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HomeMy WebLinkAboutDunkin Donuts (45 Chauncy) - 12/31/2021FOR BOARD OF HEALTH USE ONLYt�Permit# Issue FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned oprngs ate' try Establishment Name PhAvtS� G�� 17o+�v�5 Tv�G. C Dur`t�iNj` Establishment Address LA5 L'11r91Ma Cam/ gkrter r.�.anS�«1d �'`�' c�1o�4g?� Establishment Mailing Address (if different) Establishment Telephone No SOg- 337 -4730 Applicant Name & Title: E_OwPIV?-D Applicant Address %,Ak FAte--'U 7lLt.�� t4t�lelxvlo wt.4 • c��?03 Applicant Telephone No.: 45cS%C, t;k.. q %S 24 Hour Emergency No.: 5p13- Applicant Email del per" WbL-. COw. Owner Name & Title (If different from applicant)) (5w"e-) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 13 An Association partner. l A Corporation Name Title Address AvwR 7 I Fvt„�ule�a i4u� Q�r,p { An Individual Ste,� f j1A,?t( A•va6AkO V ,OAeS. 1q1 PAjtx 0rL, t4t.4 WXrj6 O A Partnership Pi16S ",ems -1- (Pa. Ch"e¢ ' wV. aetw x , Ed Other legal Entity Person Directly Responsible Daily Operations (owner, person in charge, supervisor, manager etc.) /For Name & Title: VifA lalZ�lg�'i jA6v\A04� 've_ Address: y4D :5 •e_oe^s: Ave-oAAv1Str��Uf-- ►MY4. O'io`48 Telephone No: 5-6g.33-7- (v_73® 24 Hour Emergency No: fig. ay3. CckSg FAX: -1'7 Ll - (0%[3 - (I P 3 S E-mail: 0, pyp`. c&VL^ Alt E-Mail: e,10W6bS KL4PC>SC.3'5% 6A -pNke i •Cohn District Or Regional Supervisor (if applicable) Name & Title: CA zlcS Q-br4e-V'b - p iS'�/�'c � 5 e&z ^Se'2- Address: 'a bG1llq t.AkS S DG, ✓ ma-55 • 02-7tv9 Telephone No: sob- 2--A 3 - O,1S8 24 Hour Emergency No: 5b8 • & t 1 • G 18,q FAX: -7.74- 443- 10x3S• E-mail: inn �� QJRpoSo S7 b 's/Ak d . COOn Wt0} Yrr. Food Establishment Information WATER SOURCE: TOW h SEWAGE DISPOSAL: �ow✓� No. of Food Employees: 15 DEP Public Water Supply No: (If applicable) DAYS/HOURS: $ `l0PVVN Name of Person(s) In Charge Certified in Food Protection Management: 14(e4ill M . C14,61e, Name of Person(s) In Charge Certified in Allergen Awareness Training Cw" IQ,AfOSr, )-l011� Uadd M41LIA De'?Ovt�e. G,W10 Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 pennnie or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. $J&t ove✓L bLS Se�S Does this establishment require a FOG permit? ✓ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [Annual Q Retail Food $125.00 F1 Mobile Food Consession lA Temporary My Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 0 Manufacture 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: 0 Supermarkets $400 Residential Kitchen $100.00 Rain Date: VMilk & Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF - Potentially hazardous food (tima4emperature controls required) Non-PHFs -non-potentially hazardous food(no time/temperature controls required) (Check all that pP y): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) apply): py sale of Commercially Pre -Packaged Non-PHFs B PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service dSale of Commercially Pre -Packaged PHFs [Preparation of PHFs For Hot And Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs 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 and/or HACCP Plan (including bare hand ,�,/ ,.-,/ � Customer Self -Service contact alternative, time as a public health Non PHF and Non- Ly Customer Self-ServiceFoods Onof control) Perishable Foods Only [�% Manufactured and Packaged for [!Preparation of Non-PHFs Retail Sale E Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging / Cook Chill E] Offers RTE PHF in Bulk Quantities EJ 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 CMR 590.000 anA-at h r applicable law. I have been instructed by the board of health on how to obtain cop' of405 90. band th fed FaI Food Code. Signature of Applicant: !/��/�—� Pursuant to MGL Ch.62C, sec. 49A, I certify unde penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. oLA ..3:0-0 f, la"4 Social Security Number or Federal ID: 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. Signature of Individual or Corporate Name By: Corporate Office andatory, if Applicable) **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 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le;iblY Business/Organization Name: YvV\4h& ( otnJC% Address: -kS Ck4u q City/State/Zip: MAV%SWA Wl►4 • Phone Are you an employer? Check the appropriate box: I. I am a employer with 15 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.] Business Type (required): 5. ❑ Retail 6. ❑4ire-staurantBarBating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I Ln Health Care 12.❑ Other *Any applicant that checks box #t 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 Address: O-t 5'1401 City/State/Zip: ✓L C�>1a>1 1C�'2-O Policy # or Self -ins. Lic. # pa W t' Gt✓1�3 =� Expiration 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#r4(ie pains and pe5ah1M%fperyry that the information provided above is true and correct. Sae- - &k94 Official use only. Do not write it: this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gowwu RRn NSrDONl Client#: 17413 """"-'—" DATE IMMIDDIYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 10107/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. have ADDITIONAL INSURED provisions or be endorsed. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must the terms and conditions of the policy, certain policies may require an endorsement A statement on If SUBROGATION IS WAIVED, subject to this certificate does not confer any rights to the certificate holder in lieu of such endomement(s). NAME: C Kristin M. Stone, ACSR PRODUCER Starkweather &Shepley al°c Na Set:401 436.3600 FAX 401 431-9399 PO Box 549 E-MAIL kstone@starshep.com Providence, RI 02901-0649 INSURER(S)AFFORnwocoVERAGE NAIL# 19682 401 435.3600 INSURERA: Hartford Fire Insurance Company INSURED INSURERS: INSURER C: Mansfield Donuts Inc. INSURER D: 86 D4 Washington Street INSURER E: Plainville, MA 02762 NSURER F: REVISION NUMBER: COVERAGES CERTIFICA I t NUMncrc: HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS INDICATED. CERTIFICATE EXCLUSIONS �TR A IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN. AND CONDITIONS OF SUCH ADDL TYPE OFINSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR OF INSURANCE THE POLICIES. SUB NSR SUB LISTED BELOW TERM OR CONDITION OF ANY CONTRACTOR INSURANCE AFFORDED BY THE LIMITS SHOWN MAY HAVE BEEN POLICY NUMBER 02SBAKN9406 OTHER DOCUMENT POLICIES DESCRIBED HEREIN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP IN DoMMIDD 710112020 0710112021 WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS, LIMITS EACH OCCURRENCE $1 OOO OOO DAMq�ETD gqENTED PREMISES Ea occurrence Si 000000 MED EXP (Any one person) $10 000 PERSONAL aADVINJURY S1,0000DD GENERAL AGGREGATE $2,000 0OO GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY ElJECT El LOC PRODUCTS-COMPIOPAGG $2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea awtle t S BODILY INJURY (Per person) S BODILY INJURY (Per accident)S ANY AUTO OWNED SCHEDULED AME,00NLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per.rddent S EACH OCCURRENCE S AGGREGATE S UMBRELLA LIAR OCCUR $ EXCESS IAB CLAIM&MADE OED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? A N I A 02WECEK3227 7101/2020 07101/2021 X PER OTH- E.L. EACH ACCIDENT SSOO OOO E.L. DISEASE -EA EMPLOYEE $BOO OOO E.L. DISEASE -POLICY LIMIT $500,000 (Mandatory In NH) Ees, desarpre under SCRIPTION OF OPERATIONS below _ ._. __ .- __.....,.....0 d it more space Is required) DESCRIPTION OF OPERATIONS 1 LOCATIONS I I ... — ... --- Locations: 45 Chauncy Street, Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 THE SHOULD EXP EXPIF THE RATION DATE ABOVE THEREOF, NOTICEIES BE OLLL CBE CELLED ORE DE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD SCK #516033311101603330 Town of Mansfield Health Department '�s Business/ Food Establishment Name: L L In" o """^ +-1S s: AOAUA 5� W►�Iv� 3� e�� Addres q� ��+�eti &� Mailing Address:— , Phone/Fax Number: 500S 33 �O, 34 0 7 � � 6ebeae (-a COV 19 e.. m MA. sv&. Iq3 -b9s-8 Contact Person/Title for crease I Idpb. I I — Name of Company scheduled to pump internal grease trap(s) monthly: exyeV 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) Fee Food Establishments 3 grease interceptors/traps or less and/or1 over 3 grease collection I $50 $50 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 at��rmationee documents is true, accurate and complete. and acknowledges Date /d /s Print Name �Tp w�i2b i3wb2�J � 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): NIP, Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday �/ An - Thursday �j pW�• ID Qnn Sunday per. - lour» Tuesday SAS ° 100rA Friday 0� Wednesday 1" Saturday f 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 f3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators 1 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): 1 Ah3e1 gYS�eM+ \uS�r S1ku rt3 Is dinnerware pre -rinsed before being washed? Yes V No If yes, at what station/sink? 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 j SItJ�� 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 Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? NI VA Where is the grease storage unit located? / How often is this grease storage unit emptied? Please list the vendor who removes the 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. VI 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: A� • IT, 2U20 Applicant Name (please print clearly EpWAd2-0 AtO lbe^O'e— .. . &q0- u oo-e- < „ mR„ ° § § cq ! k ;!& $ § $ £m0L/ @ ooze!, / m I� U \\�� \ w, < � \ j�} 2°� ue mz� 0 \ \ § ) § n(° mr:( o )� E© `� �� IL w J rz IL 0 w. � x CL \ b (n Cl w § \ 0 0 Z\ S } LL §m. z j \ ) ! ) f U � § (() \>\ \ <2 LO�� \\{ y y \ y §\g ..: . : I li O LO C) C\l C) C\l C) 73 Z ce) 00 cq CY) w 00 4-J ja en r,l, # � � ri (� z � z � � � � r� W4 z P4 � � � » r) t" � � � � � � � (W� z � z I � � � z �4 M ( ° \ >� \\\J \ \ \\ƒ\ \ \\\\ |