HomeMy WebLinkAboutDec's Donuts s.main 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.
905 SOUTH MAIN STREET
PERSON(S) IN CHARGE
ALEIDES CONCEICAO, MANAGER
Permit Expires: December 31, 2016
License Number: FS -72
Food Fee: $67.50
Milk & Cream V
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.
905 SOUTH MAIN 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 12131/2016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -72
Scott Leite, Heaah .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
i
Date received:
I
i
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By: Permit # Issued
FS -72
FOOD ESTABLISHMENT PERMIT APPLICATION
--(Applicafion—m—u—s-be submiffe�i-3U days -before the prannecTopening dafeJ
1) Establishment Name DECS DONUTS, INC.
2) Establishment Address 905 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 905 SOUTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-3800
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) 243-0958
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.
D A Corporation Name Title �( Address
❑ An Individual
_ _ f
p III
I ❑ A Partnership - -- - -- - - -7t_
- t .
❑ Other legal Entity
12 Person Direct) Res � -- -_-- -_- -- --- --_- ---- --- -- �
Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: , MANAGER L 6/ - -
Address: _. /
Thone No: � �-- �o��� .5� -
ele
p I(508) 339-3800 24 Hour Emergency No: (
FAX: (774) 643-6235
E-mail: DEBERCYP-AOL.COM CARLOS.RAPOSO@NATIONALDCP.NET
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title: ICAROS RAPOSO, GENERAL MANAGER
Address: 2 BELLA WOODS DRIVE REHOBOTH MA
Telephone No: ''(508) 243-0958 24 Hour Emergency No: (508) 612-9184
FAX: (774) 643-6235 E-mail:
DEBERCY@AOL.COM
14) WATER SOURCE:
TOWN
Food Establishment Information
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: 7 DAYS 5:00 AM - 12:00 AM
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 12
18) Name of Person In Charge Certified in Food Protection Management:
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
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
W Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
❑ Retail ( Sq. Ft)
® 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
❑ Food Service - Institution
( Meals/Day)
❑ 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:
❑ Residential Kitchen $50.00
❑ Retail Food $50.00 j
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - 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 ❑ PHFCooked To Order (❑ Hot PHF Cooked and Cooled or Hot Held
--- - --- -- } --- -- - { for More Than a Single Meal Service
❑ ry g Preparation of PHFs For Hot And
❑
Delivery of Packaged PHFs g Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Sale of Commercial) Pre -Packaged PHFs
1 9 9 ,
41-1 Sale of Raw Animal Foods Intended Susceptible Population Facility
❑ Reheating of Commercially I
to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
- -- - --- - - -- { ❑ Use of Process Requiring A Variance
0 Customer Self -Service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only -- contact alternative, time as a public health
Ice Manufactured and Packaged for
Preparation of Non-PHFs Retail SaleL control)
Other Food Operations
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of !
Retail Sale Animal Origin
j_--. -- ❑ Prepares Food/Single Meals for
Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service
❑ elSale of Salvage, Out -Of -Date
condit oned Food orRe( To be completed by the Board of Health
Total Permit Fee: $62.50
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'appi bJ�la I have been instructed by the
board of health on how to obtain copies of 105 C,M 90. d the,federal d dee,
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certi under the penaltie f perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 75-3017929
26) Signature of Individual or Corporate Name: 1 _
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 1 st of each year.
NAME OF BUSINESS: DECS DONUTS, INC.
ADDRESS: 905 SOUTH MAIN STREET
TELEPHONE AT LOCATION: (508) 339-3800
FAX NUMBER: (508) 339-8097
OWNER OF BUSINESS: EDWARD ANDRADE, DIRECTOR
TELEPHONE OF OWNER: (508) 612-9184
FEDERAL ID/SS NUMBER: 75-3017929
FEE: $5.00
PERMIT NUMBER: FS -72
SIGNATURE:
DATE:
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)
g
By: Corporate Officer
(Mandatory, if applicable)
** 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
Applicant Information Please Print Legibly
Business/Organization Name: 4 Yw
Address:
City/State/Zip:_ 's« Phone #: -339 3'860
Are you an employer? Check the appropriate box:
1. I am a employer with JJ�— 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, 19staurant/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 #I must also fill out the section below showing their workers' compensation policy information.
