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HomeMy WebLinkAboutDunkin Donut @ Stop & Shop - 12/31/2020"J FOR BOARD OF HEALTH USE ONLY Permit# Issued ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name V 1{I Establishment Address 3-77 Establishment Mailing Address (if different) , Donov0,-v- bRV1Cd'5 __r)C qI r�th�H'<Mrl Establishment Telephone No )Y(( 1 1 '5-6 `I Applicant Name & Title: /V� n(tii f ((t VI - Applicant Address '7J SAA J? f S�. � C�r7 if q - 7� �cit>7�17 �tti1i �n CiJOtj � Applicant Telephone No.: 7�/ - 33 I - 15 n? 24 Hour Emergency No.: '774/ --d Applicant Email `)j(4ntq ,)In C11vi✓1 0ridV011V.eJW ? (."o Owner Name & Title (If different from applicant) Gv11 G( £ EyZ Sf f -7�n '9 h,1 /6 Owner Address 7d SAA �� G�71 .� - 6")'d els ) Owner telephone number Owner email rV jOYIOVttVlr OnOVg,,-n7&iOj0pK.(-Gd Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or E An Association partner. IN A Corporation Name Title Address O An Individual rr9 A Partnership O'bther legal Entity a i Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ��> Address: %) SfY.e Oil; Y)9 ! Telephone No: 7 7 L/ a 8 UG JP 24 Hour Emergency No: 7 7�! FAX," r ?-r-L,i° 508- 337_ JV Z, `7&L 33 i iG 9 9 E-mail: ,7Y1('c ra-6 0noV0,a eiWGg,4 (.6 n— Alt E -Mail: yl g n . we Inn C do no), di District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: 1-- SEWAGE DISPOSAL: No. of Food Employees: j J DEP Public Water Supply No: (If applicable) DAYS/HOURS: 1 1 Name of Person(s) In Cha ge Certified in Food Protection Management: "8111 (U'l 0 ( Q f � Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, 9 person trained in manual choke saving procedures will be onsite at all times food is being prepared. I Yes �( Does this establishment require a FOG permit?4�If yes, please attach the FOG permit application. 33 Length of Permit: Establishment Type: [t Annual[F] Retail Food $125.00 Mobile Food Consession uT Temporary 1600d Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ins Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: I1 Supermarkets $400 Residential Kitchen $100.00 Rain Date: ilk &Cream $10.00 !::-1 Caterer $35.00 Food Operations: Dehnftlons:PHF - Potentially hazardous food (fime/lemperafure controls required) Non-PHFs -non-potentially hazardous food(no time/femperature controls required) (Check all that apply) ' RTE - ready-fo-eaf roods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs !::-1 PHFCooked To Order Hot PHF Cooked and Cooled or Hol Held IN Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service ® Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended W51 Reheating of Commercially to be Prepared by Consumer 1 Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Q Customer Self -Service and/or HACCP Plan (including bare hand contact alternative, time as a public health .n Customer Self -Service of Non PHF and Non - Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale i.1 Offers Raw Or Undercooked Food Of Q Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ® Vacuum Packaging /Cook Chill E] Offers RTE PHF In Bulk Quantities a Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000a all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 59l)� and the federal Food Code. Signature of Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 0 -3 S% 3 S7 3 S Signature of Individual or Corporate Name: SCO d 1I D 62 f ( t -e TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) OV -3`5513` 3� "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Dcsktop\Scotts Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C o D V t "n l V Z e ,F,5 Address: City/State/Zip: Are M an employer? Check the appropriate box: 1. © I am a employer with _ employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Phone #: `)k I — -2; � I -- Business Type (required): 5. ❑ Retail 6. c❑ eestaurantBar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box #1 must also 511 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 providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/Stat( Policy # or Self -ins. Lie. # (21 V_ %l 5-a 3 Z,/ � - / / !.� Expiration Date: V1 XJ If,-,) n 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. 152 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. 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 certify, under the pains and nalties ofperjury that the information provided above is true and correct. f Sianature.:.r 'Date•j6 Jam. / �.G Phone #• _7S / _ -S-3 14 -Ll 1 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/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/ma Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PQ Box 859222-9222 Braintree, MA 02185-0000 Workers Compensation and Employers Liability Insurance Policy Carrier PolicV #: Policy Period 014005034929119 08/01/2019 to 01/01/2020 Information Page FEIN: 043000008 New Agreement Item 1: Named Insured and Address Agency Donovan Services Inc Eastern Insurance Group LLC Dunkin Donuts 233 West Central Street 72 Sharp Street, Unit A-7 Natick, MA 01760 Hingham MA 02043 ___ 000201843 Second Q LLC Dunkin Donuts 377 Chauncey Street Mansfield, MA 02048 Mailing: 72 Sharp Street, Unit A-7 Hingham, MA 02043 Form # WC 00 00 01 C (Ed.) FEIN: 043513535 Effective Date: 08/01/2019 NAICS Code: 722513 Division #: 2 Workplace #: 0000000002 State Risk ID #: 000201843 0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved, Page 6 of 0 W..,1 0 W H �W V Q. z I--1 z Un W z z W W W �l o z