the states listed
� in item [3)A. The limi[s of our liability under Part Two are:
� Bodily Injuty by Accident - each accident $1,000,000
I Bodily Injury by Disease -each employee $1,000,000 '��
� Bodily Injury by Disease -policy limit $1,000,000
i
I j
' C. Referto Residual Market Limited Other S[ates [nsurance Endorsement-WC 00 03 26A �
D. This policy includes these endorsements and schedules: �
i See Extension of Information Page - Schedule of Forms �
. . . .. .. .._._ ..___._.. . . .
. . . .. _..._ _ _..._ .. .._. ._.___� _. _._ �
[4] Premium I
� The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
� Classifications, Rates, and Rating Plans. All required information is subject to verification and change �
�� by audit. (Continued on another page) i
Total Estimated Policy Premium $ 37,632 � � ���� � 3
� TotalSurcharges/Assessments $ 983.00
�: Total Estimated Cost g 38,615.00 a
, ...-: :..,. ..... . . _ .. . . . .. .. . .. .._ ... . . . . .. .. .. -_--:.. . .... . ,..,
�rvreann�use oa Page - 1 - lnformation Page
wGn : R2WC595756 WC OOOOOlA
Date :04/Q2/2014
MANOTE
16 South River Street.P.O. Box A-H.W ilkes-Barre, PA 18J03-0020•www.guard.com