HomeMy WebLinkAboutDec's Donuts 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment',
Type: FOOD ESTABLISHMENT
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
EDWARD ANDRADE, DIRECTOR
Whose place of business is:
DECS DONUTS INC.
321 SCHOOL STREET
PERSON(S) IN CHARGE
SHAWN TAVARES, MANAGER
Permit Expires: December 31, 2016
License Number: FS -50
Food Fee: $62.50
Milk & Cream 0
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Sell Milk and Cream
This is to certify that:
EDWARD ANDRADE, DIRECTOR
having a place of business at:
DECS DONUTS INC.
321 SCHOOL STREET
in the Town of Mansfield has been granted a license to sell MILK and CREAM and
is subject to the Provisions of the Laws of the Commonwealth of Massachusetts,
relating to the terms and conditions, and to the rules and regulations established by
the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream
and shall remain in force until 1213112016 unless previous to that time is
suspended or revoked.
Expires 12/3112016
License No.: FS -50
Scott Leite, Heaah .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -50
FOOD ESTABLISHMENT PERMIT APPLICATION
— -- cation musT be subrnitte�30 aysefore-thee planned -opening ae ---
1) Establishment Name DECS DONUTS INC. j
2) Establishment Address 321 SCHOOL STREET
86 D-1 WASHINGTON STREET
PLAINVILLE, MA 02762
3) Establishment Mailing Address (if different)
4) Establishment Telephone No (774) 284-4064
5) Applicant Name & Title: EDWARD ANDRADE, DIRECTOR
6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703
7 Applicant Telephone No.: (508) 612-9184 24 Hour Emergency No.: (508) 226-8697
8) Owners Name & Title EDWARD ANDRADE, DIRECTOR
9) Owner Address (If different from applicant) 141 FAIRWAY DRIVE,
ATTLEBORO, MA 02703
Owner's telephone number (508) 612-9184
10) Establishment Owned By: 11 If a corporation or partnership,give name, title and home address of officers
❑ An Association or partner.
❑ A Corporation Name Title Address
❑ An Individual
El Partnership -- y -
-- --
❑ Other legal Entity- - _ -- - _
f
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)?
Name & Title: (SHAWN TAVARES, MANAGER
Address: 112 PROVIDENCE AVENUE, RIVERSIDE, RI 02915
Telephone No: (401) 241-2788 24 Hour Emergency No: (508) .226-8697
FAX: (774) 643-6235 - - -
E-mail: DEBERCY(DAOL.COM
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title. RLOS M. RAPOSO
Address: 2 BELLAWOODS DRIVE, REHOBOTH, MA 02769
Telephone No: (508) 243-0958 - 24 Hour Emergency No: (508) 243-4806
DEBERCY@AOL.COM
FAX: I (774) 643-6235 E-mail
Food Establishment Information
14) WATER SOURCE: TOWN I 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS:
16) No. of Food Employees: 18
18) Name of Person In Charge Certified in Food Protection Management: SHAWN TAVARES
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate DONALD E. ARMFIELD
19) Person Trained in Anti Choking Procedures (If 25 Seats or more):
20) Location: Permanent Location F9-2) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq Ft)
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
❑ Seasonal
Seasonal Dates:
Food Service up to 100 or
up to 10' PHF display $62.50
❑ Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
-- _ -- -- ---I ❑ Food Service - Institution
❑ Temporary
Temporary Start Date: ( Meals/Day)
Temporary End Date:
Temporary Time:
Rain Date: - --- -- _— _-
❑ Caterer $12.50
Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts: 0
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
23) Food Operation Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature 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 1 ❑ PHFCooked To Order
❑ Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
-- - - --
❑ Delivery of Packaged PHFs
Cold Holding For Single Meal Service
_ -
-- --- -- - -- - - - -- -
❑ Sale of Raw Animal Foods Intended
Reheating of Commercially
to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non-
Customer Self -Service
Perishable Foods Only
---- --- ---
Ice Manufactured and Packaged for
�/❑ Preparation of Non-PHFs
Retail Sale
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale I Animal Origin
-_ - j ❑ Prepares Food/Single Meals for
L]Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
To be completed by the Board of Health
I I
i
or Reconditioned Food Total Permit Fee: $62.50 I
Payment is due with application ❑ waived
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 CMR 590.000 and all other applicable I w. I have been instructed by the
board of health on how to obtain copies of 1 C R X90. and tloode.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the pen
and paid state taxes required under law.
25) Social Security Number or Federal ID: 75-3017929
26) Signature of Individual or Corporate Name:
of perjury that I, to my best knowledge and belief, have filed all state tax returns
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Milk and Cream Permit
I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year.
NAME OF BUSINESS: DECS DONUTS INC.
