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HomeMy WebLinkAboutDec's Donuts, Inc. 905 - 12/31/20204 _, �%TO :9t• • W_ • •k_ Permit # Issued FOOD TABLISH M ENT PERMIT APPLICATION -App el cation must be submitted at least 30 days before the planned opening date) Establishment Name 1) no Establishment Address cloy- 5 Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: Applicant Address tLtt �e � Mkkfe Applicant Telephone No.: , �' c� y �� 24 Hour Emergency No.: , 9?.9 Applicant Email _4 eAo JAC L cow 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 An Association partner. Corporation An Individual APartnership Other legal Entity Name Title Address -,tcve, @ Yee 71 FOie,6ew IAw d V'-P• ty1 fnie ARteLyto 1-des Lp YLLeh�b Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: W-e4bc-5 6. 941e4 t�°jgc7 Address: XJ,2 rvl'lwj' bo Telephone No: L d j 6; 6 j - 7 3 7 24 Hour Emergency No: FAX: 7 7Zf --- 6� 3 S.. E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: cyk<Acs 12Aeego Qent r^v&"Act Address: a 6C-t46 1,0a67D S 97�/�(�fO�e /%r'/f 0,:2%ev Telephone No: 509, Xq m oq;B 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: °-T SEWAGE DISPOSAL: ' LAJVI No. of Food Employees: DEP Public Water Supply No: (if applicable) DAYS/HOURS: _ �✓/rj Name of Person(s) In Charge Certified in Food Protection Management: c/J ,/J_. Name of Person(s) In Charge Certified in Allergen Awareness Training y r r— �� &'�� Name of pest control company routinely inspecting the premises for evidence of pests !�OyZe ,Ae '?eS �� w 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 "J A Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual R Retail Food $125.00 Mobile Food Consession Temporary &rrood 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: 0 Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 E] Residential Kitchen $100.00 Rain Dale: [Ik & Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF - Potentialryhazardous food (tina4emperature conhls required) (Check all that apply): Nan-PHFs-non-potenNalty hazardous rood(no time4empetature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no rurtherprooessing) ,:. Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs M- reparation 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 Q Sale of Raw Animal Foods Intended ED Reheating of Commercially to be Prepared by Consumer : Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Ou Comer Self and/or HACCP Plan (Including bare hand -Service [Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ce Manufactured and Packaged for tt control) Retail Sale [reparation of Non-PHFs Offers Raw Or Undercooked Food Of ❑l Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill E] Offers RTE PHF in Bulk Quantities 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 1 R 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copi of 10 Mj2 599.000 ang.Ah€ a-49tal FqM Code. Signature of Applicant: 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: 'D d J � -'7 S 0 7 ya -ii Signature of Individual or Corporate Name: dVtG _.lnnf'. I act 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: orporate Officer (Maud tort, if Applicable) l�',309i9 6161 "Social Security No. (Voluntanj) 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:\Usem\sleite\Desktop\Scott's DocumentArood Establishments- Temp\TAX CERTIFICATION FORMAm The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly gg Business/Organization Name: ���� L vv� a Address: CW9 SOUVIA MAtn S� - City/State/Zip: MAYI&M Phone #: So,-,?- 3 3�;'00 Are you an employer? Check the appropriate box: Business Type (required): 112"'1 am a employer with ID employees (full and/ 5. Retail or part-time).* 6. estaurant/Bar/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 ) 10.❑Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 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 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 Address: l'>. &Y SL49 City/State/Zip:✓LeUattwt Policy # or Self -ins. Lic. # 0aWe1C K_ &A 1 L Expiration Date: —7 ' l ' ,'20 _10 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 certio, all gains and penaltiesofp jur that the information provided above is true and correct. c:�„a+„rP. ,�' � /� Harp• �r� • rr�• �z�� 9 M 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 Information 1'' Instructions 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 Industria► 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-NMSSAFE Form Revised 5-26.05 Fax # 617-727-7749 www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT Business/ Food Establishment Name: -D `y.0 gg C'-. //^ dd pp Address: Ct OLy �+r® 4. e'y�6"S , --( OVA - Mailing Address: sC' Phone/Fax Number: _5 (% iS •- :3 3 % — .3 77/ e Email: O L . Contact Person/Title for Grease Traps: $2!2�cso . 