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HomeMy WebLinkAboutDec's Donuts (4 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:. DECS DONUTS INC. Whose place of business is: DECS DONUTS INC. 4 SOUTH MAIN STREET PERSON(S) IN CHARGE. MICHAEL FOSTER Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS-18 BOARD OF HEALTH -%1ichaeCHeatey, Chairman Milk & Cream 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: Dec-5 NUTS ` -11C, gv i Establishment Address: y Sou}tn NApillV Establishment Mailing Address(if different): AMC Establishment Telephone No.: Sij 3 3, a g Applicant Name & Title: f-OWM-0 A^OCAO(j Applicant Address: Iql; rAiaw t7- nice- A"Ieixyzu mo v1?03Ct Applicant Telephone No.: Scot- aX -`3•% 24 Hour Emergency No.: Applicant E-mail: clebep—a j 0 AOL. 06i'Vl 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 11 An Association partner. [P<Corporation Name ,!!tt �jj� j � Title Address gg �pp OAn Individual �t� -AO6 '� Ems¢«• _ Tv__Fr°ceuiew (Aue. (�8holio Y� MA. OAPartnership FdcuA?,J l4l FAt2 . A+Q C WNA. -_---_V.&e. O Other legal Entity CWUS Av` T . &1- C Q@� Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:. Address: 3 4,14.#e- C,o f,-r Lug4 PULE 474 Telephone No: `77 y — 3 610 r �9 9 0I 24 Hour Emergency No: FAX: g i%�E io�E� CGS 3 E-mail: ckebe e&4 L -COm Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Co %t'J9 d'GS G / �02' RA//02907 Address: &) GODS " Telephone No: 0 9 S_ 24 Hour Emergency No: FAX: •(o13'- E-mail t®{ G AOL ,CC Food Establishment Information WATER SOURCE: q SEWAGE DISPOSAL: T DEP Public Water Supply No: (If applicable) No. of Food -Employees: DAYS/HOURS: 'I s A "n ro d pm Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. t Person Trained in Anti -Choking Procedures (If 25 Seats or more): N I Location: VP-ermanent Location Establishment Type $35.00 Q Mobile Mobile Start Date: Mobile End Date: Q tail ( Sq. Ft) FoService up to 100 INCLUDING FQC'aterer ilk L rv�ilk &Cream $10.00 EA Q Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 ood Service up to 101 -200 $250.00 0 Food Service up to 201 + $300.00 El Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑Pushcart $50.00 If of Pushcarts: Length of Permit: Annual -- iU Seasonal Seasonal Dates: 0 Supermarkets $400 0 Residential Kitchen $100.00 Retail Food $125.00 Q Retail Snack Food $50.00 _ Q Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ..__....._ __.—....._.. Food Operations Definitions:PHF - Potentially Non-PHFs (Check all that epply): RTE-ready-to-eat hazardous food(timellemperature controls - non -potentially hazardous food(no time/temperature foods (Ex. sandwiches, salads, muffins which required) controls required) need no hatherpmcessing) a' Sale of Commercially Pre -Packaged Non-PHFs r, PHFCooked To Order [Mot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ---- 0 Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs ry 9 — -- --- ----- [Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑'] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Sale of Raw Animal Foods Intended to be Prepared by Consumer '° Customer Self -Service ' Reheatingof Commercial) Y Processed Foods for Service Within 4 Hours ustomer Self -Service of Non PHF and Non- Perishable Foods Only — reparation of Non-PHFs —-.._..__._.- Q Vacuum Packaging 1 Cook Chill _ .......__.._. Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ce Manufactured and Packaged for Retail Sale Other Food Operations lJ Juice Manufactured and Packaged for Retail Sale ❑j Offers Raw Or Undercooked Food Of Animal Origin ❑3 Prepares Food/Single Meals for Catered Events or Institutional Food Service Ei Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date - --.. or Reconditioned Food Tobe-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 105 CMR 590.000 and all other applic law. I have been instructed by the board of health on how to obtain copies of 10 R 90.0 0 an the fe Food e. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A,(Lce(y under the penalfiewofperjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. �Mc Signature of Individual or Corporate Name: Pec's �11 UT '' • Social Security Number or Federal ID: `71S „ 301 --1 aci 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 By: Corporate 'cer (Mandatory, if Applicable) °is - 3017ci aq "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 II Please Print Legibly Business/Organization Name: De GS �bVIA's . Address: LA S 040(n Sk Phone #: S-09- 339— "% 2 Are you an employer? Check the appropriate box: Business Type (required): 1. VI am a employer with 1.3 employees (full and/ 5. ❑ Retail or part-time).* 6. estaurantBar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. 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 .❑ 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 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 ant an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 1-tt+2�}ot2,-A -To&U&AVCe_ (21"UQ Insurer's Address: V • �d_ City/State/Zip: `?(Luo K�GVCi •� D�iC31 �J Policy # or Self -ins. Lic. # �� W G?C.��3 al (� Expiration Date: 1 1 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, unde p d pena pe ju that the information provided above is true and correct. Sienature: Date: -10 - 19 • ;toy? Phone #: sog , ca o . G R4 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 r11.. W, zDaoa nECSnONU ....... I-- "'-- n, CERTIFICATE LIABILITY INSURANCE DATE(MMmonyyY) 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 such endorsement(s). PRODUCER Starkweather &Shepley NAIIM ; C Kristin M. Stone. ACSR A cNNe EX 1:401 435-3600 FAX No): 401 431-9399 PO Box 549 noonless: kstone@starshep.com Providence, RI 02901-0549 INSURER(S) AFFORDING COVERAGE NAIC9 401 435.3600 INSURER A: Hartford Ins Group 19682 INSURED Decs Donuts, Inc. dba Dunkin Donuts 86 DA Washington Street Plainville, MA 02762 INSURER B: INSURERC: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 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. INER LTR rypE OF INSURANCE ADOLSUB INS O POLICYNUMBER POUCYE F MMNO POLICYEXP MMIDD UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE❑OCCUR ov PMESEpp�nc $ MED EXF (1my one person) $ PERSONALS ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS -COMPIOPAGG $ PRO- JECT LOC POLICY OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accident BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per aWdent) $ OWNED NLY SCHEAUTODULED AUTOSHIR D NON-0WNED AUT�S ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMSMADE DEO RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIEET7'ORIPARTNERIEXECUTIVEVIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA 02WECEK3218 7/0112018 071011201 Y PER OTH- E.LEACHACG[DENT $500000 E.L DISEASE - EA EMPLOYEE $500000 E.L. DISEASE -POLICY LIMIT $SOO OOO IFyes. tlesudbe under 13 SCRIPT ON OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonei Remarks Schedule. maybe attached 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ti. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD t/S1199550/M1199548 SCK I I E § § 2 ] \ ƒ \ ( § o 2 » ® / / / \ \ \ ) )� � ) 2 ƒ Z! � \\ % \ \>©» 22/2 % �(\/ ( \\}\ \ \ §\\> \ \ƒƒ} \ \ m