ADDRESS: 321 SCHOOL STREET
TELEPHONE AT LOCATION: (774) 284-4064
FAX NUMBER: (774) 643-6235
OWNER OF BUSINESS: EDWARD ANDRADE, DIRECTOR
TELEPHONE OF OWNER: (508) 612-9184
FEDERAL ID/SS NUMBER: 75-3017929
FEE: $5.00
PERMIT NUMBER: FS -50
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 (Mandatory)
By: COfporate Officer
(Mandatory, if applicable)
1
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
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
Business/Organization Name: -;
Address:
City/State/Zip: . Phone #:
Are you an employer? Check the appropriate box:
1. 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.]
Business Type (required):
5. [] Retail
6. estaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
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 #1.
I am an employer that is providing workers' cod insurance or my employees. Below is the policy information.
Insurance Company Name:,
Insurer's Address:
City/State/Zip: t`
Policy # or Self -ins. Lic. #, 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, under—th pains nd penalti steer' ry at the information provided above is true and correct
&a- (,, �-q( 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:
www,mass.gov/dia
Phone #:
Client#: 32396 DECSDONLI DATE (MMIDD11YYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCEL 1010812015
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._ —
W — —;---
IMPORTANT: if the i(tificat�1cIaer Wan ADDITIONAL INSURED, the p0110005) mtii�t— be endorsed. if SUBROGATION S WAIVED, subject to
the terms and conditions of the policy, certain, policies may require an endorsement, A statement on this certificate does not Confer rights to the
certificate holder In lieu of such endorsement(s). co"FAc Kristin M. Stone, ACSR---,-
PRODUCER NAfAE:--___
PHONE No, 401431-9399
Starkweather & Shepley 401435-3600
,(ATC No,
F-MAII-
PO Box 549 StOnO@�sta-rShep.COrn________
Providence, RI 02001-0549
GE AIC
11867
401435-3600 INSURER A: Selective Insurance
INSURED
Does Donuts, Inc.
868 Washington Street
Plainville, MA 02762
INSURER 9:
INSURER E:
rOVERACaES CERTIFICATE NUMBER: REVISION NUMBER.
HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NDICATED. NOTWITHSTANDING ANYCREQUIREMENTATERMIOR CONDO
ION OF 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 REDUCED BY PAID CLAIMS.
LIMITSY)
ADD SU®RY1 M
,!MY EFF
ff yy_
. ____ TYPE OF INSURANCE^ IN$1?WV4 - _„ POLICY NUMBER—
0710112015 0710112010 EACH OCCURRENCE- $1,90.0,00-0---------
X COMMERCIAL GENERAL LIABILITY S1985062
A "AIIA, E ENTED
�J%R 30
Psy pp�.
$ 0
CLAIMS -MADE I Xj OCCUR
Tfi
--1 MED EXP (Any one person) __ $ 10,000
---I I ------ - ---- - PERSONAL & ADV INJURY $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1101, Additional Remarks Schedule, may be attachod if more space 15 requIred)
RE. 4 5 Main Street, Mansfield, MA 02048
E
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
1988-2014 ACORD CORPORATION. All rights reserved,
ACORD 25 (2014/01) 1 of I The ACORD name and logo are registered marks of ACORD SCK
#S738840/MT38836
GENERAL AGGREGATE
J�
00PAL
GEN'L AGGREGATE LIMIT APPLIES PER:
PAGO
$3,000,000
[:] FRO-
POLICY ECT F—ILOC
$
_OTHER:
AUTOMOBILE LIABILITY
BODILY INJURY (Par parson)
S
ANY AUTO
ALL OWNED —'I SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS AUTOS
NON -OWNED
pNO'j1EHjt CIAMAGE-
$
HIRED AUTOS AUTOS
$
UMBRELLA LIAR
EXCESS
9 LIAB CLAIMS -MADE
�H 0 IiICU R R NCE
EACH
AGGREGATE--
!3FTrNTION$
WORKERS COMPENSATION
WC7955763
0
--]p7r
_R
---- 1, x
710112015
A
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PAYNr4R/EXECLfTiVE[-4]
L
OFFICERIMEMBEREX LUDED?
NIAJ
SMUTE
E,L. EACH ACCIDENT
------
E.L.DISEASE - EA EMPLOYEE
$500,000
$500,0.0.0---.—
(Mandatory In NH)
Ir ves, describe under
i E,L. DISEASE -POLICY LIMIT
$500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1101, Additional Remarks Schedule, may be attachod if more space 15 requIred)
RE. 4 5 Main Street, Mansfield, MA 02048
E
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
1988-2014 ACORD CORPORATION. All rights reserved,
ACORD 25 (2014/01) 1 of I The ACORD name and logo are registered marks of ACORD SCK
#S738840/MT38836
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Information and Instructions
Massachusetts General Laws -chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such -employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required,"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary), A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e, a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like. to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE
Fax # 617-727-7749
www.rnass.gov/dia
Form Revised 5-26-05