HomeMy WebLinkAboutDec's Donuts, Inc. 333 - 12/31/2020*3 (i50�1�
Permit # Issued
(Application must be submitted at feast 30 days before the planned opening date)
Establishment Name DeC6Liveu%
Establishment Address 33 t 5}L r.av%,V t to y'AsLeAcA
Establishment Mailing Address (if different)
Establishment Telephone No 77 Lf
Applicant Name & Title:
Applicant Address ILAI C—Acnw
Applicant Telephone No.: t at `�L{ 24 Hour Emergency No.:
Applicant Email d FOOL
Owner Name & Title (If different from applicant)
Owner Address Sj✓Ij �J7G
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
U An Association partner.
CN°A Corporation Name Title Address
El An Individual �uew V4r + tcs 7! Fit(¢utde ,) Ave- ab
O A Partnership wAd V Pias t { (
O Other legal Entity d.S -Fac's
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: C A R j S T/i✓If A1C.1p f.*7'T
Address: p�'rrecnrexc nA. ¢AS- 1VoRTo41 mo oa74..
Telephone No: 7 741 _ �� 4 ^ 4O �y 24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title: CA-ZA66
Address: ,sp`zf, a 3 _ 9.s- 2'
Telephone No: )� G� 24 Hour Emergency No:
FAX: 'j ?`l - (,pq3 - 6n29�—
E-mail:
WATER SOURCE: ryOWVa SEWAGE DISPOSAL: —�jWyt
DEP Public Water Supply No: (if applicable) No. of Food
Employees:
DAYS/HOURS: p� 'T'o
���,� !�
P�
Name of Person(s) In Charge ertified in Food Protection Management:
GlnRiSTiN `; t Nrt rr
Name of Persons) In Charge Certified in Allergen Awareness Training
�lr �isriyR l�t�Y/1/FTT"
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. Yes
F 16 a
Does this establishment require a FOG permit? \1 fL If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
[}. Annual
Q Retail Food $125.00
Mobile Food ConsePARE
Ej Temporary
^'
�r00d Service up to 100 INCLUDING
ON
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
❑ Manufacture Frozen Desserts/Ice Cream
Temporary End Date:
Food Service up to fol -200 $250.00
$25.00/freezer
Temporary Time:
Food Service up to 201 + $300.00
Ej Pushcart $50.00 0 of Pushcarts:
Rain Date:
Supermarkets $400
Ej Residential Kitchen $100.00
[,Milk B Cream $1o.00
F] Caterer $35.00
Food Operations: Definfilons:PHF- PotentlaWhazarobus food flinwismperefure conWs regu/red)
(Check all that apply): NomPHF's-iron-potentieW hazardous food(no timMempemture controls requlreq
RTE- msdy4o.eatfoods (Ex. sandwiches, seeds, muffins which need no runher pmmutng)
ale of Commemielly Pre -Packaged Non-PHFs 0 PHFCooked To Order
E] Hot PHF Cooked and Cooled or Hot Held
El Sale of Commercially Pre -Packaged PHFs Wrepamtion of PHFs For Hot And
for More Than a Single Meal Service
El Delivery of Packaged PHFs Cold Holding For Single Meal Service
0 PHF and RTE Foods Prepared For Highly
Reheating of Commercially Sale of Raw Animal Foods Intended
Susceptible Population Facility
Processed Fooddss for
to be Prepared by Consumeror Senrice Within 4 Hours
El Use of Process Requiring A Variance
[jZustomer 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 91be Manufactured and Packaged for
control)
&J'Preparation of Non-PHFs Retail Sale
Undercooked Food Of
i] Juice Manufactured and Packaged for
Other
Other Food Operations Retail Sale
An real Orffers igin
0 Vacuum Packaging / Cook Chill
0 Offers RTE PHF in Bulk Quantities
E] Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
•,,.,o,a.anw, aueac to me accuracy of the information provided in this
establishment operation will comply with 105 C R 590.000 and all other a
board of health on how to obtain copies of C R 0.000 and th er
Signature of Applicant: � 0 l
Pursuant to MGL Ch.62C, sec. 49A, 1 certify under the
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
and affirm that the food
c I have been instructed by the
perjury that I, to my best knowledge and belief, have filed all state tax returns
11
I
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
9
*"Social Security No. (Voluntary) or Federal
Identification Number
B . orporate Officer (15amffhonj, 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.
CAUses\sleiteW"ktop%eotrs DoeomentsWood Establishments- Temp\TAX CERTIFICATION FORMAm
i>t"IA/l trir°If7 tl� �t�id�t('.7 lel '3i��1J�(iili
NFL;e��ae,rr. 1
ww➢4-mass.govldia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant IIalf®relation Please Print II.eanbly
Business/organization Name:
City/State/Zip: YAcPhone #:_774j _ .,2,y(1
Are you n employer? Check the appropriate box: —
L I am a employer with 2b 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]
3Q 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.]
Business Type (required):
5. Retail
6. estaurant/Bar/Eating Establishment
7. ® Office and/or Sales (incl, real estate, auto, etc.)
