HomeMy WebLinkAboutHoney Dew Donuts - 12/31/2020-a3s,f i�
FOR BOARD OF HEALTH USE ONLY Permit # Issued i
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name 9arfgeY n Pr -c>
Establishment Address 7 /
Establishment Mailing Address (if different)
?pj)vidence lP-X:- 0,3466
Establishment Telephone No 5-21 j 17 9- s i
Applicant Name & Title:
�reStcQecZf'Z2z>✓`tcs-ves+-- t� oD yt�G
Applicant Address %W�- l
i
Applicant Telephone No.: Szy_�z 10(./ 24 Hour Emergency No.:
Applicant Email S V 2u
I
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
1=71 An Association partner.
KA Corporation Name Title Address U
A An Individual d'ov"/t2_ _ A S. a��" f a�Qa cd�� tC •- e�
L7 A Partnership ✓-DtrV?-zz-W 'We_ lrx._-- 1
I -J Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: Tepkek, P,Q, V,42.Z(g
Address: -45q Pi sicL�u Gt�� ��vutd�p,c�_a a s v 6
Telephone No: /��` � U 24 Hour Emergency No: JVT Z,P-6k>/F
FAX: t('W-'y�' (=ti36Wi
E-mail: 5Pf 047_ A')(- (,A-1
Alt E -Mail: S (" ,j1 ) CA' -7
District Or Regional Supervisor (if applicable)
Name & Title: vltl �,( ( di(, />ez--5 �/
Address: /&c� r r l ff7 � of K niO . 6-26
Telephone No: 9�6 - 36 a--% 24 Hour Emergency No: sel-e
FAX:
E-mail: rilp YapJ -
Food Establishment Information
WATER SOURCE: �y SEWAGE DISPOSAL:
r> C �.J
DEP Public Water Supply No (If applicable) - - - -- _ No of Food Employees:
DAYSIHOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
' 1WlvYk4 1+0 o te-Z'- i 5
Name of Person(s) In Charge Certified in Allergen Awareness Training
7�q`tel
Name of pest control company routinely inspecting the premises for evidence of pests 4;v).35 q—
�� J
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. H Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
(LKAnnual
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Establishment Type:
Retail Food $125.00
[&f road Service up to 100 INCLUDING
FOOD TRUCKS $175.00
I] Food Service up to 101 -200 $250.00
L Food Service up to 201 + $300.00
0] Supermarkets $400
F/Milk & Cream $10.00
t=a Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Manufacture Frozen Desserts/ice Cream
$25.00/freezer
€ad1 Pushcart $50.00 # of Pushcarts:
q] Residential Kitchen $100.00
[:1 Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food (timeAempereture controls required)
(Check all that apply): Non-PHPs - non -potentially hazardous /ood(no timeheru erature controls required)
RTE - ready -lo -eat foods (Ex. sandwiches, salads, mu/fins which need no furtherprocessing)
[I Sale of Commercially Pre -Packaged Non-PHFs I] PHFCooked To Order
jr'] Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
7*1 Delivery of Packaged PHFs
Cold Holding For Single Meal Service
[Yr Reheating of Commercially
Inj Sale of Raw Animal Foods Intended
Processed Foods for Service Within 4 Hours
to be Prepared by Consumer
L7 Customer Self -Service of Non PHF and Non -
Perishable Foods Only
(Preparation of Non-PHFs
Other Food Operations
E�i Customer Self -Service
[I Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged for
Retail Sale
161 Offers RTE PHF in Bulk Quantities
�Inj Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
I6ai Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
I] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
[n] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
[I Offers Raw Or Undercooked Food Of
Animal Origin
] Vacuum Packaging / Cook Chill
] Prepares Food/Single Meals for
Catered Events or Institutional Food Service
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 59 00 and all other applicable law. I have been instructed by the
board of health on how to obtain coeiesof 105 CM 590. 0 and the federal Food Code.
Signature of Applicant: C .L A'A�O-3CW -
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: (' ,.4 - �J r�o� (� -p
Signature of Individual or Corporate Name: )��-FT U' —P'WG Dt:) VY �) /
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
bq--�:> �I F
"Social Security No. (Voluntan/) or Federal
Identification Number
By: Corporate Officer (Mandatonj, if Applicable)
*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:\Useis\sleite\Desktop\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
UIVM www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:_X�( 6� r-c=�, &A4e.-
City/State/Zip: 1 Qom ��^`� E' Vyt- 6 D-�b Phone #: i46 - 9L(-6,30
Are you an employer? Check the appropriate box: Business Type (required):
1. Lam" ' am a employer with _/_0 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10Manufacturing
.❑
no employees. [No workers' comp. insurance required]* I l ❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 123 Other
*Any applicant that checks box #1 must also fill 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 #I.
lam an enip/oyer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: OVIM X_eccr-d�VG g(LLe'iL_C (L�ULT i
Insurer's Addressrr,j/�C�.
City/State/Zip: IW14-.
�K
Policy # or Self -ins. Lic. # �'7 UOG��O 1 / a5'l� 3 Expiration Date: il"11- C)
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 t iris and penalties of peijuty that the information provided above is truce and correct.
Sianature: S r !� Sr _. Date: ��`/ '/ /
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
www.mass.gov/dia
Phone #:
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
Ma!IingAddress: 6�w
Phone/FaxNuu%mber/:: jV6Z 6w �tl dsdr
Contact Person/Title for Grease
Name of Company scheduled to pump internal grease trap(s) monthly: Zd;,4 y! /-(L1-e4-,
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
$50
container
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
Print Name �t �W, ! ,eky �96i///*2-T41
Date.
Facility operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count): 30
Normal Hours of Food Preparation/Service:
Monday Tuesday S Wednesday
Thursday ,��' Friday J — Saturday
Sunday
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
',
3 compartment sink
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? Yes V No
If yes, at what station/sink?
F_a
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes L// No Size �/o .-S-y gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owners Name:
Property Owner's Address:
Property Owners Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied
Please list the vendor who removes the
Please list fixtures attached to each grease trap
Grease Trap 1
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes L// No Size �/o .-S-y gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owners Name:
Property Owner's Address:
Property Owners Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied
Please list the vendor who removes the
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient sTM*EN peovtazA
Certificate Number: 2111J31
Date of Completion: 19 15
Date of Expiration: 11NA1a
lbe abro -named permn it heffly icmed tbu mtoratt
fir rompleting an atlergm ararmnas tmNingprogrrm
mcognized by theMassarhnsetu DeparmmntofPublic Health
in axorlonct with 10.5 LAIR 590.009(G)(3)(0).
This mrifimte =11 A, emlid forf w (5)lean%rom date ofrompletion.
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NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we)
have provided for payment to our injured employees under the above-mentioned chapter by insuring with:
MA Retail Merchants WC Group Inc.
NAME OF INSURANCE COMPANY
PO Box 859222-9222, Braintree, MA 02185-0000
ADDRESS OF INSURANCE COMPANY
014000501929119 01/01/19 - 01/01/20
POLICY NUMBER EFFECTIVE DATES
I -IUB NE Association Programs 300 Ballardvale Street, Wilmington, MA 01887 0
NAME OF INSURANCE AGENT ADDRESS PHONE #
Honey Dew Donuts 421 Taunton Ave, Seekonk, MA 02771-0000
EMPLOYER ADDRESS
01/10/2019
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to
furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'
Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may
select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by
the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring
hospital attention, employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER