HomeMy WebLinkAboutApplication and WC TOWNOFXAIdMOIT'X'HBOARPOFFIEAI.TH DuNKrN' DoNu75
AYTT,TCATION FOR LICENSE/PERMIT- 2014 �60 Rr 28
*Please complato form and attach all necaseary documonts bYT�OI3
Feilure to do so will rasult in the raturn of your applicat on pac et.
NAME OF BSTABLISH[ufENT: Dunkid Donuts TEL.#,�p8-'�9d-7 761 � ,
IACATIONADDRESSr 1050 Rt.28
MAILINGADDR£SS: 1R9 Main Sfre t, Steneham_ MA Q�180
- OWNBRNAM$: Salvi C'nn4n - TAX ID(FEIN or SSNI:,
CORPORATIONNAME(IFAPPLICABLE):�aoeManagt�mentTeam �,LG. _ � �
MANAGER'S NAME: �pnna Snarek�,,, TEL.#sA7-27q-02o0 � n �
� MAILINGADDRESS: 1R4 Main $treet Stoneham_ MA 027{�0 � o �
POOL CERITFICATIONS: �'' �
The pool supervisor must be certitied aa a Poal Operator,as requLed by State law. Please list t6e designated m o �
Pool Operator(s)and attach a copy of the certificarion w thls form. � � �
I. 2.
Pool operators must list a minimum oPtwoemploye�es carrently certified in basic water safety,standerd First Aid and
Commw�ity Cardiopulmonary Resuscitadon(CP1y.31ease list these employees below and attach copies ofemployce
certifications to thia form. The Health Department wW not ase past yeara' records. You must provide naw __.
copiee and mnintaln p file at your place of business. ,
� I� Q
1. 2• �C�l{,�1
3. _4.
HOOD PROTECTION MANAGERS-CERTIPICATIONS: ,`�I °�
All food servioe eatablishments are required ro have at leasrone full-time employee who is cercified as a Pood
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of ceniflcation to this epplication. The Health Department wi�not use past years'records.
Xou mnat provide new copies and maintnin a file nt your establSshment.
1, Rosalia Richard z , , '
PERSON IN CHARGE:
Bacfi food esteblishment must have at least ona Person fn Charge(PIC)on site dwing hours of operarion.
I Rosalia Richard 2 �(,i��
HEIMLICH CERTIFICATIONS:
A11 food service establislunents with 2S seats or more must have at least one employe�e tralned in the Heinilich � ��
Maneuver on the premises at all timea. Please list youremp loyees trained in anti•choking procedures below and
atroch copies of employee cerd5carions to this form, The HealtB Department wil[not use pest years'records. ��
You muat provide pew copies and maintain e tile nt your place of buainese.
1. � 2' * �
3. . 4• / k,Q.t4�✓`
RPSTtRURANC 9EATING: TOT _# 7 2 i �f f n�Qiv�
b1r^ �
CE TJSE ONLY
LODGING: �
- LICBNSEREQUIREU F6E PERMIT# LICENSEREQUIREU FCG PSRhUTN LICENSEREQUIRED PEE PERMITe
�B&8 S35 _CAB1N $55 - _MOYA. - S55 „•,�
_�NN, S55 _CAMP 955 _ _SW1IvA�tIN0Y004 SBOee. - �'��Y� ,
� LODOE SSS 'fRAll.ERPARK $105 WEIIRI.POOL SBOn. N �1 •
800D8ERVICE: . " „ypl'��.
� UC&NSER&QSIQ25D F6G PkRMffk �L[CENSEREQUIR6D �PP,L PSRMIT# LICGNSEREQULLtED FEB��,PQtMPCN - Isl �
LaaoosenTs S85 _CON'fINEMfAL S35 _ NpN•PROFIT 530
� ,;,>L0098ATS 5150 _u_ „(,.COMMONVIC. $GO �._WHOLfiSALE 880 . .
- ,� RETAIL 6EAVIC6: —RESID.KITCHEN S80 .
� LiCfiNSEREQUIliED }T,H PGRMI'fp LICENSERF,QULL2ED FEE PEAMIl'# LICBNSEREQUfRED FEF. . PEStM17'# -
� . ;,,cSOaq.t1. S50 � _>23,OOOaq.B. 5225 v_ _VENDINO�FOOD f25 �� J__ �
i—
-. _QS,OOO�aq.fl. S80 _FROZENA6SSERT S10 �TOIIACCO S55 . -
rrnu�ccn�ivice: a�a AMOUNTDiT� _ � /�f�.00 ,_._
� . ..�we«pygpgg nJ�OVER Al'7D COMPLETE OTI�R S7DE OF FORM""'•" � � . .
