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HomeMy WebLinkAboutDunkin Donuts @ Stop & Shop - 12/31/201917 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 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:. KEVIN DONOVAN Whose place of business is: DUNKIN DONUTS @ STOP & SHOP 377 CHAUNCY STREET PERSON(S) IN CHARGE: RICARDO ABRANTES & KEVIN DONOVAN Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-22 BOARD OF HEALTH AichaeCHealey, Chairman Milk & Cream nY 9 ", =CAI, 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 :WN stablishment Address 3") % C "Ju ld stablishment Mailing Address (if different) __ 1e Gt �IV' %)-,ShARP :5�t, 1ltn (f stablishment Telephone No 33�_ yO-8 i n9 h A�v� r 'l ��0 j pppicant Name & Title: r V 1 n ll0 6VGw— reef '7, applicant Address%� dr) A-� 17 _ 24 Hour Emergency No.: 339,— kpplicant Telephone No.: 70 — 3 3 i 15 OJ I 1 CA 2 v A b V 0✓n P s applicant Email 'YI 0, n u I , YYI C 1 i iq n �t �c �� V aA n ej % (-t 0 _ Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: Cl An Association L 1 A Corporation ❑ An Individual 17 A Partnership Other le al Entity L-L'0� If a corporation or partnership, give name, title, and home address of officers or partner. Address Name Title 9 - Person Directly Responsible For Dajly, Operations (owner, person in charge, supervisor, manager etc.) Name & Title: I CA /L d fIJ Address:�F ) Telephone No: &y I IS 24 Hour Emergency No: 33 q — 1/ i %— 93b FAX: E-mail: Alt E-Mail: _ District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: Telephone No: FAX: E-mail: Food Establishment Information WATER SOURCE: �In SEWAGE DISPOSAL:y, — — -- DEP Public Water Supply No: (If applicable) No of Food Employees 5 F --- - / -- DAYS/HOURS, -- -�-- - Name of Person In Charge ertified in Food Protection Management:)� /� h A If more than 3 individuals are certified, complete list is on file. Y ✓itiQa Person Trained in Anti-Chokin Procedures (If 25 Seats or more): Location: Permanent Location Establishment Type: U Caterer $35.00 Mobile Mobile Start Date: E] Retail ( Sq. FQ NV Milk & Cream $10.00 Mobile End Date: [Food Service up to 100 INCLUDING Ej Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 H Manufacture Frozen Desserts/ice Cream LP�tgth of Permit: 0 Food Service up to 101 -200 $250.00 $25.00/freezer ( Annual ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: ----- ---- -------- 0 Seasonal 0 Residential Kitchen $100.00 Seasonal Dales: 0 Supermarkets $400 Retail Food $125.00 ❑Retail Snack Food $50.00 0 Temporary Temporary Start Date: Temporary End Date: ❑Tobacco Products $150.00 Temporary Time: Rain Date: Food Op DeMillons: PHF Pofentlally hazardousfood (ffine4emperature controls required) Non -PI - non -potentially hazardous Nadine dme4empersture controls required) (Check all that apply): RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which need no further procassing) 0 Sale of Commercially Pre -Packaged Non-PHFs [Ed PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ] Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And [] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Delivery of Packaged PHFs 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer r3Reheelin of Commerclail 9 y .- 0 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours 0 Use of Process Requiring di Variance andlor HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self-service P rishabte Foods Only contact alternative, time as a public health _ control) _ 0 Ice Manufactured and Packaged for Retell Sale Preparation of Non-PHFs E] Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin ❑ Prepares Food/Single Meals for [] Offers RTE PHF In Bulk Quantities Catered Events or Institutional Food Service _ SW___—,__ 0 Retail Sale of Salvage, Out -Of -Dale --------- -- ------ or Reconditioned Food To be completed by the Board of Health ELT - - ---- - Total Permit Fee: i Payment Is due with application E] waived I, the undersigned, attest to the accuracy of the information establishment operation will comply with 105 CMR 590.000 board of health on how to obtain copies ofCrMR 59 0 Signature of Applicant:r f rin this application and affirm that the food ther applicable law. 1 have been instructed by the the federal Food Code. Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have glad all state tax returns and paid state taxes required under law. Social Security Number or Federal to: J V— 35 / '3 S 3 Signature of Individual or Corporate Name: ,SE.0 6 )-)C/ 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 01/ 35/-3535' **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. R:\HeoRhVane's DOonments\PERMIT APPLICATIONS\TAX CERTIFICATION FORM -doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip Phone Are y a an employer? Check the appropriate box: Business Type (required): 1. I am a employer with—tJl—employees (full and/ 5. ❑ il or part-time).* 6, Restaurant/Bar/Pating Establishment 2, ❑ I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl, real estate, auto, etc,) employees working for me in any capacity, [No workers' comp, insurance required] $. ❑ 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 10.0 Manufacturing no employees. [No workers' comp, insurance required]* I I El Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.J 12,❑ Other *Anv aonlicant that obwka box 91 must also GII out the section below showing tbohworkers' wmpcnsa00n policy information. **If the eorpomto officers have exempted themselves, but the corporation nos Omer employees, aworxers' compensanun punuy rr icyuucu o-„o- �uw, o-„ organization should ebeok hox HI. I am an employer that is providing iyork(rs' compensation fnsurance fob my employ'fei•. Belem is the poll y information. Insurance Company Insurer's City/State/Zip: VU I jV141 Policy # or Self -ins. Lic. # Expiration Dater �' 6 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 e. 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 Tnvestieations of the DIA for insurance coverage verification, I do hereby certify, under the pains and that the information provided above Is true and correct //Ac%a Offload use only. Do not write in this area, to be completed by city or town official City or Town; Permit/License tf Issuing Authority (circle one): 1, Board of Health 2. Building Department 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office 6.Other Cnntaet Person: Phone #: www.111aas.gur1u1e A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY1 11/28/2018 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Fred C. Church Insurance 41 Wellman Street Lowell MA 01851 CONTACT NAME: Ma Ann Homan PHONE . g00-225-1865 FAX 978-054-1865 E-DoMaL Aaess: mhorganCIrelfcchurch.corn INSURERS AFFORDING COVERAGE NAICN INSURERA: IOde endence Casual Insurance Com an 11984 INSURED DONOSER- I Donovan Services, Inc. DBA Dunkin Donuts 72 Sharp Street, Unit A-7 INSURERS: INSURERC: _ Hingham MA 02043 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1090438130 REVISION NUMBER: 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. INSR LTR TYPE OF INS ADD L SUBR POLICY NUMBER POLICCY EFF POLICY EXP UNITS COMMERCIALGENERALLIABIMTY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMA ETOREN D PREMISES Eacccunecce $ GEN-L MED EXP (An one person) $ PERSONAL a AOV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY JEo- LOC OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUr05 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBIN.nI) LE LIMIT Ea accitlenl $ _ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLALIAB EXCESS LIAB OCCUR CLAIMSMADE OCCURRENCE $ _EACH AGGREGATE $ DED RETENTION _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYANYPROPRIEfORIPARTNEWEXECUnVE Y0 OFFICERIMEMBEREXCLUDED? (Mandatory in NH) byes, describe under DESCRIPTION OF OPERATIONS below NIA WC100125601 8/1/2018 81112019 PERT ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE EA EMPLOYEE _ $1,000,000 EL DISEASE POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORO 101, Additlonal Remarks Schedule, may be attached Umore space Is required) Location: 377 Chauncey Street, Mansfield, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048 —744t,.,d.,r,,,,,,-- —,q . I �_..__.,._.._�__.—�.. ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 0 10 N d' O .�1 H rl O . 1 Z 6 W Z F i Q 0 U Q N U. !LL Q � X Lu W V 0 .� LL v ' C r p O y u a` I � a m c m � u ' 0 C O a z 2 a ih � a _ YQr G 'a a 'a G d Q L a a a T fl a Q V Y V, q� W U h U y„ O s F w 3 b