HomeMy WebLinkAboutApplication and WC rowiv oF xnxHroFrz�s aanRn oF�,ra
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•Pleeee compl�e form and attach all necessury documonts bY�2013
Faihrce to do so wlll result in tha retum of your applicxt on paq et.
NAME OF ESTABLISHML1v'P: Dunkin Donuts . . TEL.# 508-862-9062
LOCATION ADDRESS: 464 tB • _ O �J
MA1LItvGADDRESS: �R9Ma�� 5tlEflt�$tonaham n�A021AI1 � m �
OWNERNAME; �IviCo�tn �T 7CID(�,EINoq,�,SNI: ( � o �
CORPORATION NAME(IF APPLTCABLE); C1pe ManagPm -nP t TPam.y C_ —� �
MANAGBTt'S NAME: TEL.#.j$�79-0290 0 �,
MATLINC3 ADDRESS_�J 69 Main Stree . StoneJ�am• MA 027{{Q,_„ _ _ � p �
POOL CERTIFICATIONS:
The Qool aupervisor mugt be cerH@ed as a Pool Operator,as reqtdred by State law. Please list the designated
Poof Operator(s)and attach a copy of the certificadon to this form.
1. 2.
Pool operators must list s minimmn oftwo emptoyees currendy certiSed in basic water safety,staudard First Aid and '
Coummmity Cardippulmonary Resuscitation(CPRk..Flease list rhese employees below and attach copies ofemptoyee q���
certificadons io this form. T6e Health Department will not nso past years' recorda, You roust provlde new �) �
copies snd mnintnio s dle at yonr place of busineas. � �6A�
1, 2. �
3. 4,
FOOD PROTEC'ITON MANAGERS-CERTIFICATIONS:
All£ood service esiablishments are required to Lave at least one full-time employee who is cenified as a Food ��''�
Protection Manager,as defined in the State Sanitary Code£or Food Service Establishments, 105 CMR 590.000. ���/�/
Please attach copjes of certificaHon to this application. The Health Department will not use past yenrs'records. �
Yon mast provlde new copies and maintnip a tile at your estnblishment �,[�
I Deborah Fleming 2 !/"� t
PERSON IN CHARGE: � '.
i Each food astabtishment must have at least one Person In Charge(PIC)on site duri�g hours of operation.
1 Deborah Fleming 2 � �
_i� rC�'�
HEIMLICH C�ItTIFICAI'SONS: �`Q/�' U
All food service establiehments w1tL 25 aeats or more must have at least one employee trained in the Heimlicfi ,
Maneuver on the premises at all dmes. Please list your enployees uained in anti-choking procedm�es below and
attaeh copies of employee certifications to tAis form. T6e HeNth Depertment wW not use past years'records, �
You muat provide new copies and maintxin a flle at your place of business,
1. ' 2. pQ� �y,r�
3. ; 4 ./" 1 , '� `
RLSTAURAAIT SEATINGc TO AL# �4 _ _ ~(���,,�
OFFICE U ONLY
. .IADGING� � - - - �
LICENS£REQUIRED F66 PfiRMl1'N �WCENSE FE& PE2M1'1'N I.(CENS$REQUIRF.D FEE PLRMff 8 �
_B&D- _ S55 _CABIN $55 _,M01'F�. S55 -
. ]NN E55 �CAMP S55 , �3WIMMINOPOOL SBOaa. � .
,LODtl& - S55 _TRAQ.GRPARK 5105 Y_ _WHIRLPOOL 880ea.
ROOD$ERV[CE: � �
� UCBNSBR5QUIl2&D FLS P&RMIT# LIC£NSEAEQVLL� k'�E PF;RM17'A LiCENSEREQUIRED FEE pF,RiM'IR �
„�0.f00S&ATS S85 �,�� _CONTINbN7'AL S35 _NON•PROFR S30 �
. ?100SflATS 5160 �COMMONVIC. $60 F5'Q�Iy . WHOLESALG - S80 _____�
- RETAII.SERViCE: � �—R�SID.KITCHEN SSO - -
LiCENS&REQIARED FEE PERMI'1'k LICENSER6QURiED F6E PERMITA LICF,NSEREQUIRED fEL+ PERMITH
. ..<SOsq.R $50 �>45,OOOx�.ft 5225 , _VENDINO-[OOD $25 r_.__ .