ADMR+tI41itA't'[4Pi a�.—'
Undar Chapter 152,Secdoa 25C,Subseolion 5,tha Toxm ofYwmouthis nowsaquirai to hokl is��eo orr�iewal
of aQy license or pernilt to operate a businese if a persou or cpmpany daes nat have a CertiScate a£Work�'s
Compeesadan Insnrance. THE ATTACHA`D STAT� V4'ORKER'S {",QMPENSAITON 7PtSTIRANCE
A'k'FIDAVIT MUST BT CUINIPLETED AND SY6NED,OR
CSRT.pF INSU1tANQE ATTACXIE)D ,_, � '' '
OR
WORKf3R'S COMP.AIrFIDAVff SIGNI3A AND ATTACkTEDR�,,,,,,
Tnwn of Yannouth taxc+a and liane must be paid prior to renewal or isauance of qour permits, PLS.496 CHBCK
APPROPRiA"fELY IF PAID:
YSS X NO
MOT�I.�S AND OTHF,R tADG1NG E3TABI.ISHIlxENTS
'�`RA:N87ENTOCCL7PANCX: FozpurposoaofthelumtationaofMotelarAMaduae,Tran�e�rtoc�pancyshallbe
Gmited to the temporary and ehort term occupancy,ardinarlty and customarlly asspciated w%th motel and hotel uae,
Transient occu�nta niust havs and be ableta desnonstrate that they malntain a princdps�place ofrestdence dsewhare.
TYansiem opcupancy ah,all genarally refer to continuous occtrpancy of not more than thitty (a0j days, attd an
aggregate of not mare than maety{94}days within any sin{6}manth periad, Use ofa guest unit as a residence or
dwelling umt shall not be considerod transient. Occupsnoy that is subjack to tbe collection of Room pccupancy
Bxcisq as defi�red in M.G.L.c.G4t3 or 830 CMR 64G,as amecrded,ahait ga�raHy 6e cAnsid�(TYcutsi�st.
POOI,5
POOLOPF.NINGaAltawimnilng,wadfigandw}airlpaoLswh3chhavebe�eksedfarttreaensamm�stbe'
bytheHealthl�apartmentpdcrrtoopmiag. ContacttheFI�althDapartmenttoeaheduletheinapeopontta�e�
pnor to oFeaunB,p�,i.S�NO3�:Paople aza I�i4T atkawed te eIt sn the poat area wm7 the poa3 has bean 3msgacied
and opened.
POOL WA7'ER 7`ES�'iNG: The watm�must be tasted fin paeudocnanas Wtai co6foras and atan�iard plsta count
by a Stake oertified lab; sad submi4ted W the Healtli Aapertmerat duce(�)days prior to aperwMg, and quaitarly
therenftcr.
PUOL CL03ING;Every autdoor in graund swimming ppol�be drained or coverecl within sev�e(7)days of
closing.
FOOD SETIVICE
CATERDVI�POt,ICY:
Tytmewhrood ervlceAglcah'anfortn7�'Lhour�nodfythgYsnnouthklealthDepai#ma�ub5'�tharequired
P eTY " PP prior to the catered avert. 'Shesa fomoa can be obtain�t at the
Fiealth Daparkment, ,
FkiOZEN AICSSER7'S:
Finaen des.�ts�at 6e tested on a momldy basis by a State eert#fled tah. Test reaults must be sontta ti�Healih
Department. Failure to do so will resuk in the suspension or rovocation a£your Prozan Dassert Permit untit tlie
alrove torma havp!�met.
OLTTSIDE CAF�S:
Outsida cafes{i.e.,autdaar sest3ng with wtdterlwa3traas serc3ce}>�et have prior eppmval&omt�Bomd ofHe�.
OUTDOOR C44KING: •
Oatdovr aooking,prepazation,or display ofany food prodpet by a retail or food satvice astablishmpn ie protilbptwl.
NO3TCE:Petmits mti annuallyfinm 7annary 1 to Dec�n6er 31. ITLS YUUA R�PftNTS7BII,ITX T4RB't'{TKN
TI3E COMPLETE+D RENEWAT.APPLTCATION(S)ANi)RBQUIILT?D PLE(S)BY AECEMSER 15,20"C4 �
AT.L RESNOVATTONS TO ANY FOOD ESTABLISf1ML+N"T, MOTEI. OR 1'OOL (i.e,, PATNTTNG, NEW
EQUIFA�i'I',BTC.},ivtUST BH RBPQ1tTEA TO ANLt APP7t4VBD B1'THE BOA1tD QR FIEALTI�PRT4R
1'0 COJvIMENCEMENT. RENOVATIONS MAY R8 �A S PLAN,
DATE: 1'�j��9 SICrNATURL�: _.