S. ®Non-profit
9. ®Entertainment
100 Manufacturing
I l.® Health Care
12. Other
*Any applicant that checks box #1 must also fill out the section below showing thew• 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 au
organization should check box #1.
lam an employer that Is providing workers' coaaepensadon Insurance foe nay enWloyees. Below Is the policy information.
Insurance Company Name:
Insurer's Address: d .�
City/State/Zip:
Policy # or Self -ins. Lic. #7, [ ( Expiration Date: -7 • I ' ail
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 cert&,
that the information provided above is true and correct
Phone #:
Offlcial use only. Do not write In this area, to be completed by city or town ggfaCla1..
City or Town:
Permit/License
Issuing Authority (circle one):
I. 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/dia
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an earloyee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An earloyer 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 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.tmass.gov/dia
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Business/ Food Establishment Name: -Der-s --Alvtu�
Address: 313 7t L, cy t t� 1 i Ca ytn �}c tC
Mailing Address: e
Phone/Fax Number -'---Z M • 7
Contact Person/Title for Grease Traps: OS Rdla/i g a }G&' -a i �}'�
t
Name of Company scheduled to pump external grease trap quarterly: t-) I sot
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 $50 200max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation): 34)
Seating Capacity (Actual Count): LI
Normal Hours of Food Preparation/Service:
Monday 5 jqM , �AIV
Thursday 'SM _
Sunday'- Bl _
5 RIn >"a /O A17�7
Tuesday � �� Wednesday _5, -Z,Z, 'Av
Frldayr ! �A,W C7 Saturday c$�1111 P�
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
0
Handwashing sink
y�r
I
Commercial Dishwasher
r 1 P,
Bar sink
n
Mop Sink
N
Garbage Disposal
Ice Making Machines
Fryolators
02
Grills o Ovens
Exhaust Hoods
d
tj
Floor drains
KJ'pr
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
S� �cNiesg e)6kp§vS�
Is dinnerware pre -rinsed before being washed? ti -)q yes No
If yes, at what station/sink? k, /vy
\' I.(^ FJ
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 y ✓ 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? f`' kci-
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 DECSOONU
ACORD,- C RTIFICAi LIABILITY INSURANCE
-- - __—'--____ •.e .-,.., ,.�.. ,,....0 rue r
THIS CERTIFICATE IS ISSUED AS A MATTER OF INI'UMNI A nury �.,..- —••— •-- ------ -- --
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 policy(les) --must ADDITIONAL INSURED provislons or be endorsel
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 cortaloato holder in lieu of such endorsement(s).
Starkweather & Shepley we 17o�ExJ• 4uT asoroouU
E- ^'L kstone@starshep.co
PO Box 649 DD 5:
Providence, RI 02907.0649 INSURERS APF(
401436-3600 INSURERA: Hanford Fire Insurance
INSURED INSURERS;
DISCS Donuts, Inc. INSURERC:.
86 D-1 Washington Street INSURER D:.
Plainville, MA 02702 INSURER E:
COVERAGES .CERTIFICATE NUmBtK:. --:--------' - -
THIS IS TO CERTIFY THAT THE POLICIES .1 INSURANCE .LISTEC -BELOW HAVE BEEN ISSUEp TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION
OF ANY CONTRACTOR
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
LIMITS SHOWN MAY HAVE
BEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
POLIGYEFF 0 IC E PP' LIMITS
pDOLSUBR-
MR, TYPE OF INSURANCE N MD POLICY NUMBER
MMIDu1VWY MM 0011' V'
$1000000
A X COMMERCIALGENERAL LIABILITY 02SBAKN9406
710112019071011202 EACH OCCURBENCE
-FAVA S. prFhuno, Is'J000000
®OCCUR
CLAIMS -MADE
MED EXP (MY one person) S10000
-
PERSONAL B ADV INJURY $1 000 000
GENERAL AGGREGATE 52,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
❑ JECT ®LOC
PRODUCTS-COMP/OP AGG fZ OOO,OOO
POLICY
S
-
OTHER:
- EDtoBINdED silt GLEE LIMIT
o I S
AUTOMOBILE LIABILITY
BODILY INJURY (Per person) $
ANYAUTO
OWNED SCHEDULED
BODILY INJURY (Per accident) f
AUTOSONLY AUTOS
HIWRED NON -OV ED
PROPERTYDAMAGE S
Perm tlel.
NLY
S
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE S..
EXCESS LIAR
CLAIMS -MADE
AGGREGATE 5
s
DED RETENTIONS
N
WORKERS COMPENSATION
A
02WECEK3216
7/0112019
07101/202
X PER - DTH
E.L. EACH ACCIDENT. $600 000
AAND NY PROFpp VERS Lgq ABINLITY E%ECUTIVE YIN
®
NIB
EL DISEASE- EA EMPLOYE[ f600000
OFFICER/M�MBEREXCLUDEO7
Ifyastltlesbeuneer
E.LDISEASE-POLICY LIMIT $5""0'
11 OF OPERATIONS balm
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD fol, Addlaonal Remarks Schedule, may be attached if more space to mqulmd)
RE:
9D6 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.
All rights reserved,
ACORD 26 (2016103) 1 Of 1 The ACORD name and logo are registered marks of ACORD
#S13789331M1378932 SCK
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