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Home My WebLink AboutDec's Donuts, Inc. 4 - 12/31/2020FOR OA R U OF HEALTH USE ONLY Permit # Issued OCT ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name -DeCS u C. Establishment Address LA Sov Sew Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: CO Applicant Address Iql F"z yzWCA - Al4-Ae-6c,,zo Applicant Telephone No.: 568 I at ott S4 24 your Emergency No.: a26 q'7 Applicant Email a a bpi. 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 EJ An Association partner. Corporation Name Title Address O An Individual -- "Il Fug rtU Na e Ked°ec�y,�(„ OAPartnership , U•�6eS tyt rw,rLwv+�r t I 11(yc� Other legal Entity 5 ind2 iYtCS. +tare W y (2 A70 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �b B�jp7` 9"j-�/-//�/f"f Address: -j/ j D%WjTD1y /%//fie-. 77Ru,1,-ra /1 Telephone No: _ D9-- 4.2a 9 24 Hour Emergency Ito: FAX: ,v/n E-mail: 4xl,�t Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: C-WqWI&S Q�� cy � Cn OA Address: Telephone No: soa,;N3-bt)S-8 24 Hour Emergency No: FAX: `t E-mail: WATER SOURCE: T6L.v ✓\ SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: ) DAYS/HOURS: 7 _ lay 7"o is Pal Name of Person(s) In Charge Certified in Food Protection Management: l06C-RT e19101hosgi Name of Person(s) In Charge Certified in Allergen Awareness Training L�It�f�1/J�G Name of pest control company routinely inspecting the premises for evidence of 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. 0 Yes f r Does this establishment require a FOG permit? _e If yes, please attach the FOG permit application. Length of Permit: Establishment Type: S Annual [1 Retail Food $125.00 Mobile Food E] Temporary l'S 'ood Service up 40 100 INCLUDING NO PHF PREPARED ON SITE $900.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary End Date: Food Service up to lot -too $250.0o $25.00/freezer Temporary Time: ❑� Food Service up to 201 + $300.00 El Pushcart $50.00 d of Pushcarts: Rain Date: Supermarkets $400 Ej Residential Kitchen $10D.00 . o. ilk & Cream $10.00 El Caterer $35.00 Food Operations: DehnflADM PHF - PatentialN hazardous rood(dnnutemperehhe controls required) (Check all that apply): Nmr-PHFs-rron-poterrhaw hazardous hwd(m timalemperature controls required) RTE- ready-roeat foods (Exsandwiches, salads, muffins which need no furtherpmcossing) (-Vale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held El Sale of Commercially Pre -Packaged PHFs QPreparation of PHFs For Hot And for More Than a Single Meal Service I Delivery of Packaged PHFs Cold Holding For Single Meal Service [3 PHF and RTE Foods Prepared For Highly Ej Reheating of Commercially Sale of Raw Animal Foods Intended Susceptible Population Facility b Processed Foods for Service Within be Prepared hin 4 Hours p y Consumer E] Use of Process Requirtng A Variance [yj,Custamer Self -Service of Non PHF and Non- []Customer Self -Service and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only 5�,<oe Manufactured and Packaged for control) [(j.Pleparatkm of Non-PHFs Retail Sale RawUndercooked Food Of Q Juice Manufactured and Packaged for Other Food Operations Retail Sale AnmalOarrigOr in E] Vacuum Packaging / Cook Chill Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for I Retail Sale of Selvage, 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 establishment operation will comply with 105 CMR 590.000 and all other ap board of health on how to obtain copies of 10§CAI�2 590,000.and the tartan Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certify under the and paid slate taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: ion and affirm that the food law. I have been instructed by the that I, to my best knovdedge and belief, have filed all state tax 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. bers Uov,. Signature of Individual or Corporate Name *"Social Security No. (Voluntanj) or Federal Identification Number By: boqo—rate Officer ( tonj 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. CAUseM\sleite\Desktop\Scotrs Doe ments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Business Type (required): 5. D Retail 6. estaurant/Bar/Eating Establishment 7. ® Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing I L Health Care 12.® 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 cheek box #1. I am an employer that is providing workers compensation ausurancefor easy employees. Be/ow Is thepolicy enforrnwtlola Insurance Company Name:_ Aar �VF 7 - o -E--1. Insurer's Address: X .C, :RG]l q City/State/Zip: _ i (2- Policy # or Self -ins. Lic. # Expiration Date: �7 l Attach a copy of the workers' compensation policy declaration page (showing the policy numleer and aspiration 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 certfgy, and the pains that the fee jora>aeatfoaa provided above is tree and correct. ..I Official use only. Do not write in this area, to be completed by chy or town official City or Town: ailrlt �i/ uJ��ar�lia.E�trk D)�•'�nd-�,:,-jra sir l' �ilil�.Yiritl �i��tn%� ir, Office of investigations 600 (Washington .Street Boston, MA 02111 wwov.Malss govIdda !Workers' C®>anpensafiion Insurance AB°idavit- General Businesses Business/Organization Name: Aaaress:_ y O-CV1 �&f City/State/Zip: Avj5d Ma Phone #: Are you an employer? Check the appropriate box: I • am a employer with IS� 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.] Permit/Licease Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6e. Other Contact wµw.mass.gov/dia Phone InstructionsInformation and 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 enVloyer 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 till 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 cant' 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 burn 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 Department's 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-MASSAFE Fax # 617-727-7749 Form Revised 5-26-05 www.tnass.gov/dia P121r I FGAT,�i) tsi",_Ya '✓�' fdTS Business/ Food Establishment Address: `iSOLA, MA'vW St.wi 4✓i I Mailing Address:Y�rtig Phone/Fax Number: . AM - 3: 9 - f 19 Contact Person/Title for Grease Traps: <'_ 1e$ Name of Company scheduled to pump internal grease trap(s) monthly: d aat ne�rLc u &✓L �vcue ws wa P Name of Company scheduled to pump external grease trap quarterly: NJ 1 yA 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 that the information submitted in these documents is true, accurate and complete. Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unlessotherwise specified, please print or type, Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday S- frm _ LD PM Tuesday ,ri /i/i7 _ �D po Wednesday 5�m_ lqjo Thursday S R► ' _ �D f�/% Fridayld 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 IV Mop Sink Garbage Disposal Ice Making Machines n` Fryolators Al Grills r vens N Exhaust Hoods .3 N Floor drains Other: now are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Iles - `s.sk �VkAUS� Is dinnerware pre -rinsed before being washed? 7 ' Yes No If yes, at what station/sink? A , d � How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 b d foy- Grease Trap 2 Grease Trap 3 Grease Trap 4 L:7 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes 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? _ 1. Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: Client#: 32396 DECSDONU T,PIrATE HOOLADIEE(RI'TIDHDAV IO9AC ,x CERTIFICATE LIABILITY INSURANCES THIS CERTIFICATE IS ISSUED AS A MATTER OF R1t-UHMH IJvn -- —11 --- •-- --- - -- - DED BY THE POLICIES - CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOR BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. t h ADDITIONAL INSURED prOVlsions or be endorse uvirv,"n,.,.,......-.-....._-.- If SUBROGATION IS WAIVED, subject to the terms and conditions aft the this certificate does not confer any rights to the certificate holder In Ileu Starkweather & Shepley PO Box 549 Providence, RI 02901-0549 401 436-3600 INSURED Dacs Donuts, Inc. 86 D-1 Washington Street Plainville, MA 02762 mus ave certain policies may require an endorsement. A statement on Fire 401 COVERAGES CERTIFICATE NUMBER; '."-""---' ISSUED ToTHE INSORED NAMED ABOVE fOR THE POLICY PERIOD THIS I6 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS TERMS, INDICATED. NOTWITHSTANDING ANY REQUIREMENT, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, CLAIMS. LIMITS SHOWN MAY HAVE BEEN BY PAID EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, - ADD SUB PREDUICYE�D 10 ECP LIMITS oo Y fry LNTR TYPE OF INSURANCE NSR WVD POLICY NUMBER IMNJDONYYYI MMID _.. 710112019071011202 EACH OCCURRENCE 51000000 A )( COMMERCIAL GENERAL LIABILITY 02$BAKN9406 OA�dAC�FESj �tENTEO 000 i Y cmmonce _ CLAIMS -MADE ® OCCUR $1 00 MED E%P (MY one parson) 51 D 00D ME - PERSONAL SADVINJURY $1000000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: P RD, PRODUCTS -COMPIOPAGG S2000000 POLICY ❑ JECT ®. LOC $ OTHER'. LIABILITY - C KnNEu SINGLE LIMIT Eaa dent BODILYINJURY(Perperson) 5 —— AUTOMOBILE 5 BODILY INJURY (Per SWdOnt) 5� ANY AUTO OWNED SCHEDULED _ PROPERTY DAMAGE Par tdtlrs l S ARITS ONLY AUTOS AUTOS ONLY b AI TOS ONLY EACHOCCURRENCE 5. UMBRELLA LIAa OCCUR AGGREGATE a 5 EXCESS LIAR CLAIMS -MADE DED RETENTIONS WORKERS COMPENSATION. A 02WECEK3216 7101/2019 071011202 ER OTH- X. PSTATUTE AND EppMPLppO�VEETTRS' LIABILNryITY YIN E.L. EACH ACCIDENT. s600 000 MM OFRCERMEMBEREXCLU IEYECUTNE® NIA ELDISEASE -. EA EMPLOYEE S500000 (Mandatory In NH) If yes, describe Under E.L. DISEASE-POLICYUMIT 1 $500000. DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddWonal Remarks Schedule, may be attached if more space Is rertulrod) - RE: 906 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, 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. reserved. M 1988-2016 ACORD 26 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S13789331M1378932 SOK � I z z � W14 0 z W14 W4 / / 4 / u W4 .0 P4 ; T 4 � � ƒ � � � �§ §Ra w ) ~`) \ nm{a ƒ§t\ § ® \})\ §\mow ] * /%\ \ / NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES: ROBERT CAMARA HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS #0656 6751 Forum Drive, Suite 220, Orlando, FL 32821 P (800) 446-0257 F (407) 352-3603 www.NRFSP.conn National Registry of Food Safety Professionals" Notification of Test Results ID#: xxx-xx- Scaled Test Score: 75 Candidate Status: Pass Test Date: September 30, 2019 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. Preventing Contamination and Cross Contamination (Needs review) Ensuring Personal Hygiene and Employee Health (Needs review) Actively Managing Controls In a Food Establishment (Competent) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Needs review) Conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Competent) ISSUE DATE: SEPTEMBER 30, 2019 EXPIRATION DATE: SEPTEMBER 30, 2024 CERTIFICATE NO: 21 62957S TEST FORM: EXE82 This cenificete is aol valid for more than five years from dale of Issue. National Registry of Food Safety Professionals CERTIFIED FOOD SAFETY MANAGER ROBERT CAMARA ROBERT CAMARA 219 DIGHTON AVE TAUNTON, MA 02780 Certificate No; Z 1629575 Issue Date; September 30, 2019 Expiration Date: September 30, 2024 National Registry of Food Safety Professionals® 1 6751 Fomm Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3830 � Fax: 407.352,3603