HomeMy WebLinkAboutMansfield Donuts, Inc. - 12/31/2020:-�05nq_F(,t�- sal
FOR Vic; BOARD `.+; lei • F HEALTH USE ONLY
r:
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening data'
Establishment Name mAv%Sc-cekt cbv%J�s -X--e_.
Establishment Address 45- Ghwvsk c }
Establishment Mailing Address (if different)
Establishment Telephone No 5- • 33-7 -C. -73 p
Applicant Name & Title: 6DwA2J A4 xq •e—
Applicant Address t`tt Fore_LA>v '1 'Dcjue, "l e, OA7o3
Applicant Telephone No.: ��$ Cot 7 1 t �q 24 Hour Emergency No.:
Applicant Email
Gi N ivT AOd-. C®ws
Owner Name & Title (If different from applicant)
Owner Address j ✓vh�
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
El An Association partner.
MIA Corporation Name Title Address
El An Individual 56jen ( Pecs 7t Fw.$u;ew AU
APartnership (cdw it pie—v. lq( fir*cwav s>r c4Nf Lp�
O Other legal Entity
i S d GAw, w r2. etle UA
Person Directly Responsible For Daily Operations (owner, person in charg supervisor,rrranager etc.)
Name & Title: 6 ,e4
Address: Lr 0 src �� �L . 0,2a 44
Telephone t , , So,?— ,?— 3 3 7 — a .7,30 24 Hour Emergency No:
FAX: Y- 77/ a 3 -� 6 �3S_a
E-mail: < `�
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: GA46S lZiseoso
Address: o9(32LL/t Lr3rr�d� �e2• �LJjf/%��p p176�
Telephone No: SCE - 24Y. - OgS-QJ 24 Hour Emergency No:
FAX: 774 — 45 el :3 S
E-mail:
WATER SOURCE: TOWy SEWAGE DISPOSAL: ®c>UOJ
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS: S ""
Name of Person(s) In Charge Ce ified in Food Protection Management:
R
Name of of Person(s) n Charge Cartified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of 2e
pests }
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. U yes��
Does this establishment require a FOG permit? VrIl If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
[ nnual
E] Retail Food $125.00
Mobile Food Consession
Q Temporary
ood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desseris/Ice Cream
Temporary End Date:
E] Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary Time:
E] Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Rain Date:
El Supermarkets $400 0 Residential Kitchen $100.00
�ilk $ Cream $10.00 El Caterer $35.00
Food Operations: Defindlons: PHF - Potentially hazardous Food(Nmalempengure controls requ/md)
(Check all that apply): Non-PHFs-non-potenvaly hazardous food(no limeRempersture controls required)
R7E-ready4o-satfoods (Ex. sandwiches, salads, muffins which need no further processing)
N"Sale of Commercially Pre -Packaged Non-PHFs El PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
El Sale of Commercially Pre -Packaged PHFs Wreparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly
Reheating of Commercially 0 Sale of Raw Animal Foods Intended Susceptible Population Facility
Processed Foods for Service Within 4 Hours to be Prepared by Consumer E] Use of Process Requiring A Variance
[}'15ustomer Self-service and/or HACCP Plan (including bare hand
(Customer Self -Service of Non PHF and Nan- contact alternative, time as a public health
Perishable Foods Only
S oe Manufactured and Packaged for control)
[Preparation of Non-PHFs Retail Sale
Juice Manufactured and Packaged for ❑ Animal Ong10r Undercooked Food Of
Other Food Operations
Retail Sale
Q Vacuum Packaging / Cook Chill
Offers RTE PHF In Bulk Quantities Prepares Food/Single Meals for
0 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 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain Ie o!�05 91VIR 59 a elederel Food Code.
Signature of Applicant:
Pursuant to MGL Ch.6267sec. 49A, I certify
and paid stale taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
penalties of perjury that I, to my best knowledge and belief, have filed all stale tau returns
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 andatory, if Applicable)
"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\Desktop\Swtt's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
%�"iP /l r•lPl �/ � lY7i�/;ili l4� 'i;;.'(rt(i",'1/�
Office of investigations
h®® Washington Street
Boston, MA 02111
www.aaacess>govldlaa
Workers' C®anpensati®n Insurance Affidavit. General Businesses
Business/Organization
Address:
r
City/State/Zip: &&6hS A /yt&4- Phone #: SOS y 3 ? 73C�
Are you an employer? Check the appropriate boa:
1. am a employer with IS- employees (full and/
or part-time).*
2.0 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.]
"Any applicant that checks box #1 must also fill out the section below sho ' Ih
Business Type (required):
5. Retail
6. estaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. Entertainment
10.® Manufacturing
11.0 Health Care
12.® Other
wmg eu —,xcrs uwmpensanon pony rntbrmati m.
organization should check box #l. the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
orga
I am an employer that is providing workers'
Insurance Company
Insurer's
City/State/Zip:
2
insurance fior may emaployees Below is the policy information.
