HomeMy WebLinkAboutApplication and WC TO'WN OF XARMOiI'T'H BOARD OF$I;ALTH ��6��d�p
APPY.YCATIOIV FOR LICENSE/PERMl1'-2014
*Pleasa complete form and sttach sll necessary doaamonts by 01�EC � � 1��4 '
Feilure to do so w3ll result in the return of your appGcauon p�
rrAMEOFES'rA&z,ISIiIvI�N'r: Dunkin'Donuts �L # OEPT.
IACATiONADDRESS: 7$53 Rte. 28 .„
MAILINGADDRF,SS:_1,�19,. ai S}raat Stenp�m_ MQ�Q2180
OWN�R NAM&: Sa�vi ('[�utn T�ID(F'EIN or SSNI , �
CORPORATIOM NAME(IF APPLICAHLE):(',,�pe Managgment Team. LLC_ , fL���!p
MANA(3ER'S NAME: TEL.# 7Ri_97Q_02Q(1 ���P�
MAILINGADDRESS: _ 169 Main $tre Stgneham. MA 02180 �
POOL CER"[1FICA7TONS: �'�`"'
The pool aupervisor must be certitied as a Pool Operator,as required by State law� Please list the designated "'
Pool Operator(s)aud attach a copy of the certificadon to tbSs form. —
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pool operators must llst a minimum oftwo employe�es currendy certified in basic water safety,staudxrd Fiist Aid and
Community Cardiopulmonery Resuecitadon(CP1y.1'lease list tLese employeea below and attachcopies ofemployce
certifications to this form.The Health Department will not ase past years'records. You must proWde new
copies and roaintain�tile nt your place of bnsiness. �
' n ;l
1. 2. �V
3. � 4.
FOOD PROTECTION MANAGERS•CERTIPICA'I'IONS: � � �
All food service establisbments are required to have at least one full-time employee who is certified as a Pood /� n D
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000. (1'l�lf (
Please attach copies of certification to this application. The Heak6 Depertment will not use past years'records,
You mast provide new copies aud maintain n file at yonr establishment. �
1 Daniella Pereira Z i
�
�
PERSON IN CHARGE: /p,�r�
Lach food establishment must have at ieast one Person In Charge(PIC)on site during hours of operation. �� j'�;��r�
Daniella Pereira � (,•rv�
L 2. �
HEIMLICIi CERTIFICATIONS: � �y �
All food service estsblislunents witd 25 seats or more must have et teast ono employee trained in the Heimlich V,Y:�
Maneuver on the premises at all times. Please list your employees heined in anti•choking procedures below and %'""1 � n1'�
attach copies of empioyee certificnrions to thu form. The Health Depardnent wW not use past yeers'records, N� ! 1
You must provide new copies and maintain a file nt your place of buainess. ��,�
1, ' 2. (2���
3. 4.
RESTAURANC 98ATING: TOTAL# 0
OFFiCE USE ONLY
LODGING:
� LtCENSEREQUTAED FEfi PL'RMITii LICENSEREQUIRED FCG PERMI'fN I.ICENSEREQUIItED PEE PERMI'fN
_B&B S55 _CAB1N S55 � _MOTA. � E55 �
. �INN, S55 _CAMP S55 __, _SWIMA�UNOPOOL SBOee. -
�_LbDGE S55 _7RAILERPARK SI05 _WHIRLPOOL S80en.
nooa seav�c�e:
- L1CfiN5$RELjVIRED FCE PF,ItM1T# �LICENSEROQURtBD fEl' PERMITk LICCNSLRE(jUIRED FEE",PFI2MITN � -
�„0.100SFAT3 Y85 _CON1'WGNTAL S35 , �NON-PROFIT 530 . .
� ,�>1009&ATS 5160 ,^COMMONVIC. $GO � ��WHOLESAL£ E80 . .
� � RETALL BSRVICE: _RESID.Ktt'CFIEN S90 � -
. . � TdCTiNS6REQUIREb FLG PERMI'!N LICENSL'AEQUR2ED FF.B PERMIT# LIC4T'SERF:QUIRED FEE . PERMTfti �
� . - . _„BOeq.ft. SSO _>25,OOOsq.R 5225 __ _VENDINO-FOODS25 -- _ �
i
. �QS,ODOsq.R, S80 _FROZEND633fiR?S10 -_TOBACCO S55 . -
N.�csntvGE: S�s AMOUN'r DU� @ $ HS.00
� - � •"•""PLEA9E TURN OV6R AND COMPLETS UTHER SmE OP PORM""••" �'QQ L�c� ��p . . .
: C.,� �l�l�a f?.�61��`�
AD1�IID1I8'CitATION . m..�—'
l7nder Chapter 152,Section 25C,Subaection 6,the Town ofYarmouth ia aow required to hold issuanra or ranawal
of any lic�se or parmit to operate a businass if a peraon or company does uM have a CartiScata of Worker's
Compeasation Insurance. 77iE A1"PACHED STATE �'ORKIr.R'S COMPEN3ATION 1N$URANCE
AP'FIDAVIT MUST BE COMPLETED AND SIGNED,OR
CBRT. OF 1NSURANCE ATTACI�IED____. .
