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Home My WebLink AboutDec's Donuts (School St. ) - 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 333 SCHOOL STREET, UNIT 10 PERSON(S) IN CHARGE. SHAWN TAVARES, MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-19 BOARD OF HEALTH Michae(Healey, Chairman Milk & Cream W FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: I7c'cG -oLmUTS Tvj•. (�D BAj -puPAbvN �JcNUT$ Establishment Address: Scl^eo� St" PAAnS e—k( MvNSS. �3Q Ur�� Establishment Mailing Address(if different): �VrC'.s Establishment Telephone No.: '7 74 _ ti 0 0 y Applicant Name &Title: JFd JA'zd) tAr`('AeAde- Applicant Address: (L{ t ff* +A4 ' j !D4' I*" f 2-bc✓w VW VJ �a763 Applicant Telephone No.: 24 Hour Emergency No.: $®� fol3•�i\$�{ Applicant E-mail: de� f ¢r;� %�aL•- C avh Owner Name & Title (If different from applicant): Sr%,Mp- 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 9 An Association partner. WA Corporation Name Title Address y An Individual Skeoag AWW nd( ?1 QS/, • '71_ (AiiA iew Rev& • ee�b� uY1�� O A Partnership �_d(wfizt� r�itok U •_YrGPS l+� 1 Fraiyw`y`r .. Rd I p�0" 1•� Other legal Entity C�2rs 1�nG1�21�Gi» Cu�rhQty✓t �� e�IF Id Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:.S h n U1N PAt1AK03 Address: / ,�Z POZGYi br Ve"L R Uc- CA5r AQi"I 3�, ✓� r R. �. !! ? 9 !S` TelephoneNo: 'to)- a(.f t _ '� 7xy 24 Hour Emergency No: FAX: 1 - i-7`1 • li%N 3 - & E-mail: deloC3vLG1" d lk01.. C'Ctvi Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: elvae75 R,4peSCt Address: Q p GLfl wa&bf O 11 _lya ri l Telephone No: 5_a ' -,24 3 _ 0 9 S 0' 24 Hour Emergency No: FAX: 1-7"1`(, inL(3` yr tlS E-mail: (JebLeCy a ACA, • ce4AA am M vm Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: -(-CtA.)^ No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: "441 TP // 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): Location: OKermanent Location Establishment Type F-1 Caterer $35.00 QMoblie Mobile Start Date: 0 Retail ( Sq. Ft) &411ilk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING Q Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 [L]'food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Lett th Of Permit: Annual � Food Service up to 201 + $300.00 [D Pushcart $50.00 If of Pushcarts: I] Residential Kitchen $100.00 — Seasonal Seasonal Dates: IQ.' Supermarkets $400 Retail Food $125.00 Retail Snack Food $50.00 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operafions Definitions:PHF- Potentially hazardous food(timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperaturs controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) Lys Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Nflut PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs reparation of PHFs For Hot And 0 PHF and RTE Foods Prepared For Highly Population Facility Cold Holding For Single Meal Service Q Delivery of Packaged PHFs ------- Susceptible -- Q Sale of Raw Animal Foods Intended to be Prepared by Consumer L Reheating of Commercially _ ❑I Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand - Customer Self -Service of Non PHF and Non- ustomer Self -Service I� Perishable Foods Only contact alternative, time as a public health control) _ Q Offers Raw Or Undercooked Food Of A& Manufactured and Packaged for [W- Retail Sale _. reparation of Non-PHFs _ Other Food Operations _ I] Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service 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 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 5 "Q0 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 590 00 d t fader ood Cc e. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penaltles9 Jury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name:CS '✓G't^�' ` Social Security Number or Federal ID: `7S'- 301'-7Ci ;?-61 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. 7D . Signature of Individual or Corporate Name • Corporate Officer andatory, 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 - Please Print LeLibly Business/Organization Name: T- Address:— City/State/Zip: ww hr,(,eA VyVlq<;S Phone #: ] % 12 •-,a 961 - t i o ('�i Are yopan employer? Check the appropriate box: Business Type (required): 1. R I am a employer with 36 employees (full and/ 5. ❑ Retail or t❑ I part-time).* 6. cstaurant/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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address t�•e% •X S�l� City/State/Zip: U1C•'(�� Policy #or Self -ins. Lic. # 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 the pains and pengifies ,rWjury that the information provided above is true and correct S00"•1.0Na-• QW14 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Yd -/% 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 II t# 32396 DECSDONU C an ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMNO/YYYY) 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 he 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 & Shepley PO Box 549 Providence, RI 02901-0549 401 435.3600 ka° E; cT Kristin M. Stone. ACSR C o Ext: IB401 435-3600 ac.Na: 401 431-9399 N EMAIL ADDRESS: ketone@starshep.com INSURER(S) AFFORDING COVERAGE NAICM INSURER A: Hartford Ins Group 19682 INSURED Decs Donuts, Inc. dba Dunkin Donuts 86 D-1 Washington Street Plainville, MA 02762 INSURER B: INSURER C: NSURER D: INSURER E: INSURERF: sneo. RFVI%I0N 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 CONDITIONOF 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. LTR TYPE OFINBURANCE ASRL SU pR POLICY NUMBER Mr°uoo/YErFF MMIDI) XP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ pA,dp�E ELATED PREMISE eaccuRenm $ CLAIMS -MADE OCCUR MEDEXP(AnYone Peman) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS -COMPIOPAGG $ PRO- JECT POLICY LOC OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident) BODILY INJURY (Per parson) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY(Pareaddeal) $ PROPERTY DAMAGE Per emltlent S UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMSMADE DED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY P gqOPRIE,7OPJPARTNNER;EXECUTIVEVIN OFFICERIMEMBER EXCLODEDT ® (Mandatory In NH) Ryes. desalbe under DESCRIPTION OF OPERATIONS below Y PER oTH- $ A NIA 02WECEK3216 7/0112018 07l01I201 E.E.L. EACH ACCIDENT $SOD OOO _ E.L. DISEASE -EA EMPLOYEE s5000OO E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tot, Additional Remarks Schedule, may be attached It 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 ABOVEDESCRIBEDPOLICIES 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 SCK \I==Lu .ƒ0 :� �k) : m ƒ\ < \ \ \< » ) \) /� / Cl j f� � LLI )} ƒ/ UmLU }\ somm flumm $ ix F- �\ /} : / L(... §7 \ 0 R 00 \ n �! .,\ \ \\ m $ ! N C .E LL V o ._o �v v 0 a` U o W li ao g G � O � W C G P U e LL z v o M B .F W a� e' w N R m � Z Z m u g0 v Y S MA 5z V 1` r i D B 0 Q w a o os V 0 y @. E _, w 0 W U wu J w z w P4 z w W F 0 cd Q C 0 m bo b � h h m O M W ti J- e Y d y rC by C w ti