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Home My WebLink AboutDec's Donuts (905 S. Main) - 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:. EDWARD ANDRADE, DIRECTOR Whose place of business is: DECS DONUTS, INC.(DBA) DUNKIN DONUTS 905 SOUTH MAIN STREET PERSON(S) IN CHARGE ALEIDES CONCEICAO, MANAGER Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS-20 BOARD OF HEALTH AichaeCHeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Establishment Name: Dfc5 I-)6noTs�+ ��A�UnY_Ipl �SNuiS Establishment Address: q6S 3001A 11"I'k''s STOecl_ (V'%P"g �d � Establishment Mailing Address(if different): 5A✓VN& Establishment Telephone No.: J 0? 3 7 Applicant Name & Title:p(vatUo Applicant Address: Applicant Telephone No.: S-U.6 a3la glace 24 Hour Emergency No.:� Applicant E-mail: � � Lx igCjL cew1 Owner Name & Title (If different from applicant): 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 OAA Association partner. l✓f A Corporation Name J� Title Address ' n E] An Individual �vt _.'u'u ��' �1_._ ��l'oI t^ n4A. OAPartnership ��( A(dp�e U.02a r41 Cpi,LL.)"- b2. (e64a W4 O Other legal Entity "&wL�, its Person Directly Responsible For Daily Operations (,Owner, person in charge, supervisor, manager etc.) Name &Title: 6-1,61,birk eolve -kwo q Address: t3ii 6,—C-0.ve t Telephone No: 40) , 6 o; , j - 7S3/ 24 Hour Emergency No: FAX: 77L( - &43 - &n L3`;_ E-mail: 6e�C� G 14pL. u� Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: 6'14R1 Y' 09PO.S47 Address: 2 9)-< Telephone No: St,7?•-,243- 09S�? 24 Hour Emergency No: FAX: i--n14 - (d-(9 • �J3S E-mail: cWoe_ ey a viol_•Ctmn Food Establishment Information WATER SOURCE: "fiOlulf'� SEWAGE DISPOSAL: ' Tcwe. No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: / /jn1 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): Location: W' ermanent Location Establishment Type ❑ Caterer $35.00 []Moblie Mobile Start Date: rn R( Sq. Ft) d Ilk & Cream $10.00 [1�'ivod Mobile End Date: oe Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: Food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Innual ❑l Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: ❑ Residential Kitchen $100.00 Q Seasonal Seasonal Dates: ❑ Supermarkets $400 ❑ Retail Food $125.00 Retail Snack Food $50.00 Q Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: - Food Operations De(Initions:PHF - Potentially hazardous food(timeRemparafure controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order v11. not PHF Cooked and Cooled or Hot Held [1 Sale of Commercially Pre -Packaged PHFs reparation of PHFs For Hot And for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly c, Delivery of Packaged PHFs ry Cold Holding For Single Meal Service ------ ----- — ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Susceptible Population Facility k=? Reheating of Commercially t 1 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring di Variance R'fustomer Self -Service of Non PHF and Non- ustomer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health e Manufactured and Packaged for reparation of Non-PHFs Retail Sale control) t❑ Offers Raw Or Undercooked Food Of Other Food Operations 0 Juice Manufactured and Packaged for Retail Sale Animal Origin ❑ Prepares Food/Single Meals for Q Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service l 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 ❑ 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 10 MR 590.000 and all other pphcable law. I have been instructed by the board of health on how to obtain copie tOS�a e federal Signature of Applicant: Pursuant to MGL Ch.62C, sec. 9;4, I certify under the ies of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: �� j -�- Social Security Number or Federal ID: -7S'r 3D `7 gr2ci 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. �eCS 1� J T Signature of Individual or Corporate Name By: Corporate O er (Mandatory, if Applicable) -IS -3o179)A "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\Scott's 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 Please Print Legibly Business/Organization Name: -T it°C's -DOnt Address: quS )Mtq l�u S-k City/State/Zip: W4 -' Phone #: _�;®Y - 3 39 -3?00 Are you an employer? Check the appropriate box: Business Type (required): 1 am a employer with _ �3 5. Retail 1.employees (full and/ ❑ or part-time).* 6. b❑ 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #I 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 Name: ��w?cuzel%5Ul2wne� C�e��tn Insurer's Address: T.O . BOX S(49 City/State/Zip: ?gw6\e4.10 ' V2---2—F Policy # or Self -ins. Lic. # to Expiration Date: -7 ' " D-019 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. 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 Cn " 32396 DECSDONU on ACORD. CERTIFICATE LIABILITY INSURANCE DATE (MMIDDlYYY11 1010412018 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 s�u�ch endorsement(s). PRODUCER Starkweather & Shepley PO Box 549 Providence, RI 02901-0549 401 435.3600 NAME: GT Kristin M. Saone. ACSR a�CGN+pE%t:401435-3600 ac.Ne:401431-9399 ADDRESS: kstone@starshep.com INSURER(9 AFFORDING COVERAGE NAIC0 INSURER A: Hartford Ins Group 19682 INSURED DISCS Donuts, Inc. dba Dunkin Donuts 86 D-1 Washington Street Plainville, MA 02762 INSURER B: INSURER C: NSURER D: _ INSURER E: INSURER F: r_ su uaeeo. RFUISION NUMBER: COVERAGES 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. INR TYPEOFINSURANCE ADD INS SUB POLICY NUMBER MM/DDYEFF MPMLINDYEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ��EASES RINTE.Den� $ CLAIMS -MADE ❑ OCCUR MEDEXP(Anyonepemon) $ PERSONAL& AOV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRODUCTS - COMP/OP AGO $ PR0. POLICY JECT LOC OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea al _ BODILYLY INJURY (Per person) $ ANY AUTO RNED SCHEDULED UTOS ONLY AUTOS HIIRED NOWOWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) 4 PROPERTY DAMAGE PROPERTY Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVEY/R OFFICEMMEMBER E%CWDED7 ® (Mandatory In NH) Ifyea.descnbeunder DESCRIPTION OF OPERATIONS below R OTH- EATUTE PSTATUTE ER $ A NIA 02WECEK3216 710112018'071011201.:::Y E.L. EACH ACCIDENT $SOO OOO E.L. DISEASE -EAEMPLOYEE $SOD OOO E.L. DISEASE -POLICY OMIT $500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached If more space is required) RE: 905 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S11995501M1199548 SICK O � � 3 m � / z 0 / z . N N 00 00 . / o < m o (o kq§q\ ° - \ b$%M!| 2 5l�k/ | § 00z w m \ I- w \§ oo§/r :) § . k ( X <ew w .zm / � � ( U) n w -7 m w o . / \ a22 W, i w- . { R.2LL \ u . B ! w ) ) q - �� .- . \�{� � •\ % � I Lo � ) � / # a \ \ \ / \ \ § \ \ \\ \ \ _r \ \ \ }\\ }ƒ\} \ DECS DONUTS INC. DEC 1 8 ZO'r0 FOOD PERMIT Of Bank H PktH