�
PKINTNAMEBGTITLG: S81VI COuYO
04l25N9 � . � . .
� The Commonwealth ofMassachusetts
Dej�artmerat of Ir�dustrc'al Acciderars
Of,ftce of Iravesttgatwns
6p0 Washdngton Street
13oston, M,4 02111
www mass.gavtdin
Workers' Cnmpensation Insurnnce AfCdavit: Geners�l Bnsinesses
Analicant Information Please Prxnt� eeib�
Business/OrganizationNarr►e: Gape Management Team, LLC
Address: 1050 Rte. 28
CitylStatetZip: South Yarmouth, MA 02664 phone#: 5Q$-771-1118
Are yoa an employer?Cdeck U�e apgropriate box« Busiaess Type{requircd):
1.[,1� 1 am a employez with_�,Z.__employees(full and/ S� ❑Retail
orpart-time},* 6, [�Restauranf/BnrlGating�stnbtishmant
2.❑ I am a sole propriekor or partnersiilp and have no 7, (�p�ccs andlor Sales{inei.rea!estate,aato,etc.)
employees working for me in any capacity.
(Ido workers' camp.i:�surance required] 8. ❑Non•profit
3.❑ We are a corporarion and its officars have exercised 9, ❑ Entertaiument
their right af axampfion per c, 152, §t(4},and we laave 14.�Manufacturing
no employees.[No workers' comp. insuranca required]* �t ❑��$�th Care
h.❑ We are a uon-profit organization,staffed by volw�teecs,
witix no empioyees. [No warkors'cotnp.insuranea req.� ZZ•� ��her
*Any epplicant tha[checks box#I musi aiso 511 out the soction below alrowing thcir wodrors'componsadon policy inCurmadon
*�'tl'the corporatc affice�s have examptect ti�eives.but ll�e corpqr�t3on has otha empfayces,a workcrs'compaisatlon pallcy ic requirect end sercft an
organization should check box if I,
!arx an employar tliat ls provldixg workers'eo,mpensntioxi lnsrrrance for my emplayees� Beloiv ts Uia pottay Inforrnntton.
InsurancaCompanyName; rqM GUaCd �11SUt'atiC� �d.
Insurer's Address: 16 South River St. PO Box A-H
ciry�sca�r���: Wilkes-Barre, PA 18703- 0020
Palicy#ar So1F ins. Lic.�! R2WC595758 Bxpiradon Dste; 4J22120�5
Attaeh a copy of the workers'eampensut[on poliey deelaration page(shawing fhe golicy number nnd expirat[on date).
Failure to seoura ooverage as required under Secrion 25A of M(3L c. 152 can lead to die smposition of crimiu�tl penutaas of n
fitte up to$t,500.00 and/ox one-yenr rmprisonment,as wall as civil penalcies in the form of a STOP WORSC ORDER and a fine
of ug to$250.00 tt dayagainst tha violafar. Be advised that a copy of this statement may be farwarded to the Office of
Investigations of the DIA for insurance covezaqe veri£'icadan.
I do hureby cent r s and pennitles of perf ury that tlte informatian provided nGove Ps true and correct.
S�anature: patq. 11/24/2014
ehone�F� 781-279-029p
Ofj�cta[use only. Do not wrlte in thJs m�ea,to be complated by atry or�town offtcirtl.
City or Town: T�ermit/Llcense#
Issuing Authority(circle one):
t.BOArd of Aeaith 2.12ullding LlepartmenT 3.Citytl'own Clerk 4.Licensing Baard S.Selectmen's Offlce
6,Other
Contnct Person: Pixone#:
www.mass.gov/dla �
BERKSHIRE HATHAWAY �lorkers'Compensatian and Empiover`s L'eabilitv Policv
� G UA RD INSURANCE AmGUARLI Insurance Company - A Stock Company
COMPANIES Binder I�mber 456527
Policy Number R2WC595758
Renewal of NEW
NCCINo. [21873]
Paltcy Information Page(AR)
[1]�mad7nsuredandMailingAddress�`�.� __ __�Agency __�_._J _ ..._�...___.a.____ __ _.