6m, M _ soy, 2L4 - oq� Name of Company scheduled to pump internal grease trap(s) monthly: LA.) °�U c ✓t%+ Name of Company scheduled to pump external grease trap quarterly: ka't4 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 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledgesthatihe.,knformation submitted in these documents is true, accurate and complete. Date ✓• /S-' ! Print Na Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): L( Normal Hours of Food Preparation/Service: Mondays Thursday /Q Sunday / n Tuesday 1 — /Q Friday ,�i %} /b Wednesday Saturday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink 1 Handwashing sink to I P, Commercial Dishwasher Bar sink i� Mop Sink t' ®' Garbage Disposal Ice Making Machines Fryolators Grills o Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? ('e(i.e., in three (3) bay sink, off site by private company): We$ -Xys$ Ct (r,4,,n - NOC$e—a' Ig —Yu$S4'% c VV&d 'e_Vk'A , 01- Is dinnerware pre -rinsed before being washed? NI4 Yes If yes, at what station/sink? tj jA No Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 OA S ikJ Grease Trap 2 4 Grease Trap 3 Grease Trap 4 Grease Trap S External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes Where is the existing outdoor GRU located? No Size gallons 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: Yellow Grease Waste Do you store yellow grease waste from fryolators? hJ f P" 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 wYED1 AC CERTIFICATE LIABILITY INSURANCE 4THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS FORDED BY THE POLICIES BELLOIW C THIS CEERTIFICATE OF NSURA CE DOES NOT CONSTITUTE TUDTE A CONTRACT , EXTEND OR LBETWEEN TTER THE HE ISSUING GE F SURER( ), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. h ADDITIONAL INSURED provlslons or be endorse IIYIYNR,Mn,.,,'N"IS— u.,--. 'su - If SUBROGATION IS WAIVED, aubJect to the terms and conditions oft e this certificate does not confer any rights to the certificate holder in Ileu Starkweather & Shepley PO Box 549 Providence, RI 02901-0649 401 436.3800 Decs Donuts, Inc. 86 D-1 Washington Street Plainville, MA 02762 )must ave certain policies may require an endorsement. A statement on COVERAGES - CERTIFICATE NUMBER: ""--'- ___-- THAT THE POLICIES OF INSURANCE LISTED SELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS THIS 16 TO CERTIFY INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE. AFFORDED BY THE LIMITS SHOWN HAVE BEEN REDUCED BYPDPAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. .MAY SUO PRE.D 10 LIMITS p AOOL �TSR .TYPE OF INSURANCE N R D POLICY NUMBER O2SBAKN9406 MMIDo IVYYY MMIDD 7101IZ019O7I011202 EACH OCCURRENCE 51000000 A X COMMERCIALOENERALLIABILIN ENTEO SA��A��ST Eo ocwrronw Is1000000 ® OCCUR 10 000 CLAIMS -MADE MED EXP (MY one PBBen) s PERSONAL S ADV INJURY $1000000 GENERALAGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: jj''1I PRODUCTS-COMPIOP AGO $2 OOO O00 P RO• POLICY ❑ JECT [R] LOC S OTHER'. AUTOMOBILE LIABILITY - C MSINED SI OLE UNIT EeaGHdanll S .— BONLY INJURY (Per person) S BODILY INJURY (Per Bcdden) S ANY AUTO SCHEDULED PROPS RTYDAMAGE. PbracGtlpa] 5 OWNED _ AUTOOS ONLY AUTOS AUTOS ONLY ANOWOVINED UTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE 5. AGGREGATE 5 S EXCESS LIAB CLAIMS -MADE DED RETENTIONS WORKERS COMPENSATION A 02WECEK3216 710112019 07/01/202 ER OTH- X. PSTATLa E L. EACH ACCIDENT S600 000 AND EMPLOYERV LIABILITY . YIN ANY PggGPppIIErrOR/PARTp�EppIEXECUTIVE OFFICERIMEMBEREALUDEDY ® NIA ELDISEASE -EA EMPLOYEE $500000 (MandalorY In NNI It yaa, tleacnba untlar E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, mey be anached if more space is required) RE: 905 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. reserved. ACORD 26 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S73789331M1378932 SCK w O w V z z I No Cif W z W 3 z W W a U W U Z O U w W N m N ry o N O N \ J N N O N O Q V goo u 4a O U " Q z o Z99 I —�o o w ° to q L b q t� y tl w 42 A „ om.; - moo,l \ § \ qq7§/ . §®m..,j ` / \ §§)}/ k k w RR{;/ < w : x tw z # 0 0 2fm � � ( § §(/ U~I awP 2$w 2 ! 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