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HomeMy WebLinkAboutDec's Donuts (4 S. Main) - 12/31/20214.3 06 01 a - a �'j5" FOR BOARD OF HEALTH USE ONLY Permit # Issued ESTABLISHMENT PERMIT APPLICATION (AW�n must be submitted at least 30 days before the planned opening date) Establishment Name Dees 4ionurS -Xvc• (_-04jA1clh') Establishment Address -A 5ptk'n Vv\+Qty\ Sv• Vr'lW-sts, 0'ao Establishment Mailing Address (if different) (.>>P e'1 e- Establishment Telephone No Sob- 339- (va�°i Applicant Name & Title: eowr4eo "rJa4Ato'C- - l7� aCCA-ore-- Applicant Address l,lt (r^iezW" oa-ode A'Vlc�xao VK • Applicant Telephone No.: SvS, 411 , 611 94 24 Hour Emergency No.: 5613- 2?to- WWI Applicant Email &e6eaC�'f a Cc✓ % Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IN An Association partner. NK A Corporation Name Title Address ' ' 9'• Nts AVe An Individual Steve',, IA'id2AGe • 71 Frileyiew F-Jwq/Le( "at* V .P. I II r-Ai2wr9-y De-. P44"cow O A Partnership CkCi 4nd&Adp, 7&S. Let W . AeLICIC 13 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: az,b� Cb'n"P,.z`4 - ,n�w.,a�t✓L_ Address: a%ot l7tqIAA. `C aV✓Ct� 1 wt Wyss . p2T�U Telephone No: 50g , 33� ��q 24 Hour Emergency No: SG $ , 243 - oq S7g FAX: wit(- W43- E-mail: 600e" 0v ✓-FOB- - WWI Alt E-Mail: COAZACS 9_"q& 5;7 (3 Y41460. CowN District Or Regional Supervisor (if applicable) Name & Title:-A'eA65 Rwyosa - !7"S ` SuPe✓LdisCl— Address: bGt1b wacatS 2we veC dbwk . G27CoS Telephone No: svg, 2%43 - Oq 58 24 Hour Emergency No: S �jg . I FAX: -7-7y -E-mail:— G57 6i h'Lq. Food Establishment Information WATER SOURCE: -rbwy� SEWAGE DISPOSAL: .tow h No. of Food Employees: a, DEP Public Water Supply No: (If applicable) DAYS/HOURS: S Name of Person(s) In Charge Certified in Food Protection Manageme t: Q'C)oe" CAM 6-4-A- N,chbl.e� I<tAcJ Name of Person(s) In Charge Certified in Allergen Awareness Training Nr�tivle IC�`'� �h,A,ygtly, ��n_c6 (Lobe-LV CAY+%.4rZfc► r�I9-VP" A ft, MrAV Name of pest control company routinely inspecting the premises for evidence of pests a�'-O' 1""A 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. E Yes Nc)v oueyL Does this establishment require a FOG permit? ✓' If yes, please attach the FOG permit application. Length of Permit: Establishment Type: X?rnnual ❑ Retail Food $125.00 0 Mobile Food Consession Temporary [la -food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $2%00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: ilk & Cream $10,00 Caterer $35.00 Food Operations: Dentitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no tlme/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) }'Sale of Commercially Pre -Packaged Non-PHFs [7] PHFCooked To Order D Hot PHF Cooked and Cooled or Hot Held [0ale of Commercially Pre -Packaged PHFs [17 Vreparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended I] Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand [Customer Self -Service [Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only P Manufactured and Packaged for control) [L}IPreparation of Non-PHFs Retail Sale � Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 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 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 f,Mfi 590.000 and all ot)1er plica I�w. I have been instructed by the board of health on how to obtain copies of 5 R*90,P00 and a fed o ode. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penplk'ces of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: S 36 t -7 Q 1� Signature of Individual or Corporate Name:���— 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. -0e-cS 7_')Ghvt5 YAC Signature of Individual or Corporate Name -Is--30\-lg ag "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Offic Mandatory, if Applicable) *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 DECSDONU Client#: 32396 ACORD CERTIFICATE OF LIABILITY INSURANCE V1oio712020 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 policypes) must have ADDITIONAL INSURED provisions or be endorse 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 endomement(s). a ^co Starkweather & Shepley PO Box 549 Providence, RI 02901.0549 401 435-3600 HID No Eat :401 noopaEss: ketOf INSURER A: Hard INSURED Dees Donuts, Inc. 86 D-1 Washington Street Plainville, MA 02762 INSURER B INSURER C: INSURER D: INSURER E_ COVERAGES CERTIFICATE NUMBeK: ""------ OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD WHICH THIS THIS IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO HEREIN IS SUBJECT TO ALL THE TERMS, INDICATED. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED SHOWN MAY HAVE BY THE POLICIES DESCRIBED BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SUB POLICY EFF PO ICY EXP LIMITS ADDL ILTRR TYPE OFINSURANCE NS bViVm POLICY NUMBER 02SBAKN9406 MMIDD MM/DO 710112020 0710112021 EACHOCCURRENCE$1 OOO OOO A X COMMERCIAL GENERAL LIABILITY PREMISES La oNcurence $1 OOO OOO CLAIMS -MADE ❑X OCCUR MED EXP (Any one person) $10 000 PERSONAL &ADV INJURY $1,00D 000 GENERAL AGGREGATE $2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO PRODUCTS-COMP/OPAGG $2,000,000 POLICY ❑ JECT LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea amment BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) S OWNEO SCHEDULED AUTOS ONLY AUTOS NON -OWNED PROPERTY DAMAGE S Per accitlenl HIRED AUTOS ONLY AUTOS ONLY S EACH OCCURRENCE $ AGGREGATE S UMBRELLA LIAR OCCUR $ EXCESS LIAe CLAIMS -MADE DEO RETENTIONS WORKERS COMPENSATION 02WECEK3216 7/0112020 0710112021 X PER o A AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $500 000 E.L. DISEASE. EA EMPLOYEE $SOD OOO ANY PROPRIETOWPARTNERIEXECUTIVE OFFICERIMEMeER EXCLUDED? NIA E.L. DISEASE -POLICY LIMIT S500000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddItionai Remarks Schedule, may be attached if more epace la required) RE: 906 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, Mansfield, MA 02048 .......�„ arrnu 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 n 4QR11.2n15 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD SCK #S1603370IM1603366 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: !� -DOVIo -S ' x:0C - Address: �A Svtktl\ MAi✓1 54-- City/State/Zip: [M OA Sep A, 1M o4 . Phone #: Are yo an employer? Check the appropriate box: Are Business Type (required): 5. ❑ Retail L am a employer with 1 2.- employees (full and/ or part-time).* 6. ED-Ke—staurant/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. 8• ❑Non-profit 3.❑ [No workers' comp. insurance required] 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 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 Insurer's 6). IWY- City/State/Zip: 2ecut a _2x-- O?xiUk Policy # or Self -ins. Lie. # oaweCeK3a (U Expiration Date: % - ( - aGaA 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, tine r t e pains that the information provided above is true and correct. � 'A Phone # • SG8 • & I a` • 91,9Y Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License - / T. .20a6 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 Phone www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: 'Decs 'ajrw`ts rthC . Address: -1 SoA N4r(Ve �jc.ywgr s�tr-ili MA .0-X48 Mailing Address: SOUVA VAP1111 MAnSt,&C Aj OaOy'a Phone/Fax Number:, Email: C .VaGL.L L'GV1/1 Contact Person/Title for Grease Traps: c A2kbs - -'�U� • ay 3 - ©q S8 Name of Company scheduled to pump internal grease trap(s) monthly: lNtv%AekyeCrr- Ut✓!DInle-nW Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledge5,that the information submitted in these documents is true, accurate and complete. Date /U- /S'.20'16 Print Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): (Jl� Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday 5AM, 10 fr4 Thursday � . (b pM Sunday Pan - Ib ph 0 Tuesday 5Am- to QfA Friday 5AM - (G (1� Wednesday ] an-lbeo Saturday Spw.t -16 Pm Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink 11 Mop Sink j N 5404F2cv1 Garbage Disposal Ice Making Machines Fryolators Grills or Ovens 0 Exhaust Hoods 7 Floor drains Other: How are hood vents cleaned? (i.e., in three -?,./ 4" Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? bay sink, off site by private company): • •u Yes l,N0 ME 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 3 QV - Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes k," No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Nl A Property Owner's Address: / Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? ./ Please list the vendor who removes the waste: 3 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 violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. V� I have received a copy of the Plastic Waste 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 Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and 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, compostable 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. 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 with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. �/ I 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 < Date: Applicant Name (please print clearly) 01 \ tl #0656 6751 Boron Drive, Suite 220, Orlando, FL 32821 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES -. HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE ISSUE DATE: SEPTEMBER 30, 201 9 EXPIRATION DATE: SEPTEMBER 30, 2024 CERTIFICATE NO: 21629575 TEST FORM:EXES2 This cedificate is not valid for mare than five years from date of issue. it Drive, Suite 220, Orlando, FL 32821 1257 F. (407) 352-3603 mmNRFSP.com icglstry of Food Safety Professionals" ` NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES NICHOLE L KING HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE ISSUE DATE: FEBRUARY 22, 2019 EXPIRATION DATE: FEBRUARY 22, 2024 CERTIFICATE NO: 21 SS2656 TEST FORM: EZS43 nis tttlifioem is not valid to, noon Wen five Y. from dam of n, ve. / y Rb§$ � ( [�§ƒ$N w a ( � r [ f B a I I � / \ \ƒ\7 � 4! \ RR k ,�> \ \\}[ \ƒ/\ / �\\\ ƒ �q! } � �( [\( � • �§! ( / f 0 �mm d K � f3 N nPi F o Z m z m onq M=01 z F=0 z 0 Mn l + , u_ i / ( {76\ \ \$ƒa $\I \ »��; ±im( � \ � emu( ] ■)r \§({( ƒ m `G{ ƒ , f � � � � � �