Cape Management Team LLC EASTERN IN5URANCE
169 Main Street 233 West Centrai 5treet
iStoneham, MA 02180 Natick, MA 01760
i Agency Code: MAEAINSO
� Federal Emptoyer's ID Insured is Limited �.iability Co. {LLC}
i Rixk IDr Number 456527
�
i
i Additionai Names af Insured I
(N2} punkin Dcrnuts �
LoCations On PaliCy -See Extension of[nformation Page -Schedule of locations
__—__- --___--___ --_._.__ __ _ _ _. __ _ _ __ , _ . i
__ _—__ _ --____ —__....___ _. _. __ __ __ _ ;
j [Z� Policy Period
� From April 22, 2414 tp April 22, 2015, 12:01 AM,standard time at the insured's mailing address !
i
. .. _..�. ....__.. ._._. . .. ..
, ��� _ Coverage _ _ _ _ --�
A. Workers' Compensa[ion Insurance - Part One bf this policy epplies to the Workers' Compensation �
Law ofthe foilawing states: Massachusekts
' B. Employer'S Liability Insurance - Part Two of this policy applies to work in each of the states listed i
' in item [3]A. The limits of our lia6ility under Par[Two are:
�� Bndily Tnjury by Accident - each accident $1,000,000
f Bodily tnjury by Disease -each employee g2,000,444 ;
Bodily Injury by Disease - policy Iimit $1,000,000 '
� (
!
, G. Refer to Residual Market Limited Other SCates Insurance Endorsement-WC 00 03 25A �
D. This policy includes these endorsements and schedules:
; See Extension of Information Page - Scheduie af Forms ,
___ _ ,._,_._ ..__ __ _ - . . _ _ _ _ ___.._ _ __ ,
_ , _ _
. _ __ _._ _. ,
' [4] Premium �
The Premium Basis a�d,therefore, khe premium will be determined by our Manuai of Rules,
Qassifications, Rates, and Rating Plans. All required information is subject to venfication and chanqe i
�� by audit. (Continued on another page} �
7oWi Estimated Poiicy Premium .. .... .. .. .. � 37,532. . . . .... . ..... . . . . .�.. .. .. .. . .y
TaWI Surcharges/Assessments $ 983.00
ToWi Estimated Cost $ 38,615.80 �
�
_ : ,.. ..:,.:� ,.;
1Nrersnnt use ars Page- 1 - informatlon Paga
MGA : R2WC595758 WC OOOOOYA
Date :04(tl21z414
MANOTE
15$outh River Streek�P.O. Bax A-H•Wiikes-Barre, FA 2&703-0420.www.guard.com
BERKSHIRE HATHAWAY Workers' Comoensation and Em�byer's Liabiiitv Policy
G � /� INSURANCE AmGUARD Insurance Company - A Stock Company
A�D COMPANIES BinderNumber456527
Policy Number R2WC595758
Renewal of NEW
NCCI No. [21873]
� Poliry Information Page (AR)
Extension of Information Page
Schedule of Locations
(L2) 1050 Route 28 , South Yarmouth, MA 02664 (04/22/2014 -
04/22/2015)
(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 02649 (04/22/2014 -
04/22/2015)
(L7) 156 Iyannough Road , Hyannis, MA 02601 (04/22/2014 -
04/22/2015)
(L8) 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)
(�ll) 702 Iyannough Road , Hyannis, MA 02601 (04/22/2014 -
04/22/2015)
(l12) 464 Route 28 Main Street , West Yarmou[h, MA 02673 (04/22/2014 -
04/2Z/2015)
Schedule of Forms
� WC 0000006 -STANDARD POLICY
WC OOOOOlA - INFORMATION PAGE
WC 000414 - NOTIfICATION OF CHANGE IN OWNERSHIP ENDT
W C 200101 -MA TERR. RISK INS. PROG REAUTHORIZAT[ON
� W C 200102 -MA NOTICE OF PEND LAW CHANGE TO TRIPRA
WC 200301 - MA LIMITS OF LIABILITY ENDORSEMENT
- WC2U0302A - MAASSESSMENTCHARGE
� WC 200303D - MA NOTICE TO POLICYHOLDER ENDORSEMENT
� WC 200306B - MA LIMITED OTHER STATES BENEFIT ENDT.
W C 200307 -MA ASSIGNED RISK POO� ELIGIBILI7Y ENDT.
WC 200405 -MA PREMIUM DUE DATE ENDORSEMENT
WC 200601A - MA CANCELLATION ENDORSEMENT
WC 200604 -MA POLICY DEFINITION ENDORSEMENT
�rvrearon�use oa Page - 2 - [nformation Pa e
MGA : R2WC595758 9
Date : 04/02/2014 WC OOOOOlA
MANOTE
16 South River Street•P.O. Box A-H.W ilkes-Barre, PA 18703-0020•www.guard.com