Loading...
HomeMy WebLinkAboutHoney Dew Donuts - 12/31/20190 Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment J Type: FOOD SERVICE ESTABLISHMENT 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:. STEPHEN PROVAZZA, OWNER Whose place of business is: HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS 99 COPELAND DRIVE PERSON(S) IN CHARGE. STEPHEN PROVAZZA Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -36 BOARD OF HEALTH -%lichaeCHeatey, Chairman Milk & Cream Y�L? X`' ,v FOR BOARD OF HEALTH USE ONLY Permit # Issued' FOOD ESTABLISHMENT PERMIT APPLICATION ECEIVEE (Application must be submitted at least 30 days before the planned openin a OCT 2 9 2118 Establishment Name: lye IZ�� ou'v OU/n ✓� - Sf'cwo' ��. 17,864 //Tj�c4> P a� f1 Establishment Address: 92 Cotaeker,Y 'Pr V e_ " Establishment Mailing Address(if different): %�,f � ✓� �J-eu-tlz- t2�- o � �! 0 C� Establishment Telephone No.:�� Applicant Name & Title: LO nzZ-- Applicant Address: oZ f" aA-L Tl a ui a— Ved '0a-'906 Applicant Telephone No.: aFS k% O E /7 24 Hour Emergency No.: Applicant E-mail: S.4PL64T 0 pq�G 6e� Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: O An Association KA Corporation O An Individual O A Partnership ® Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ypp�P(' e(COt/e UA - Address: � �Y Y ✓e�JA�,_e CPxe6 . AZO, �f ©a Telephone No:��- p 24 Hour Emergency No: FAX: E-mail: sPO Ljf1 li% f}OL• C" Alt E -Mail: SFKO S "G' 6 -k7 - District Or Regional Supervisor (if applicable) Name & Title:: `rerLr. Address: Telephone No:996 �� a 24 Hour Emergency No: FAX: / c E-mail: Food Establishment Information WATER SOURCE: -ro4lyL SEWAGE DISPOSAL: f t,J Vj DEP Public Water Supply No: (If applicable) No. of Food Employees: r� DAYS/HOURS: d h - ,Sup( Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. D Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: ." Permanent location Establishment Type Caterer $35.00 h Moblie Mobile Start Date: 0 Retail ( Sq. Ft) H: 6Ailk & 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 R"Annual Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations ;heck all that apply): Q Manufacture Frozen Desserts/Ice Cream M Food Service up to 101 -200 $250.00 $25.00/freezer ® Food Service up to 201 + $300.00 ® Supermarkets $400 Pushcart $50.00 # of Pushcarts: ® Residential Kitchen $100.00 Retail Food $125.00 Retail Snack Food $50.00 Definitions: PHF - Potentially hazardous food (timeitemperature controls required) Nan-PHFs - non -potentially hazardous foodfno lime/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 0 Sale of Commercially Pre -Packaged Non-PHFs Pre -Packaged PHFs PHFs Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations Q PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale la Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for I [3 Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin Offers RTE PHF in Bulk Quantities ❑`t Prepares Food/Single Meals for Catered Events or Institutional Food Service U Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health- - - - Total Permit Fee: Payment is due with application Q waived _ J 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 copies of 105 CMW90.000 and the federal Food Code. Signature of Applicant: JYC%'� Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. n _ Signature of Individual or Corporate Name: Social Security Number or Federal ID: 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. L2(�, Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0 � I �)-1 `1 F "*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:\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 wrvw.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/OrganizationNamee: xc-etr tri j)Ba -fkpft*ajpe, �,,Lf -s Address: a L�e_56 dz&e Zd City/State/Zip: �Dvut�.�e, sem- r `�_ oy'D� Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. © I am a employer with _40-- employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/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 L❑ Health Care 4. F-1Weare a non-profit organization, staffed by volunteers, e with no employees. [No workers' comp. insurance req.] 12.0 -Other ,/G!�lCJ p *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **tribe 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. _ n n . r , , Insurance Company Insurer's Address: T D . E,-6— p j � o? � ,I- 9.,�0 ',�_ City/State/Zip: iii -h --e— . Policy # or Self -ins. Lie. # D l I Expiration Date: 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, under t/ is is and penalties of perjury that the information provided above is true and correct Cionan,rr• (V ipl/ .�.e� _�7,� n,,P. to-�3—/� 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 A^"?"® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODmYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 10/30/2018 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB NE Association Programs CONTACT NAME: PHONE FAX AIC No Ext: AIC No: E-MAIL ADDRESS: 300 Ballardvale Street Wilmington, MA 01887 INSURERS AFFORDING COVERAGE NAIC# INSURER A: MA Retail Merchants WC Group Inc. COMMERCIAL GENERAL LIABILITY INSURED INSURER B: ----- -...._ SPCAP Inc.---- Donuts `- dIbI284 Preside t Avenue 284 President Avenue NSURER C $ INsuRER O: CLAIMS -MADE 1-1 OCCUR INSURER E; Providence, RI 02906 INSURER F: MEDEXP(Anyonepelson) COVERAGES CERTIFICATE NUMBER: 00013 REVISION NUMBER: 00001 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 CONTRACT OR 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. NSR LTR TYPE OF INSURANCE ADDL INS SUBR MD POLICY NUMBER POLICY EFF MMIODIYYYY POLICY EXP MWDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETOREWED PREMISES IFaowu encs $ CLAIMS -MADE 1-1 OCCUR MEDEXP(Anyonepelson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ $ POLICY JEo LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ac dant BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per acedent) $ PROPERTY DAMAGE Per accident) $ NON OWNED HIRED AUTOS AUTOS UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION X VdCSTATD- OTH- AOFFICER/MEMBER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EXCLUDED? FN I tArumm nyin NH) NIA 014000501929118 1/01/2018 1/01/2019 E. L. EACH ACCIDENT $ 188.808 ---- ELDISEASE-EA_EMROYE _ 8 100,000 -- If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT 8 600,800 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) COVERING LOCATIONS: Covering Location: 9 Copeland Drive, Mansfield, MA CERTIFICATE HOLDER CANCELLATION Town of Mansfield Town Hall SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE '.. Mansfield, MA 02048 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ''.. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '.. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010108) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient. STEPHEN PROVAZZA Certificate Number: 2161331 Date of Completion: 12rYla15 Date of Expiration: 1113rN2a Be alow-named person is hereby ioned thio wrtiffeate for rompletingan allergen awareness training program nragniud by the MasrarARsws Drpanmmt of Ra4mr Health in arrordantr with IDS CAM 590.W9(G)(3)(a). Dtis wtifimv willlw eared fnrfre.e (5) years fmm dare afrompinion. 3c, tura sr MR aEs°uNR6riI' M- ASSOCINHON, MKsxIu m R�t As,.mla° BW765.2122 333 Tucnp$e R°,d, Svitr 102 01 mmurantnxg Sowhhomvghj,A 01772 508 ,'10.3.8905 xuumantovravmsRr.wg I I I I m § U c \ / m BASICLIFE SUPPORT BLS_ r vAmerican ''(rlj Heart rove �' � Association® _ Tanya Andrews The above Individual has successfully completed the cognitive and skills evaluations In accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. 12/04/2017 12/04/2019 Issue Dere_.. _ Recommended Renewal Data This card contains unique security features to Protectagainstforgery. R BLSgT,� American Provider Heart Associations Dominick Pacelli The above individual has successfully completed the cognitive and skills evaluations In accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. 12/04/2017 12/04/2019 issue Date Recommended Renewal Dale This card contains unique security features to protect against forgery. MEM -FI W y, t American kHeart t Associations _ Angela_Huestis The above Individual has successfully completed the cognitive and skills evaluations In accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AEU) Program. 12/04/2017 12/04/2019 Issue Date Recommended Renewal Date Tu .I Training Safety Program ConsultanW.1416 MA4688 Center Name -T50 Rafiiob'ofh-Tvl'Ft TO; Ox �T Info wv+gy,Aspcj,com _ ,.if, 5,8,4.252-3049 Course Location ___Spumoni's Restaurant Instructor Inst, ID If Name Bryan Syrett 04113341646 Holder's 0201fi 0.maticen Hoan Aazacielion T pen,g wily NJs cart wiNellerifs appesrer2o15-1805 15-1805 11/15 Training Safety Program Consultants,i t; MA4688 Center Name --P07BoR'zasaSKab�tn-MIfo27s9--- Tc s Info^W�(`'_.4,Pcl.com �O8-252-3049__ Course Location _ Spumoni's Restaurant Instructor t ID If Name Bryan Syrett 04113341649' Holder's 02015Amerlwn Hear)Association iamperinB with lNs card wdl alhrlls appearance. 15-1005 BASIC LIFE SUPPORT Training TO ID 9 Center Name Safety Program Consultants, )no MA4688 TO PO Box 259 Rehoboth MA 02769 c Info vvWW;4$p6r.com,____„_`_ 508 262-3�9 _ Course Location.SPgT ni's Restau�l[_t,�______ Instructor Inst. ID N Name - Bryan Syrett 04113341646 Holder's uj 2015 American Heart AssJclalion Ibmperirg wife lMs cwd will Nferliseppearam'e. 151805 15-1805 11/15 This card contains unique security features to protect against forgery.. l 15-1805 11/15 03 d4 .'H 0 6e Oe 0 r a 4s N r df n 0 BLSr� Arnarican Heart Provider ---t. ;` Associations PEEL HERE Stephen Provazza The above Individual has successfully completed the cognitive and skills evaluations In accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. 12/04/2017 12/0_4/2019_ _ Issue Date Recommended Renewal Date This card contains unique security features to protect against forgery. IO M 0 0 41 0s U Y S 0 U r r m n U Trainingbanter Name Safety Program ConSUltanls IPnc MA4688 TC PO Box 259 Rehoboth MA 02769 c Info_ www_4spoi.com,1P—_ 508'+252-3049__ Course Location Spumoni's Restaurant Instructor Inst. ID H Name Bryan Syrett 04113341646 Holder's 02015 Am scan Mean Aesoolafion Tempedng wdh this rad nN affas lis nnp vance. 154805 4American Center Name Safety Program ConsultantTs, IRS MA4688 Training BLS #x Heart PO Box 259 Rehoboth MA 02769 Provider Associations TC Info www,4spci,com , q- 506x262-3049 PEEL _ HERE Sheila Bozek Course Location Spumoni's Restaurant The above individual has successfully completed the cognitive and -- skills evaluations In accordance with the curriculum of the American Instructor at. ID D Heart Association Bastc Life Support (CPR and AED) Program. Name Bryan Syrett 0411334164° 12/04/2017 12/04/2019 Holder's Issue Date �— Recommended Renewal Date This card contains unique security features to DMtarr 02015 Ameda Hun Assoelama T penrg with fhe rad willelleriis apVea2M'6. 1S1e05 <k EARTSAVE R CPR AED American CPR E Heart Associations Sue Meyer The above individual has succasslully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heansaver CPR AEO Program. Optlonal� completed modules are those NOT marked out: 4/03/2 MY CPR AED Infant CPR Exam _ _ 4/03/2019 Issue Date Recommended Renowal Date