_45,OOOery.11. 580 � _FROZCMDESSERT.S40 TOBACCO S55 -
- NAM4CHANGE: SIS _` AMOUNTDUE _ $ ��"rJ•60 -
«H««ePLBASETORNOVERANDCOMPLSTEOTE[ERSIDEOFFORht••»•• �� �(l.E��.
��v,��� ��-t��
ADMIIVI$TitATION . ¢`"-�
TJnder Chapter 152,Section 25C,Subseation 6,tha Town of Yazmouth ie now required to hold lssuance or rmewal
of any license or pernilt to operate a businass if a persou or compeny daea uot heve a Carti9cata of Worker's
Compensadon Iusurence. TIiE ATTACf7F.D 9TATE WORKI.R'S COMPEN3ATION IN5URANCE .
ArFIDAVfT MUST BE COMPLETED AND SIGNED,OR
CERT.OP 1NSi1RANCS ATTACkIED�. . . .
OR
WORKER'S COMP.APFIDAViT 5I(iNBD AND ATTACHED_�
Town o£Ya�mouW ta�cces and lians muat ba p�d pcior to renewal or isauance of yow permits. PLSASB CITBCK
APPROPRIATELY IF PAID:
Y&3 X NO
MOTELS AND O'1'HER LODGING ESTABLISHII�NTS
'CRANSIEN'I'OCCUPANCl': ForpurposasofthelimitationsofMotelorHoteluea,Transiemoccupattcyshallbe
Gmited to tha tamporary and short tarm occupancy,ordinarlly and watomarily asaociated with motal and hotel use,
Tranaient occupanta muat have snd be abla to demonatrato that they maintain a prinolpal placa ofreaidarce elaewhara.
Transient occupancy atiall generally refer to conWruoua occupancy of not mora tLan thir[y (30) days, and an
' aggregate of not more than ninety(90)daya within any alx(6)moath period. Uae of a guest unit as a residence or
dwelling umt shall not ba considered uansiant. Occupancy that is subjad to the oolleotion of Room Occugenoy
Excise,as defined in M.G.L.c,64G or 830 CMR 64G,as aznanded,ahall generally ba oonsldared TransIaM.
POOLS
POOL OPENING:All swimming,wading and whirlpools wltich have been closed fortha eeason must be inspected
by,tho Hoalth Dapartment prior to openiug. Contect the Health Daparhnent to schedula the inapectionthree(3)days
pnor to ope�m�g.PLSA,SE NOTE;People are NOT allowed to sit m the pool area until the pool has been lnspeated
and opened.
POOL WATER TESIING: Tha watar must be testad For pseudomonas total coliform and atandard plste count
b9 a State cerd8ed lab, attd submitted to the Aealt6 Aapartment three(�)days prior to opaning, and quartedy
thereafter,
POOL CLOSING:Every outdoor in ground awimming pool must ba drained or covared witttin eevea('n days of
closing.
FOOD$ERVICE
CATERING POLICY:
ArryonewhocatarswltluntheTownofYarmouthmustnotitytheYarmouthkIealthDapartm�tby�tharequired
Temporary Food Service Applicatlon form 72 hours prior to the catered evert. Thesa forms can ba o6tained at the
Health Departruent. ,
FROZEN AESSER7'S:
Prozen desserta must be tested on a monthiy basis by s Stats certiftad lab, Test rasulta must be sant to the I3ealth
Department. Bailure to do so will resuh in tho aueponsion or revooation of your Prozan Deasert Pennit until tha
above terms hava bean met,
OUTSIDE CAFLS:
Outsida csfes(i.e.,outdoor seating with walterlwaitreas servlce),must have prior approval&omtheBomd ofT3ca1H�.
OUTDQOR COOHING: �
Outdoor cooking,prepararioq or diaplay ofany food product by a refail or food sarvice establisbmeeott is protiibihd.
NOTICE:Permits run anmially from Jenuary 1 to Decembar 31. IT IS YOUR RESPON31B1LITY TORII7't]RN
TI�COMPLETED RENEWAL APPLICATION(S)AND R6QUIltBD FEE(S)BY DECEA2HER 15, "70�11 '
ALL RENOVATIONS TO ANY FOOD &STABLISFIIvffiNT, MOTEL OR POOL (i.a, PAXNfING, NEW
EQUIl'MENT,BTC.),MUST BB REPORTED TO ANA APPROVHD BY THE HOARD OF F]EALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY R� A STI'E PLAN.