**]f 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 Name: le& %y e,"
Insurer's Address: 0.73-1c,)6
City/State/Zip: 4
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, ndd� the®pain�and penalttesro er ry that the information provided above is true and correct.
Phone #• v
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Contact Person: Phone #:
www.mass,gov/dia
Client#; 32396 DECSD®NU
ATE (MMIDlYY)
ACORD. CERTIFICATE LIABILITY INSURANCE 10
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 certtficate holder is an AAb®1710NAL INSURE® the policy(les) must be endorsed, If SUBROGATION IS WAIVE®, 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),
PRODUCER NA E" __ Kristin M Stone, ACSR
- -- — - --_--- FAX
PHONE 410`14311-9399 ---
Starkweather & Shepley (A1C, E Ext 401 4353600 — - (Arc, NoL--
PO Box 549 EMAIL SSf. kstonestarstle _.Com
AODRE.---l/� am -----_.p.—__—_
Providence, RI 02901-0549 INS URER(S)AFFORDINoCOVERAGE NAICO
_.._
401435-3600 INSURER A : Selective Insurance 11867
INSURED
Decs Donuts, Inc.
86B Washington Street
Plainville, MA 02762
OVERAGESCERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 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,
- - --- ---
TR AUDUSUBR -------_- ----' POLICY CFp POLI6YFOfP LIMITS
TYPE OF INSURANCE LNSR I U POLICY NUMBER M{ INDDIYY'yk MMIDDIYYYY) -
.-.--- __ _ - i
A COMMERCIALGENERALLIABILITY ` S1985062 7IO1/2015 O7/O1/ZO1 EACH OCCURRENCE 31000,000- _ --
��.,ryry GG 7(Aqn�
CLAIMS -MADE _�_ J OCCUR f�REMjSS iFa olCcui once) S300y0®® _ _ ,._--
MED EXP (Any one person) S10,000
PERSONAL & ADV INJURY S 1,000,OOQ
GEN'L AGGREGATE LIMIT APPLIES PER;
J POLICY F]JECTPRO-
0 LOC
AUTOMOBILE LIABILITY
_ ANY AUTO
ALL OWNED SCHEDULED
_. AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
UMBRELLALIAB
EXCESS LIAB [COLCACIUMR
S•MADE
S
4{7MIIINGD SIN6L1. I.It�lll
BODILY INJURY (Per person) l S
BODILY INJURY (Per accident) 3
PftQPCI TY f?AMAGF $
S
A- WORKERS COMPENSATION WC7955763 7/01/2015 07,10 1201 STATUTE.
AND EMPLOYERS LIABILITY
ANY PROPRII TQHIPARTNER/EXECUTIVE Y r N E.L. EACH ACC
01 rlr FIVIAEMnER EXCLUDED? ® N I A �-
-
(f+landalary In NHEL_DISEASE) -
If yes, describe under E.L. DISEASE -
DESCRIPTION OF OPERATIONS below ___� __ -. — _—_-.— —. -_------------
I
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DESCRIPTION OF OPERATIONS f LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace In required)
Locations: 905 South Main Street, Mansfield, MA 02048
4 South Main Street, Mansfield, MA 02048
Town of Mansfield
6 Park Row
Mansfield, MA 02048
S
$500,000
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 -
V tvBtf-zv-I4 AuuKu k#uKrvmtkiIVN, HN nBma imiu,vuu.
ACORD 25 (2014101) 1 of 1 The ACORD name and logo are reglstered marks of ACORD
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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. '"ere 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.mass,gov/dia
Form Revised 5-26-05