Policy # or Self -ins. Lic. # Od Lt/� k s 2-. `% Expiration Date: -7 - / - ;Zt,;3-20
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 cent, a eder,(he pains and
that the inforan don provided above is true and correct
i +►
®KIcial use only. DO mot write in this area, to be completed by eity or town a,piciaL
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.mms.gov/dia
Phone
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departments address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-AMSSAFE
Fax # 617-727-7749
Fenn Revised 5-26.05 www.mass•gov/dia
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RIMEip" i l n0{o-..T
Business/Food Establishment
Address: `-li dyer ® SLI.Crjnn ,S C
B
Mailing Address:v a�
Phone/Fax Number: S(�FS 3! (oi ECG
Email:
Contact Person/Title for Grease Traps.
Name of Company scheduled to pump internal grease trap(s) monthly: us`rk` R W-24
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
container $50
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 hat the information wbTitted in these documents is true, accurate and complete.
f _
Print Name 60w14110 17
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):
Normal Hours of Food Preparation/Service:
Monday r-
in P
Thursday` C ✓/
Sunday 5 8 — /0 P
Tuesday 5-4 — /p 110
Friday ,S 11 — /0 %'
Wednesday-ry _ is 19
Saturday 15_ _ l�, f
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
6
i
3 compartment sink
14
Handwashing sink
Commercial Dishwasher
N
r'
R
Bar sink
(
N
Mop Sink
a '
Garbage Disposal
9
==e
Ice Making Machines
/
Fryolators
Grills or Ovens
02
Exhaust Hoods
S
Floor drains
N
Other:
Now are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
NO 115 C ca Ft,wt�eCC
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?
P/A Yes No
to) a
How many indoor Grease Removal Units (GRU/trap) are on site?
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 4./ No Size
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 Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Do you store yellow grease waste from fryolators? ti'' A
Where is the grease storage unit located?
How often Is this grease storage unit emptied?
Please list the vendor who removes the waste:
3
COanfil: 17A13
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ACORD.. CERTIFICATE OF LIABILITY INSURANCE
DATEIMMIDDNYYY)
1010412019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the polioy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer any rights to the certificate holder In lieu of such endorsement(s).
PRODUCER
Starkweather & Shepley
n
E: Kristin M. Stone, ACSR
"'j°N
lA
- 401 436-3600 4
c, o EXD: {ac Nol: 01 431-9399
PO Box 549
ADosless• kstone@starshep.com
Providence, RI 02901.0549
401435-3600
_
INSURER(SLAFFORDING COVERAGE
NAIC#
INSURER A: Hartford Fire insurance Company
19682
INSURED
Mansfield Donuts Inc.
86 D-1 Washington Street
Plainville, MA 02762
INSURER B:
INSURERC:
INSURER D:
INSURER E
INSURER F..
CCVERAGF_S CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVEBEENISSUED TOTHE INSURED-NAMEDA13OVE FORTHE POLICY"PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
qp
TYPE OF INSURANCE
BUeqPOLICYEFFPOLICYEXPLIMITS
O
POLICY NUMBER
MWOD
MMJDD/YYYY
A
X
COMMERCIAL GENERAL LIABILITY
-( CLAIMS -MADE ® OCCUR
TADDL
02SBAKN9406
7101/2019
07/011202C
EDDAAnCMMHAAGGOEECTCTOpURRRRENCE
51 000000
PREMISES,tEea nrs�
$1 000 000
MED EXPfMy one emon)
510000
PERSONAL&ADVINJURY
$1 000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JEC IM LOC
OTHER:
GENERAL AGGREGATE
s2,000,000
PRODUCTS-COMP/OP AGG
32000000
S
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
_ AUTOS ONLY AUTOS
HIgED NON -OWNED
AUTOS ONLY AUTOS ONLY
E0,81 EDISIN LE LIMIT-
S_
BODILY INJURY (Per Person)
5
BODILY INJURY(Perauddenl)
S
PROPERTY DAMAGE
IPeta&itlenll-
S
5
UMBRELLA LIAR
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
S
RE
AGGGATE
S
s
DEO W .RETENTIONS
5
A
WORKERS COMPENSATION
AND EMPLOYERS UABIUTY
ANY PROPTq�ETORIPARTNEMXECUTIVEY/N
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) ❑
Ifyyes tleacnbsundar
9ESGIRIPTION OF OPERATONS below
NIA
02WECEK3227
D710112019
071011202
X_PER °TH'
EL EACH ACCIDENT
s600000
EL DISEASE - EA EMPLOYEE
$500000
E L DISEASE -POLICY LIMIT
$500 OOO
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AE01Uonal Remarks Schedule, may be allached It more space Is requlmd)
Locations: 46 Chauncy Street Mansfield, MA 02048
Town of Mansfield
6 Park Row
Mansfield, MA 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD CORPORATION. All rights reserved.
ACORD 26 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD
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