OR
WORKER'S COMN.AFFIDAViT 5IGNBD AND ATTACI�D�_
Towa oY Yannouth taxes and liene must be paid prior to ranewal or iseuance of your permite. PLSASB CFTHCK
APPROPRIATELY IF PAID:
, YES X NO
MOTELS AND OTHElt LODGING FSTABLIBHMENTS
TRAN9IEN'1'OCCUPAN(:Y: ForpurposesofthaliroitationsofMptelorHMetuse,Transie�ocwpancyshallbe
limited to the temporary and shoxt term occupency,ordinadly and customarlly associated with motal snd hotal usc.
Tranaient accupants must have and be ableto demonsfrata that they mnintain a prinapal place ofrasidence elsawhara.
'Cransient occupancy ahall generally reFer to contiuuous oacupancy of not mora than thirty (30) cleys, and m
aggregata of not more thaa ainety(90)daya witliln any six(6)month pedod. Uae of a guost unit as a raqtdence or
dwelling umt shal(not be considered uansiant. Occupancy that is subjed to the colleotion of Room Occupancy
Excise,as defined in M.G.L.a 64G or S30 CMR 64G,as amended,ahall genafatly ba considaral Transiem.
POOL.S
POOL OPENING:All swinuning,wading snd whidpoole wbich have bean closed for the aeaeon muet bew' sp�
bytheHealthDapertvtent�p�ri_o�rtoopenLig. ContacttheHealthDepartmenttoachedulatheinepecliontlue�(3)days
pnor to open'vig.�I,S�S.�No'�:PeoP1e are hIOT allowad to sit m the pool ams und7 the pool has been lnspected
and opened.
POOL WATER 1'ES'fIlHG: Tha wat�muet bo taeted for pseudomonas totnl coliform and atendarA pSate cow�t
by a Stata certifiad lab, ekd submitted to the Aeehh Aapertmem three(§)days prior to opening, and quarterly
thereafter.
POOL CLOSING:Every outdoor in ground awimmiag pool must be dreined or covered within seven('n days of
closing.
FOOD SI1tVICG
CATERiNG POLICY:
Anyone who catera within the Town of Yarmouth muet notiPythe Yamwuth Health Dapartment byEllnatl��quired
Tamporazy Pood Service Application form 72 hours prlor to Wre cstered event. Thesa fmma cen be o6tained at the
Health Dapartment, ,
FROZEN AESSERTS:
Prozen desserts muat be tested on a monthly basis by a State cerdflad lab, Tast rasults muet ba s�t to the Health
Departmeeott. Failure to do so will rasuh in tha euepension or revocarion of your Frozan Dessert Parnit until tka
above terms have been md.
OUTSIDE CAF�S:
Outeida cafes(i.e.,outdoor sesting wlth waiter/waiuesa service),muet hava prior approval8nmtha Hoard ofI3ealth
OUTDOOR COOKiNG: ,
Outdoor cooking,prepararioq or display of any food product by a retail or£ood serviu establishmam is prohibihd.
N0110E:Permits run annually fYom January 1 to December 31. I1'IS YOUR R�BPONSBILITY TOREITJRN
TI�ffi COMPLETED ItENEWAL P.PPLICATION(S)AND RBQUIRED FEB(S)BY DfiCEMBER 15,2QT4 •
ALL RBNOVATIONS TO ANY FOOD SSTABLIST�Ilv]L+NT, MOTEL OR POOL (i.e., PAII9TING, NBW
EQUII'MENT,BTC.),MUST BB REPORTED TO ANA APPROVBD BY TF1E BOARD OF HEALTH PRTOIt
TO COMMENCEMENT. RENOVATIONS MAY R�QUI
DATE: 11/25/2014 SI6NATURE: � - - ,
�
PRINTNAME&TITLE: Salvi Couto
osnsio� � � � - _
,,;. The Commonwealth ofMassnchusetts
Department of Industrial Accidents
� � ' � Of�ceoflnvestigations
' 600 Washington Street
� Boston,MA 02X,i.l
t i www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apulicant Information . Ple�se Print Lesiblv
Bus�nessrorgan��ctonrrame: Cape Management Team LLC dba Dunkin
�__. .._
Address: 1353 Rte. 28
c��yistat�izip;S. Yarmouth, MA 02664 Phone #: 508-394-1220
Are you en employer7 Checic the eppropriate box: Business Type(required):
1.� I am a employer with �� employees(full and/ 5. ❑ Retail �
or part-time).* 6. �RestaaranH[3ar/Eating�stablishment
2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.renl estate,auto,etc.)
employees working for me iu any capacity.
[No workers' comp, insurance required) $• ❑Non-proGt
3.❑ We are a corporation And Its officers have exercised 9. ❑Entertt�inment
their right of exemption per a 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp,insurance required]* 11.❑I-Iealth Care
4.❑ We are a non-profit organization,staffed by volunteeis,
with no employees. [No workers' comp.insurance req.] 12.0 Other
� '"Nry epplicnnt thnt checks box 81 mnst�Jso fdl out the secqon below showing tlieir workers'compensation policy information. .
•*if tlic cor�wrate ofFicers have axtlmpted themselves,but 1he corporuNon I�as othcr cmployees,a workcrs'compensation policy is reqaired and such an
orgaulzation shoald check box Nl. . q.
I mm�n employer deat!s providing workers'compensatton insurnnce fnr my employees. Relow is tke poiicy informatton.
InsuranceCompaayName: AM Guard Insurance Co.
Insure�'s Address: 16 South River Street PO Box A-H
city/State/Z;p: Wilkes-Barre. PA 18703-0020
Policy#or Self-ins,Lic.# R2�NC595758 Expiratiou Data: 4/22/15
Attach a eopy of the workers'coropensation policy declarntion page(sl�owing the policy number nud expiration date),
Pailure to secure coverage as requlred 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 in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against tlte violator. Be advised t6at a copy of this statement may be fonvarded to the Off ce of
InvestigaUons of We DIA for insurance coverage verification.
I do kereby ce� , �er t!e ul �ennitles of��erJury tk«t t/ae!r�/'irrntatlon provlrled nGove!s true«nd correcl.
�nature: Date: 11 @5/14
Pbone s: 781-279-0290
Officla!use only. Do nnt write tn t/tis nrea,to Ge completed by ctry or toivn officin(.
City or Town: PermiULicense#
Issuing Authority(circle onc):
1.lioard of Ilcaltl� 2.Building De���rtment 3. City/Town Clerlc 4,Licensing Board 5. Selectmen's Oftice
6. Other
Contact Person: Pl�one#:
www.mnss:gov/dia
BERKSHIRE HATHAWAY WO�ers'Comoensation and Emolover's Liabiiitv Policv
INSURANCE AmGUARD Insurance Company - A Stock Company
G UA R D COMPANIES Binder Number 456527
Policy Number R2WC595758
Renewal of NEW
NCCI No. [21873)
Policy Information Page (AR)
. __ .__.._..__ . . ..._.-__ . _.____._ _ _..._...� .__._......_.-____ .. _ ..__.__..._
[3]Named Insured and Maili�g Address Agency
� Cape Ma�agement Team LLC EASTERN INSURANCE
169 Main 5[reet 233 W est Central Street
� Stoneham, MA 02180 Natick, MA 01760
� Agency Code: MAEAINIO
I Federal EmployeYs ID Insured is Limited Liability Co. (LLC)
Risk ID Number 456527
i
; Additional Names of Insured I
(N2) Dunkin Donuts �
. Locations on Policy -See Extension of Information Page - Schedule of Locations
� �--..___ _..---� - ---.-_---- .____ . .._ . . _._ . ._. _ ._.. . . .... .. . .__. .._. .. ___._. ._..I
� i -- ___.._.. .___---- — �--___ . . . .__ . ._ .. ._. ...
_ ._... . _. .. __.
___.. ._.__ _.
[Z] Policy Period ;
" From April 22, 2014 to April 22, 2015, 12:01 AM, standard time at the insured's mailing address. ;
...- --- - -- � � �
--
i L3l Coverage _ __ __ _1
; �
: A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation (
Law of the following states: Massachusetts
' 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 liability under Part Two are: i
Bodily Injury by Accident - each accident $1,000,000 j
� Bodily Injury by Disease -each employee $1,000,000
Bodily Injury by Disease -policy limit $1,000,000
i
i +
��; C Refer to Residual Market Limifed Other S[ates Insurance Endorsement-WC 00 03 26A '
D This policy includes these endorsements and schedules: �
� . See Extension of Information Page -Schedule of Forms
.. . .. . .._... . .... .. .. . ... ..
. ... ..__..._._..... .. .. ____. . .._.
. . __. .. -----__ __.._. _z
i [4j Premium �
� The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
� Classifications, Rates, and Rating Plans. All required information is subject to venfication and change �
� by audit. (Continued on another page) ,
�. ._... _._.... � .__ _ . .._... .. .... . . . .. . ���.
. . .. . . . . . . .._ . . . __ . _ _. __. _..
ToWI Estimated Policy Premium �$ 37 632 � � � � a
. Total Surcharges/Assessments $ 983.00 �r
� Total Estfmated Cost $ 38,615.00
. :.... ,..,- .. . . . . . ... .:._ . . . . . .. . . . ,. .::<� ,. . .....,.;
�rvrearv.a�use ors Page- i- Information Page
MGP : R2WC595758 WC OOOOOlA
Da[e : 04/02/2014
MAYOTE
16 South River Street.P.O. Box A-H.W ilkes-Barre, PA 18703-0020•www.guard.com