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Home My WebLink AboutDec's Donuts (333 School) - 12/31/2021i �' "— � R BOARD OF HEALTH USE ON Permit # Issued GC1 2 aFA® E ,jTABLISHMENT PERMIT APPLICATION (Applica6on t ust be submitted at least 30 days before the planned opening date) EkablisIn ame �2CS i�GV1V`C$ SVC, ( IDUAVAv1) Establishment Address 33-3 SCI+�I s 2�.1 W8. 19 $u1+c l0 Establishment Mailing Address (if different) VVI 01ts s . 0 -xo %-A a Establishment Telephone No Applicant Name & Title: C6WAPZ& A Avt,� Applicant Address 1641 epoew" —04-w' W'kAkeAx j ✓ oo, b3?63 Applicant Telephone No.: 5p-6. (ol a- .q 24 Hour Emergency No.: S�� 2alo g(o0} Applicant Email dejoe" (a, FFDL. CG✓L-\. Owner Name & Title (If different from applicant) Owner Address �J Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 9 An Association partner. u A Corporation Name Title Address ?we$. -71 FAt" i�Gl iG�+t 1 Ed An Individual Skeuei4 6(2 ew Kye M,^,g- f iikdd*&_ vows. lyl CA'" oz. 14webcwo APartnership C 6ag 4,id Gwde TkeSL't Cot C'JAmwl L" Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: ShAw^ �'4vta2eS Y�1A^�� Address: la I�PGJiCS�C�Ave,�wS� +��?1�viC1G'✓K'� F2 -� G�41S Telephone No: 1y _ a�.,11i _ y ploy 24 Hour Emergency No: SO$, ;L43 _ pq S'8 FAX: 7 �l io1 (o73T- E-mail: d p lOe2e� ( r,&L . C.vw1 Alt E-Mail: Cyg2\g 0S0 57 6 Akoo • CCw1 District Or Regional Supervisor (if applicable) Name & Title: C_A,-1.1e3 P�✓-1PG3G st-eit'k sLPeVevi sat Address: a bell4 vz4rA Decve_ VKIO-. 6,:)7(o9 Telephone No: 506 - 243 _ 24 Hour Emergency No: FAX: " 77L1 - (d-t3 - Cp;�L3S E-mail: Ca len "posco s7 y �_ COw, MA Food Establishment Information WATER SOURCE: I-Dwy\ SEWAGE DISPOSAL: No. of Food Employees: S DEP Public Water Supply No: (If applicable) DAYS/HOURS: Li AvVN _ 1� -1 S Name of Person(s) In Charge Certified in Food Protection Management: Shwtw,n Tt 0A"S �}tr�iskt,vA' 4<ehn�' Name of Person(s) In Charge Certified in Allergen Awareness Training IACKSC4N f I A 1,,\eWJ' gh�r 'rites se A- n V,CAo Name of pest control company routinely inspecting the premises for evidence of pests-auA4Jrr 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. El Yes "4 Cyum_ Does this establishment require a FOG permit? V'0� If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual E] Retail Food $125.00 Mobile Food Consession Temporary [QFood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 107 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 0 Residential Kitchen $100.00 Rain Date: . °. ilk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF-Potentially hazardous food(timeRemperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Neale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held Wale of Commercially Pre -Packaged PHFs Wreparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service l PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer E] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Wustomer Self -Service and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Eft Manufactured and Packaged for control) Retail Sale V-Kreparation of Non-PHFs [] 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 10,5.6(v1R 590.000 and alyotri'E'f ppli able law. I have been instructed by the board of health on how to obtain copiesp 105 M%p594e000 r(d the f er�ood Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the p7halties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. '7S- 301-761 o1q Social Security Number or Federal ID: 't'� Signature of Individual or Corporate Name: IJ4'�-' 0, 1, V� �N�' 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 Offic andatory, if Applicable) -7S-3b1"[0Al-q "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:\UseB\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc DECSDONU Client#:32396 ACORD CERTIFICATE OF LIABILITY INSURANCE I 10i0712020 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. DDITIONAL INSURED provisions or be endorse/ IMPORTANT: If the certificate holder is an AUDI DUPIAL uXorar. ".. Pam^-n.-- If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, ♦Hic certificate does not confer any rights to the certificate holder in lieu of such Starkweather & Shepley PO Box 549 Providence, RI 02901-0549 401 435-3600 INSURED Dees Donuts, Inc. 86 D4 Washington Street Plainville, MA 02762 must have A certain policies may require an endorsement A statement on Fire Insurance NUMBER: ES CERTIFICATE COVERAGES NUMBER: LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY P THIS THIS IS TO CERTIFY THAT THE POLICIES IS NOTWITHSTANDING ANY REQUIREMENT, OF INSURANCE TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INDICATED. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN POLICY EFF POLICY EXP LIMITS ADDL ILTR TYPE OF INSURANCE SUB NSR lWD POLICY NUMBER MMIDDrIYYY MMIDD 710112020 0710112021 EACH OCCURRENCE $1 000000 A X COMMERCIAL GENERAL LIABILITY 02SBAKN9406 P�VAISFES Eaoa un0ence S1 OOOOOO CLAIMS -MADE [XOCCURMEDEXP (Any On- Person) SiO000 PERSONAL& ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,OOO PRODUCTS •COMP/OPAGG S2000,000 GENL AGGREGATE LIMIT APPLIES PER: PRO- POLICY ❑ JECT LOC 5 OTHER: COMBINED SINGLE LIMIT Ea ecGtlenl AUTOMOBILE LIABILITY BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per accident) S GAMED SCHEDULED AUTOS ONLV AUTOS PROPERTY DAMAGE S Per accitlenl HIRED NON -OWNED AUTOS ONLY AUTOS ONLY S EACH OCCURRENCE S AGGREGATE $ UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE $ 02WECEK3216 7101/2020 07101/2021 X PER OTH• DED RETENTIONS COMPENSATION A WORKERS AND EMPLOYERS' LIABILITY YIN E.L EACH ACCIDENT 5500000 ANY PROPRIETORIPARTNERIEXECUTIVE NIA DISEASE -EA EMPLOYEE $600000 OFFICER/MEMBER EXCLUDED?IR E.L. (Mandatory In NH) E.L. DISEASE - POLICY LIMIT $500,oO0 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be anached It more space is requlretl) RE: 905 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, Mansfield, MA 02048 CANCELLATION CE TIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park ROW Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE 6 mAA_9ndA acnml CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD- SCK #S1603370IM1603366 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: TDe-CS LGvlu6s �hr Address: -15373S&100� S� -�>�d . 6 Suu l�� tic) City/State/Zip: VMAA$L "_I A&4 . Phone #: %7 1 - aSq - qWk4 Are y an employer? Check the appropriate box: I Business Type (required): 5. [_]Retail l.g am a employer with 1 employees (full and/ or part-time).* 6. �estaurantBar/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 30 [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 .❑ 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 p1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: ? . o . —,9GX G4 1 City/State/Zip: ?2GU i if (L -� G 2� b Policy # or Self -ins. Lie. # o116 Expiration Date: -7 - I 2odLl 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, underikeWains and penalt/�fR�rju lrat the information provided above is true and correct. Phone #: 'Gg � & I a , C) , N 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.gowdia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: DeC 3 POhJCS 1 hC ld 010 o';ko4a Mailing Add Phone/Fax Number:, Email: CjC�JPN.�1� �L co� Contact Person/Title for Grease Traps: Name of Company scheduled to pump internal grease trap(s) monthly: IlJlr Avayee kvwl4Om evtW 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 $50 container 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 acknowledgespart�e information suit YP these documents is true, accurate and complete. Date & I /.�-' ';�611?-o 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): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: M Aa Monday t4p^- ID pryvi Tuesday 14" ' (� jMh Wednesday -Ilbem Thursday pbm • i M Friday L4 ovyh ` 1b pm Saturday Am- joorm Sunday grvi - o rA -r 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 s/ 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal j Ice Making Machines Fryolators Grills or Ovens 'al Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 3y NorvA / No A6SeA SVOam Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes K—No �, le�s RCK 7 Grease Traps 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 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 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: N" Ulnni YYt'Ltrt��J Property Owner's Address: on hu2� nG � Wo�S l7I'^0jk `VV% Property Owner's Telephone Number: "1�'il-�1Q�-in�o'Z�% rna. D18d3 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: 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. �V"'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. V 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) 0Lk)A&b Ati Da440'e— OAF 0OD Notification of Test Results ID#: xxx-xx- Scaled Test Score: 88 Candidate Status: Pass Test Date: September 30, 2019 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONA SHAWN T HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. a Preventing Contamination and Cross Contamination (Competent) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls In a Food Establishment (Mastered) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Competent) Conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Competent) ISSUE DATE: SEPTEMBER 30, 2019 EXPIRATION DATE: SEPTEMBER 30, 2024 CERTIFICATE NO: 21629577 TEST FORM: EXE82 This ernifitale is not valid for more Iran five years fiom date of issue. National Registry of Food Safety Professionals CERTIFIED FOOD SAFETY MANAGER SHAWN-TAVARES. SHAWN TAVARES 12 PROVIDENCE AVE RIVERSIDE, RI 02915 F Ctrtifica[e W 21629577 Issue iJafC 9eptem6�30, 29[9 ` t Expiation Dam September 30,2024 National Registry of Food Safety Professionals® 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 I Phone: 407,352.3830 1 Fax: 407.352.3603 W V u CO O Y w 0 W V w W U Q) z 0-4 W W 7j. Tj O y Q tY Z O N as In � U a h d d �y� o N W 31 u y w O W U _w 1� W U V z 7� z � J W z w z W P4 W `I k� w z' z Z n m N U M m N in N ro � _, tam y,•� O z � � Q ti O ^y Q o m 3t3wya w �- C� y Q Q c3 Q iQ: � N %• ..�Q U y „ N O Q O