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HomeMy WebLinkAboutDunkin Donuts - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMNET In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. EDWARD ANDRADE, VICE PRESIDENT Whose place of business is: MANSFIELD DONUTS INC. dba DUNKIN DONUTS 45 CHAUNCY STREET PERSON(S) IN CHARGE. KIM GREIGE, MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-47 BOARD OF HEALTH Michae0feafey, Chairman I Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: mAAdve1d -C)o,, S Establishment Address: y,s- CJAt%UkV_� SV V'Avk +S �Ie-W WkV) S . Establishment Mailing Address(if different): sjW+n% e Establishment Telephone No.: s-&p6Y- 337-i 13© Applicant Name & Title: �tiGuo�a'Ej 1� ^Gi2 wc�� - l� i eec�C 2' Applicant Address: )o( Fe,»41 osuv- A#(e6cwo VV'V-1 &-.703 Applicant Telephone No.: SGB . ?36 - �cfaq"7 24 Hour Emergency No.: Applicant E-mail: 1 ebP W_�,j (3 K61» CA'PA Owner Name & Title (If different from applicant): �Y-Tm Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. P<Corporation Name Title Address `n �' 1 't j, An Individual Skv` wnL� �� .__.fit `d(�eu1Ea9 1�1+>e "C�of,IM 13 APartnership yu 0W&We VARS 1qt CPfi�PaU� i�G•__. Itt06t1'IU Other legal Entity �d� � t'bAV49U , Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: K1 A'/ 64&F/" Address: 4 f-f 0 5 r/ /i kAfS /}f1r ' Telephone No: j'02T - ,3 9 % -ai S3 6 u 24 Hour Emergency No: FAX: 1 -1'-1`{ . t.0%4 • (p x3Sr E-mail: 6ebe (N 3 i(AGL • Ccm Alt E-Mail: District Or Regional Supervisor (if applicable)Name Address:&Title �� L� C(xva 6Q• ✓y7,q Telephone No: ��/�' ��" fy 3 ,-U�j S 24 Hour Emergency No: FAX: t -77L(• C k43 ^ (c),3S E-mail: debe" o M0L. 0W% mm t'ttit4 PA A- Food Establishment Information WATER SOURCE: Tc)wv\ FSEAGE DISPOSAL: 'CC'�LUr\ f Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: '"1 041-0 (-`AOM _ SYtM 7-0 _ // PM Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): 13 l Location: [IrJermanent Location Establishment Type F-51 Caterer $35.00 kD Moblie Mobile Start Date: ® Retail ( Sq. Ft) 5;�Milk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Eli Manufacture Frozen Desserts/Ice Cream Length of Permit: ['Food Service up to 101 -200 $250.00 $25.00/freezer nnual Q Food Service up to 201 + $300.00 Q Pushcart $50.00 It of Pushcarts: ---- f❑^', Seasonal � Residential Kitchen $100.00 Seasonal Dates: Supermarkets $400 Retail Food $125.00 l Retail Snack Food $50.00 t0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous rood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHPs 0 PHFCooked To Order of PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service C-i Sale of Commercially Pre -Packaged PHFs D,Vreparation of PHFs For Hot And __... E] PHF and RTE Foods Prepared For Highly Population Facility Cold Holding For Single Meal Service -- -- Q Delivery of Packaged PHFs -- —.. E] Sale of Raw Animal Foods Intended to be Prepared by Consumer Susceptible 0 Reheating of Commercially '❑1 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑'' Use of Process Requiring di Variance — [�'� ustomer Self-service of Non PHF and Non- l� ustomer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only ° a Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) reparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin_ E] Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Ej Retail Sale of Salvage, Out -Of -Date _-..:::—... To be completed by the Board of Health or Reconditioned Food — "— Total Permit Fee: Payment is due with application [] waived 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 59Q0 and all other applicable I have been instructed by the pies board of health on how to obtain coof 105 Cfy]R 590.0�0 E� a d Co w Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I ce and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Lodi 3� 'xa•o 1 ,6 A 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. m4n,4w`A Tbiv,6 Signature of Individual or Corporate Name By: orporate Officer ( tdatory, 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\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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information II Please Print Legibly Business/Organization Name: :�n ASC City/State/Zip: YVAMSkteld nAftSS Phone #:�5OX, -� S7 ( %j0 Are you an employer? Check the appropriate box: Business Type (required): 1. & I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ©-ftestaurant/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]* I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1A W � ToSuttYt'•+eP Cwu vP Insurer's Address: �• O • l�Gx� City/State/Zip: F rmdevycp, t— ® Policy # or Self -ins. Lie. # 03tWeCe-K Expiration Date: "7 1 ac%1`j 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, undthe pains and pen perkry that the information provided above is true and correct. Phone #: 1 D% ' (% k -.)- - LI 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 Person: Phone #: www.mass.gov/dia Information and 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 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 Form Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia a, l+Cr�^.1 oaTE(MMmorvwv) ,ACORDr. CERTIFICATE LIABILITY INSURANCE 10/04/2018 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 policy(ies) 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 8: Shepley NA E: Kristin M. Stone, ACSR ac°Nt+ Exl :401 4353600 ac Net: 401 431-9399 AE-MAIL kstone stershe tors Doness: � P• ._. PO Box 549 Providence, RI02901.0549 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Hartford Ins Group 19682 401 435-3600 INSURED Mansfield Donuts Inc. INSURER B INSURER C: INSURER D: dba Dunkin Donuts 86 D-1 Washington Street Plainville, MA 02762 NSURERE: INSURERF: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF 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. TBRR TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR ADDL INSS SUER MD POLICY NUMBER POLICY EFF MM/DO POLICY X MMIDD LIMITS EACH S p �OCCURRENCE PREM19E5 Ea ovain0ence $ NEED EXP (my one person) $ PERSONAL SADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Ijj:jj PR0.ECT LOC J J OTHER: AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HE AUTOS ONLV AUTOS ONLY PRODUCTS - COMP/OP AGO $ COMBINED SINGLE LIMIT Ea a,cldentl $ BODILY INJURY(Per person) $ BODILY INJURY (Per ecddenQ $ PROPERTYDAMAOE Per aaltlenl $ A UMBRELLA LIAS EXCESS UAS OCCUR CLAIMS -MADE NIA 02WECEK3227 V0112018 0710112019 EACH OCCURRENCE $ AGGREGATE $ PER OTH- X I S DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 0qNNyy PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? ® (Mandatory In NH) If yes,descdba Under DESCRIPTION OF OPERATIONS below EL EACH ACCIDENT $SOD OOO E.L. DISEASE - EA EMPLOYEE1 $500.000 E.L. DISEASE - POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sohodula, may be attached if more space Is mqulmd) Locations: 45 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 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD r� SCK #S11995751M1199573 T K 2kk k/7 emm ,f-q)°o QQ I7i;@ R X ;a / mto- amm.. \!)e00 ga0§4 »a\ > o K § § A m 0 . � § 2 j/ K .:\\ 2 ACM R § m k/ mz \` k0 r m r 2 §z/ k2:m �§ r k ®m ( > ; 2°»m # « 2 2§ ■ 2 2 ƒ\ ƒ;`2 / M ( : ^) ® > 9 \ < a > } 2 § , w m ; \ fi L r