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HomeMy WebLinkAboutDomino's Pizza - 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 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:. DUFFICY ENTERPRISES, INC. Whose place of business is: DOMINO'S PIZZA 235 CHAUNCY STREET PERSON(S) IN CHARGE: JUSTIN LEVESQUE Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS-21 BOARD OF HEALTH MichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Permit Is Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: amm,)15 ` Establishment Address: 2%j j daune 1 44RIf. 8a, Establishment Mailing Address(if different): ?, rh I rI O � 9 201 f<cm 1 ir)q vr�t7✓lG Establishment Telephone No.: (%r�+) 3 37 r 1004 — Applicant Name & Title: TeK-(vj A DA9, Pwhd Applicant Address: a I�� qjce,�, FMK4J;nl1nA 659 Applicant Telephone No.: (Sbo) 5-'�6 ^( LSD 24 Hour Emergency No.: Am (L?)9) 651 166A Applicant E-mail: 41z' 4�e L%! *I 1 - ikZ Owner Name & Title (If different from applicant): Ot/#! GG4 1d, OwnerAddress: �I�I ( �Zrlii Ff 1Y1 6s` `iVA j Owner Telephone No.: (!52)5 �L100 �j�S/�/lj Owner E-mail: 440- pQ �� <.Cll?fj . 4d Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El qn Association partner. A Corporation Name Title Address El An Individual El A Partnership E] Other legal Entity Person Directly Responsible For Daily Operations (ow4r•; "person in charge, supervisor, manager etc.) Name&Title: JV4)y I-eUY,j )P ) Address: �� GQGt4AyI ✓✓$� (/ / Telephone No: (�po) 33<� -(p6C� ?�?4HeurEmergencyNo: ChC1J (���)63t- wa FAX: CSo�I'1d E-mail: ,1IQ Alt E-Mail: U District Or Regional Supervisor ��jjif applicable) Name & Title: Choi 6V�irft!l1(k vFdi opoyd ?MS' / Address: ;� fr ii-)r 1*4 Azl* �hrts (sD)�3! lba�Z Telephone No: �`f-0fl��?""I Dd) 24 Hour Emergency No: r FAX: C p�j� I -'IDbb E-mail: tl CL GP GGutTC t lC Food Establishment Information WATER SOURCE: 'fQ],{ /) SEWAGE DISPOSAL: �yt DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: 5o -" t j6'3,94k -12: aA W --Th l0:36AM-1:OAm3b^ - 3: ioAA Name of Person In Charge Certified in Food Protection Management t6hV, oosq U(, If more than 3 individuals are certified, complete list is on file. 'J� 1tq (I,%/ &I C`hii'rT�cs"' 1C�+YV<f��"i�nun Person Trained in Anti -Choking Procedures (If 25 Seats or more): 7 u Location: Permanent Location Establishment Type U Caterer $35.00 ❑-9 Moblie Mobile Start Date: K/Retail ( Jl SOU Sq. Ft) t9i Milk & Cream $10.00 [.,J{ Mobile End Date: Food Serviceup to 100 INCLUDING rid Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream Length of Permit: 0 Food Service up to 101 -200 $250.00 $25.00/freezer a Annual Food Service up to 201 + $300.00 0 Pushcart $50.00 # of Pushcarts: Seasonal Seasonal Dates: I Y Supermarkets $400 E�1 Residential Kitchen $100.00 Retail Food $125.00 Temporary Gi Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF- Potentially hazardous food (timeRemperaturs controls required) Non-PHF's - non -potentially hazardous tood(no h'meRemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no turtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs Foods for Service Within 4 Hours !elf -Service of Non PHF and Non - Foods Only i of Non-PHFs Other Food Operations I, the undersigned, attest to t)ae'accuracy ofthe establishment operation comply with 1 board of health on how to btain copies 10 Signature of Applicant: '�' Pursuant to MGL Ch.62C, sec. 4 , 1 rti un and paid state taxes required u0 er law. Signature of Individual or Corporate Name: Social Security Number or Federal to: [TPHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer El Vacuum Packaging / Cook Chill 0 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) '.:� Customer Self -Service Ice Manufactured and Packaged for Retail Sale El Juice Manufactured and Packaged for Retail Sale i❑-' Offers RTE PHF in Bulk Quantities _. Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application E] waived Irmation provided in this application and affirm that the food 590,000 and all other applicable law. I have been Instructed by the d 590.000 and the federal Food Code. fI of perjury that I, to my best knowledge and belief, have filed all state tax returns 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. rd�elybes Iy. Signature of Individual or Corporate Name "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:\Usem\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 2 . psm z� :ƒ \ `\\ . � W \) . � CY )) � � .. � $# \jLIJ F f7 co |/ a� � $$ � \) � no w U w H W u z *W i z W z d z W W j 5 � N N t) � N � W tl lVV 42 tl •O +w 3 �: xis. �. N •, �r �s•w EL tau r }�_ s� U C LL z i LL Z) •s o G. N w M u I W LO Lij ° N o N 2�EE x N o m m W W 0 o E m o o dv O EwM uoU 38 FQ 3a ©- A 3 CD 3.6a eyey IJ �i S" Q X U "��F's'`' N W '0 o co LL N oN W O W H � N H a a5 J z z Jr Lei 1 LJ z *W4 z Un ron z z W 0 w x a n N N m m m U in'• x i o of z¢ I LLJ cy z w w 0 z � z � W � 0 W un � \ $ k $ . »:CIQ . . � /< »2\ ^ °x% u ° § 2 § a o \/ k n' "' ■ C i r ■ i S w O U w H W u z H z N rV JJ V J W z P4 z CWr`J7 V W O ti "o O O cd „ w O O H Boa 0 _W W O o U w O O O a)y H Q Q L 0 .w m l - lk ai � m N V N ti 4 O l V V The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N