�i
DATE: 11/24/14 SI(3NA ,
PRINTNAME&TITLE: S81VI COUtO
osnsiov
� The Commonwealth ofMassachusetts
Department oflndustrialAccideaas
Of,/Bee oflnvesttgations
600 Washington Street
Boston, MA 02111
www.mass.�ov/dia
Workers' Cmnpensation Insurnnce Af�davit: Genernl Bnsinesses
Anpl9c�nt Information Please Print Leeiblv
Business/organiZationName: Cape Management Team, LLC
Address: 464 Rte. 28
City(State/Zip: West Yarmouth, MA 02664 phone#: 508-862-0124
Are you nn employer? Check tl�e approprinte box: Busiucss Type(reqtdred):
1.[,� I am a employar with�_employees(fuil and/ 5, ❑Retail
or part-time).* 6. [�RestaurantBar/Guting Estublishment
2.❑ I am a sole psoprietor or parMership and have no �, � OfEico and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
(No workers'comp.insurance requiredj 8• ❑Non-profit
3.❑ We are a corporation and its officsrs have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have �0.0 Manufacturing
no employees. [No workers' comp.insursnce required]* 1 f.0 Health Care
R.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.0 Other
°Any applicant that checks box#1 must atso fill out[he soetion below ahowing their workors'compens�Uon policy inCormatlon.
+•If the corporak otiicere hnve axempted themselvea,but Ihe corporation has other employees,s workers'compensation policy is required and such en
� organizationshoiddcheckboxifl,
I am an employer tliat ls providing rvorkers'compensatiox insnrnnce for my employees. Be[ow!s tlie poltcy lnformation.
InsuranceCompanyN¢me; AM GUBfd �IlSUf811C8 CO.
Insurer's Address: 16 South River St. PO BOX A-H
ciryiscar�iz�p: Wilkes-Barre, PA 18703- 0020
Poliey#or Se1F ins.Lic.�{ R2 W C595758 Expiradon Date; 4/22/2015
Attach a copy of the workers' compensation policy declarntion page(showing the policy number und explration date).
Failure to secure coverage as requrced under SecHon 25A of M(}L a 152 can lead to die imposition of crimiwtl panaldea of t�
fine up to$1,500,00 and/or one-yenr imprisonment,as well as civil penalties in the form of a STOP WORK ORDSR and a fine
of up to$250,00 a day against the violatox. 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 cvrtlf, i � nins axd penalties ofperjury that tha lnformatlon pravided above is trrre and correct.
si�nature: , [�ate• 11/24/2014
Phone#: 781-279-0290
Offlclal use only. Do not wr/te in thls area,to be completed by stty or town of,f/ctn!
City or Town: PermitlLicense#
Issaing Authority(circle one):
1.Board of He�Ith 2,Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
G.Other
Cont�ct Person: PAone{l:
www.mass.gov/dia �
BERKSHIRE HATHAWAY Work�rs' Compensation and Emolover's Liabillri Policy
GUARDINSURANCE AmGUARD Insurence Company - A Stock Company
COMPANIES B��derNumber456527
Policy Number R2WC595758
Renewal of NEW
NCCINo. [21873]
Policy Information Page (AR)
.._,.__,._.,.. ., . __.._..____._�.._ _._. _ ._...,._ ..._......_.�__.._._.---_..___..._.
� [1]Named Insured and Mailing Address Agency
Cape ManagementTeam LLC EASTERNINSURANCE
i169 Main Street 233 West Central Street
Stoneham, MA 02180 Natick, MA 01760
� Agency Code: MAEAINIO
; Federal Employer's ID Insured is Limited Liability Co. (LLC)
i Risk ID Number 456527
!
; Additional Names of Insured I
(N2) Dunkin Donuts
Locations On Policy - See Extension of Information Page - Schedule of Locations i
------- ----- - - ------- ..._. .... . .__. _.i
_._ .. .... .__ ._.. . _._. . .. ... .
..___.--- ------._._____._--. _�__. . ..._.
. .. -- -- --_...... .. . .. . _
. . . .._.._._. .._.. . ...__.__,
� [Z] Pohcy Period i
From April 22, 2014 to April 22, 2015, 12:01 AM,standard time at the insured's mailing address. !
-- -- - -- -_. . . _ . . .._. . . _ _. �
_. __ . ._ .._ . ._ . . . .
