HomeMy WebLinkAboutDunkin Donuts in Stop & Shop - 12/31/2021#I6q - r�
FOR BOARD OF HEALTH USE ONLY., Permit#Issued
FOOD ESTABLISHMENT PERMIT APPLICATION ' ` ''
(Application must be submitted at least 30 days before the planned opening d e ` (
Establishment Name 'PWYI l��Ui1 a ) ✓I JI Q-PN sh*t �✓ �
Establishment Address 3?7 ett,lVv) Ot Cam'
Establishment Mailing Address (if different) -d OUOVyt�yvl.�(t �nC-
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Establishment Telephone No `7�I _ 33 1 ._
Applicant Name & Title: 1Vq nu r � 11
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Applicant Telephone No.: 791 33 1 - (" q 24 Hour Emergency No.:
Applicant Email VI01hCt�,h1CCI1nru�pdvr70(/dnllQ>GUG�(e.0'lAl
Owner Name &Title (If differentfr�o/ma/pnplicant) EV/Tn /GIIGI/G(�-
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Owner Address 7 f1/� J/ . Vt %1 !� 7 /l rl ,�� Atii, (l GL�
Owner telephone number W/ ,+_ 33 (— V�G/j
Owner email RUC-b . ry (J�OVQ�n.. (/ o1vm ? n e lbvak4 , (ym
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
1-1 An Association
partner.
11 A Corporation
Name Title Address
11 An Individual
A Partnership
I ther legal Entity
Person Directly ResponsibleForDaily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ccC//nl /t� rce �I /
Address: %J uil/i1-/ . I 7, ` 7 )IAk-( /"��
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Telephone No: j 111S - 7?-- J-,.�-(, 24 Hour Emergency No: 7,7q'J4.�-
FAX: ?k! _ 331 - /G q q
E-mail: rel'rl,Aek/;hr anOVannP�WGn (4&4
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Alt E-Mail:/JkApM,.'nj0g!rY/70 C�yYr/iy�Y1�7 W0/L�.
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: (��LL/
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees: 1J-'
DAYS/HOURS: 4 yyU _ le
Name of Person(s) In Chaige Certified in Food Protection Management:
C,,rliA
Name of Person(s) In Charge Certified in Allergen AwaYbness Training
tepremises for
Name of pest control company routinely inspecting evidence
of pests
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. ❑ YesiI
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Le th of Permit:
Establishment Type:
I.. Annual
❑ Retail Food $125.00
Mobile Food Consession
Q Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
1-1Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
❑Pushcart $50.00 # of Pushcarts:
Temporary Time:
S permarkets $400
❑Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
❑Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(timenemperature controls requires)
Non-PHFs- non-potenhally hazardous food(no 6me/lemperature 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
Q Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
Cold Holding For Single Meal Service
❑PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer
❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Customer Self-service of Non PHF and Non -
Perishable Foods Only ❑ Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
I] Vacuum Packaging / Cook Chill
Offers RTE PHF in Bulk Quantities
Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply with 105AA''CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain c4ies of IAA CMR 590.000 and the federal Food Code.
Signature of Applicanr. Y
Pursuant to MGL Ch.62C, sec. 49A, I eelity
and paid state taxes required under law.
Social Security Number or Federal ID: 17
Signature of Individual or Corporate Name: -
the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
._ 55/3s35
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.
Q, U aAn,�,
Signature of Individual or orporate Name By: Corporate Office andatory, if Applicable)
4*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:\Usen\sleile\Desktop\Scolrs Documenls\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:
Address: %J h fl C b 1Y. _ 1An l7 /t
Are on an employer? Check the rpropriate box:
1. 'urn I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #: M.— -331
Business Type (required):
5. ❑ Retail
6. EIRestaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I LE] Health Care
12.❑ Other
*Eery applicant that checks box # 1 trust 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
City/State/Zip:
Policy # or Self -ins, Lic. # O �rr0 D tl �9 / 6 Expiration Dater
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, der a pains and penalties of perjury that the information provided above is true and correct.
Signat1wrol �A Date:
Phone #:
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
Insurer ID No (s): 34356
MA Retail Merchants WC Group Inc.
PO Box 869222.9222
Braintree, MA 02186-0000
Information Page Reissue
Donovan Services Inc
Dunkin Donuts
72 Sharp Street, Unit A-7
Hingham, MA 02043
Second Q LLC
Workers Compensation and Employers Liability
Insurance Policy
Carrier Policy #: PolicyPerlod
014005034929120 01/01/2020to 01/01/2021
Eastern Insurance Group LLC
233 West central street
Natick, MA 01760
Dunkin Donuts
FEIN:
043513535
377 Chauncey Street
Effective Date:
01/01/2020
Mansfield, MA 02048
NAICS Code:
722513
Division #:
2
Mailing:
Workplace #:
0000000002
72 Sharp Street, Unit A-7
State Risk ID #:
000201843
Hingham, MA 02043
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TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by;the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
6
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin�film, single -use plastic check-out
bags to
customers.
i
I have received a copy of the Plastic Waste Reduction bylawi understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared foodand drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostabie
alternatives. Compostable materials must meet ASTM (American Society of the international Association
for Testing and Materials) Standards for compostability.
I have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines, i
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction withthe serving by business establishments or at any town -sponsored event of liquid,
slurry rozen, semi -frozen, or other forms of beverages to the public for consumption.
1 have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature "1(.l�Ft!.( �/ 1�ti Date: j 10 ,
/ 0
Applicant Name (please print clearly) nl .4 v-)P.A,'E �'�/-� i rr ✓}