City/State/Zip: ► r I jn;1 e W t MA 6�M Phone #: (569) 33q "iuD Are ypu an employer? Check the appropriate box: Business Type (required): 1. Q' 1 am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6.ffRestaurant/Bar/EatingEstablishment 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 LEI 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 belowshowing 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 N Insurer's Address: �qP () 00i 1�56 City/State/Zip: I ept libwD / n�N O ��G/q/t�y " lob �t Policy # or Self -ins. Lic. #� (/ r�T77 d a�U Expiration Date: 3� i I Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure cov ge 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 /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 da gainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the I for insurance coverage verification. I do h 06y certify liar the pains and penalties ofperjury that the information provided above is true and correct. v 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 ACORO® CERTIFICATE OF LIABILITY INSURANCE is / DATE(MMIDD/YYYY) 11/14/2018 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(les) 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 endorsements . PRODUCER CONTACT NAME: Chris Armbruster PNONE 508) 471-1159 FAX No: INSURANCE MARKETING AGENCIES INC noD�RELss: cra imaagency.com INSURERS AFFORDING COVERAGE NAIC If 306 MAIN ST INSURERA: TRAVELERS PROPERTY CAS CO OF AM 26674 WORCESTER MA 01608 INSURED INSURERS: INSURERC: DUFFICY ENTERPRISES INC DBA DOMINOS PIZZA INSURER D : INSURER E : PO BOX 707 1 INSURER F: FRANKLIN MA 02036 COVERAGES CERTIFICATE NUMBER: 337961 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. ILTR TYPE OFINSURANCE ADDLSUBR INSD VIVO POLICYNUMBER POLICYEFF MMIOD/YYYY POLICY EXP MMDO LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES(Ea ocalnence $ MED EXP(Any one arson) $ PERSONAL S ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ P' LOG POLICY JECT PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea eccul dt $ BODILY INJURY (Par person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per ecrAdant) $ PROPERTYDAMAGE Par accident $ NON -OWNED HIREDAUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION $ $ WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXA OFFCERIMEMB REXCLUDEDT ECUTIVE NIA (Mandatory In NH) NIA NIA 7PJUB2E47409218 09/30/2018 09/30/2019 X STATUTE ER E.L. EACH ACCIDENT $ 600,000 E.L. DISEASE -EA EMPLOYEE It 600,000 If yea, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more apace Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in stales other than Massachusetts If the Insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy In force on the date that this certificate was issued (unless the expiration date on the above policy precedes the Issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/Investigations/. CERTIFICATE HOLDER CANCELLATION r 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. 6 Park Row AUTHORIZED REPRESENTATIVE `D"'�). t" 9 Mansfield MA 02048 Daniel M. Cr way, CPCU, Vice President — Residual Markel— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD , I I �► �® CERTIFICATE OF LIABILITY INSURANCE DA,E,MMDDYYYY) 11/14/2018 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(les) 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 endomement(s). PRODUCER insurance Marketing Agencies, Inc. 306 MAIN STREET Worcester MA 01608 COUT NAMEA T insurance MarketingAgencies PHONE FAX ac o Bat 508-471-1164 ac No:508-071-1864 aooness, cedificate imaa enc .com INSURERS AFFORDING COVERAGE NAIC% INSURERA: Citizens Insurance Co. of America 31534 INSURED DOMINI INSURERS : Allmerica Financial Benefit Insurance 41840 Dufficy Enterprises Inc DBA Dominos 2 Mill Street INsuaeac: Commerce Insurance Company 34754 INSURER D: Franklin MA 02038 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 808249321 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 INSURANCE ADOL SUER POUCYNUMBER MM/�UT� MMI�O� LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Ifl OCCUR OBNA795M 12/1/2017 12/112018 EACH OCCURRENCE $1,000,000 -DAMAGE T RENTED — PREMISES Eeoccumance $300,000 MED EXP(Any one arson) $6,OOD PERSONALS ADV INJURY $1,000,0DO GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRLOC OTHER: GENERALAGGREGATE $2,000,D00 PRODUCTS-COMP/OPAGG $2,DOD,DDO $ B C AUTOMOBILE LIABILITY ANY AUTO AUTOS X SCHEDULED X AUTOSWNED HIREDAU10S AS AWNA778003 BGZGXL 12/112017 9/30/2018 lVi/2018 9/30/2019 IN IT Ee ecGtlenl $ 1000000 BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ aGnDAMAGE r EUN E A X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE OBNA795944 12/1/2017 12/1/2018 EACH OCCURRENCE $5,000,000 AGGREGATE $6,000,00D FDED DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? tMandatory In NH) If yas, describe under DESCRIPTION OF OPERATIONS below N/A STERI I 0EIM. E1. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT If DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additlonal Remarks Schedule, maybe atfachad if moreepace Is required) CERTIFICATE HOLDER CANCELLATION r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD