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HomeMy WebLinkAboutDec's Donuts (905 S. Main) - 12/31/2021306 0 � 1 -)35, = 1, FOR BOARD OF HEALTH USE ONL j Permit # Issued!' , FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening da Establishment Name Od.-- s �170✓�UTS .S i^C �%Uh�UN, Establishment Address q 6S Sflv"A ✓A^A r% Sk,2cr� wX0N'q reid WU4 . a26' - Establishment Mailing Address (if different) Establishment Telephone No ��$ �3q- 51800 Applicant Name & Title: O 2� A-VXD'L ^0e_ -D"r=6rc � Applicant Address t `4 � FA%2 W" 'De we_ Applicant Telephone No.: 5&C6,(,,j6_6i1StA 24 Hour Emergency No.: SUii' Applicant Email 6'0e a (AO —., Com Owner Name & Title (If different from applicant) l� Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. kA Corporation Name Title Address nn ff II'' �2c5 7( FAu2V([W (}uG KE�ObC�I AnIndividual Uet1 Y lr• Piecs. ;�1 FR,¢,OaN 47Q. W 1k(@.6Ck"C A Partnership kyas Tr Soc Lot cA� W 9-ekO64'44 13 Other legal Entity Person Directly Responsible For Daily (owner, person in charge, supervisor, manager etc.) Name & Title: A100eS lam' ee�ia-F4,0 - r ogv%"V-P ` Address: 13(v Qec[cje 8t� �auvClc ✓L'�' a1$(c[� Telephone No: 5bg , 3301 , 3$66) 24 Hour Emergency No: So$ • of V 3 o9�S $ FAX: -7 i`{ - (043 - le'3-'3 r E-mail: cAebe" e ►46-,. CCK,% Alt E-Mail: C4465 Q,p OSO 59 & Ktl1cG • CO'*" District Or Regional Supervisor (if applicable) Name &Title: C w21GS eaee,4v _DiSkeL�� 50,qe.G)j0SOvE_ Address: a beAla WOOCi -D✓(_• 2P-J'ro6� , wu4-. 6a-)69 Telephone No: 30$ _ a y 3 - ()gS6 24 Hour Emergency No: Sig- f 1 9 `914 FAX: 7 714- (oci3- io23S' E-mail: C4-04S 210jOcso S? 1440 YVl{!F IYU4 Food Establishment Information WATER SOURCE:-t-obJt1 SEWAGE DISPOSAL: rbf u, No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYSMOURS: Name of Person(s) In Charge Certified in Food Protection Managem nt: at0'0es cone, eiW Name of Person(s) In Charge Certified in Allergen Awareness Training AlctdeS conceie'a rvtw2a'4n� C�pPs ,M;clARe1 p�lvt�or,acc� (,aw�r2pr1 h.aM �+�rav� �eS�"• Name of pest control company routinely inspecting the premises for 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. El Yes tQA- ovc +— Does this establishment require a FOG permit? ✓ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual . [:] Retail Food $125.00 Mobile Food Consession l Temporary �ood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $176.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: E] Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: 0 Supermarkets $400 0 Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHF's - non -potentially hazardous food(no timeAemperature controls required) (Check all that pP Y): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) apply): [male of Commercially Pre -Packaged Non-PHFs I] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service of PHFs For Hot And 14� Sale of Commercially Pre -Packaged PHFs [V]?old Holding Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended Y to be Prepared by Consumer E] Use of Process Requiring A Variance Reheatingof Commercially Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand 'Customer Self -Service of Non PHF and Non- [}'Customer Self -Service contact alternative, time as a public health ,-,.�� Perishable Foods Only t� ice Manufactured and Packaged for control) [Preparation of Non-PHFs Retail Sale El Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale l 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 9000 and all o pplicable I3w. I have been instructed by the board of health on how to obtain copies 0 M 59 00 an a fed r oc ode. Signature of Applicant: e/ w ' Pursuant to MGL Ch.62C, sec. 49A, I certify under the p a ties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. IS' _ 36 rl %Q a Social Security Number or Federal ID: Signature of Individual or Corporate Name:-s 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 Of ' (Mandatory, if Applicable) -Is-3os-7gag **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\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc DECSDONLI Client#: 32396 ACORD CERTIFICATE OF LIABILITY INSURANCE 1 10107/2020 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 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 on KrsomeM1 Stone, ACSR Starkweather & Shepley P'IC No Ext:4U1 qaOvvV. E-MAIL kstone�Astarshep.co PO Box 649 ADORE a, Providence, RI 02901-0549 INSURERIS)AFF( 401 435-3600 _ INSURER A: Hadlord R e msuranco Dees Donuts, Inc. 86 D-1 Washington Street Plainville, MA 02762 )VERAGES ucl<r I;i n,r=,...,.,.11 1 :POLICY PEKIL)U THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TO THE INSURED NAMED ABOVE FORTH 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 RED CED B P CID Xp IMS. LIMITS A X COMMERCIAL GENERAL LIABILITY 102SBAKN9406 CLAIMS -MADE O OCCUR L AGGREGATE LIMIT APPLIES PER: PRO EJ - POLICY ❑ JECT LOC AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NONOWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAR H OCCUR EXCESS LIAR CLAIMS NIA 02WECEK3216 BODILY INJURY(P., Person) $ BODILY INJURY(Per accident) $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD iOl, Additional Raiment. 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 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 ACORD 26 (2016103) 1 of 1 #S1603370IM1603366 ©196K�8 8.2016 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD SCK The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DecS l�nu�s II S`1C Address: C(bS SOA,, YKAlY) SC ' City/State/Zip: `'U1pwsS & M4 Phone #: Ste' 339 Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail 1.RrI am a employer with %a- employees (full and/ or part-time).* 6. ©'Itestaurant/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. g, ❑ 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]* 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.l *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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is Ike policy information. Insurance Company Name: Insurer's Address: ?, O -jox 549 City/State/Zip: ?(ZfU1a� V,' olgy, Policy # or Self -ins. Lic. # oZW'L'c' K3l1LP 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, un�the pains and pen�es-j/�er that the information provided above is true and correct. so&• w i- q'i 84 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License - IS- aU16 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: �rGS T\C• 1�✓WS :y tt'' Address: cic>S '5C A\ yy\pelf\ -EA.✓V\s+c✓tSVeAd M4 , cSac>` 8 l5 Mailing Address: Cmg1v\ 3� V e4ls}'m M ad049 Phone/Fax Number: 5COR , W4 - YFOO — 779 - &4Sf9;`35 Email: Contact Person/Title for Grease Traps: C1Ck�0S — 5b$' ogS'8 Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: _ Please attach the following documents to this application: w,nd2iverz eAAU _0W'0 t,W 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 acknowledges t_* the information suited in these documents is true, accurate and complete. Date /a lr- 2oZeD 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): N1P' Seating Capacity (Actual Count): L Normal Hours of Food Preparation/Service: Monday qyv� - rv1 Thursday 5"IL1 Sunday SA110 • 1001M Tuesday '5AV.. ib e!!2 Friday SAW �V'VIA Wednesday 5Prm - (6a^1 Saturday 1 A-K-� —10 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 3 Handwashing sink Commercial Dishwasher Bar sink 1Q Mop Sink GRS 15 0�io✓I Garbage Disposal I Ice Making Machines ® ►N Vk4 S"o" Fryolators Grills or Ovens ( Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): tJO A+ISet 9 Ste —A �05�- S Is dinnerware pre -rinsed before being washed? Yes l�No If yes, at what station/sink? I•a 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 $ swN - 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 y 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: N11A Property Owner's Address: Property Owner's Telephone Number: / Yellow Grease Waste Do you store yellow grease waste from fryolators? N Where is the grease storage unit located? / How often is this grease storage unit emptied? Please list the vendor who removes the 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. 1"� 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. V11" 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: /O-/ --.7 Dab Applicant Name (please print clearly) LL N �6 L1. 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