� [3l Coverege _ _,
A. Workers' Compensation Insurance - PartOne of this policy applies to the Workers' Compensation �
Law ofthe following states: Massachusetts
, ', B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
�� in i[em [3]A. The limits of our liability under Part Two are:
� Bodily Injury by Accident - each accident $1,000,000 i
+ Bodily Injury by Disease -each employee $1,000,000 �
Bodily Injury by Disease -poiicy limit $1,000,000 j
i
I
� . C, Referto Residual Market Limited Other States [nsurance Endorsement-WC 00 03 26A
D. This policy includes these endorsements and schedules:
; See Extension of Informatioo Page - Schedule of Porms .�
. . . .__.. ..... ... . .. . _.. . .
_ __ ._..__. ______. ._.._ . .._
! [4] Premium f
� The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, �
�. �� Classiflcations, Rates, and Rating Plans. All required information is su6ject to venfication and change �
� � by audit. (Continued on another page) i
Total Estimated Policy Premium � g 37,632 � � �� � ���� � �
7ota1 Surcharges/Assessments $ 983.00
I Total Estimated Cost g 38,615.00 =
. __ .,.. ... .._.. ... .. . .. . .. .. . . . . : .. . . . . . . . . __.:.:_ ... .. . ...;
�rvreaNn�use oa Page - 1 - Information Page
nGA : R2WC595758 WC OOOOOlA
Date � 04/OZ/2014
MA�TE
16 South River Street.P.O. Box A-H•W ilkes-Barre, PA 18703-0020.www.guard.com
BERKSHIRE HATHAWAY �orkers' Comoensation and Em�lover's Liabllitv Policv
GUARDINSURANCE AmGUARD Insurance Company - A Stock Company
COMPANIES BinderNumber456527
Policy Number R2WC595758
Renewal of NEW
NCCI No. [21873]
Policy Information Page (AR)
Extension of Information Page
Schedule of Locations
(L2) 1050 Route 28 , South Yartnouth, MA 02664 (04/22/2014 -
04/22/Z015)
(L3) 526 Route 28 , West Yarmouth, MA 026�3 (04/22/2014 -
04/22/2015)
(L4) 1353 Route 28 , South Yarmouth, MA 02664 (04/22/2014 -
04/22/2015)
(LS) 14 16 East Main Street , West Yarmouth, MA 02673 (04/22/2014 -
04/22/2015)
(L6) 39 Nathan Ellis Highway , Mashpee, MA D2649 (04/22/2p14 -
04/22/2015)
(L7) 156 Iyannough Road , Hyannis, MA 02601 (04/22/2014 -
04/22/2015)
(LS) 792 Main Street , Osterville, MA 02655 (04/22/2014 -
04/22/2015)
(L9) 40 South Street , Mashpee, MA 02649 (04/22/2014 -
04/22/2015)
(L10) 343 Scenic Highway , Buzzards Bay, MA 02532 (04/22/2014 -
04/22/2015)
(�li) 702 lyannough Road , Hyannis, MA 02601 (04/22/2014 -
04/22/2015)
� (L12) 464 Route 28 Main Street , W est Yarmouth, MA 02673 (04/22/2014 -
04/22/2015)
Schedule of Forms
WC 0000006 - STANDARD POLICY
WC OOOOOlA - INFORMATION PAGE
WC 000414 -NOTIFICATION OF CHANGE IN OW NERSHIP ENDT
� WC 200101 - MATERR. RiSK INS. PROG REAUTHORIZATION
W C 200102 -MA NOTICE OF PEND LAW CHANGE TO TRIPRA
W C 200301 -MA LIMITS OF LIABILITY ENDORSEMENT
WC2U0302A - MAASSESSMENTCHARGE
� WC 2003030 - MA NOTICE TO POLICYHOLDER ENDORSEMENT
. W C 2003066 - MA LIMITED OTHER STATES BENEFIT ENDT.
' WC 200307 -MA ASSIGNED RISK POOL ELI6IBILITY END7.
� WC 200405 -MA PREMIUM DUE DATE ENDORSEMENT
� WC 200601A - MA CANCELLATION ENDORSEMENT
� WC 200604 -MA POLICY DEFINITION ENDORSEMENT
inrertNa�use o2 Page - 2 - InFormatlon Pa
MGA : R2WC595758 9e
Date : 04/02/2014 WC OOOOOlA
MANOTE
16 South River Street•P.O. Box A-H•W ilkes-Barre, PA 18703-0020•www.guard.mm