HomeMy WebLinkAboutDomino's 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: RETAIL FOOD
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:.
DUFFICY ENTERPRISES, INC.
Whose place of business is:
DOMINO'S PIZZA
235 CHAUNCY STREET
PERSON(S) IN CHARGE.
ALLYSSA GOMES, GENERAL MANAGER
Permit Expires: December 31, 2016
License Number: RF -112
Food Fee: $50.00
BOARD OF HEALTH
MichaeC3WcCCean, Chairman
I FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
I
RF -112
FOOD ESTABLISHMENT PERMIT APPLICATION
7�p7ic_abon must be submi-feet at-7east 3Udays before the pinned opening date)
1) Establishment Name DOMINO'S PIZZA
2) Establishment Address 235 CHAUNCY STREET
3) Establishment Mailing Address (if different) 2 MILL STREET
FRANKLIN, MA 02038
4) Establishment Telephone No (508) 339-1000 �!
5) Applicant Name & Title: JEFFREY P. DUFFICY
I
6) Applicant Address 2 MILL STREET, FRANKLIN, MA 02038
7) Applicant Telephone No.. (508) 520-1000 24 Hour Emergency No.: (508) 531-1602
j 8) Owners Name & Title DUFFICY ENTERPRISES, INC.
9) Owner Address (If different from applicant) 2 MILL STREET, FRANKLIN, MA 02038
Owner's telephone number 5085201000
j 10) Establishment Owned By: ' 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
V A Corporation Name Title Address
❑ An Individual -- - -- - -- -
❑ A Partnership
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 1ALLYSSA GOMES, GENERAL MANAGER
- - -- - - --
Address: 235 CHAUNCY STREET, MANSFIELD, MA 02048
Telephone N!o: (508) 339-1000
24 Hour Emergency No: OE(508)631-1602
1 FAX: II(508) 541-1000
E-mailOFFICE@DUFFICY NET
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
-
Name & Title: �KERI SHUNSTROM, DISTRICT MANAGER
Address: !2 MILL STREET, FRANKLIN, MA 02038
Telephone No. (508) 520-1000 C(7441 -67-3-N-2 24 Hour Emergency No: (508) 269-7838 (508) 631-1602
E -mall: KERI@DUFFICY.NET CHRIS@DUFFICY.NET
FAX: (508);541-1000
0
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 1 16) No of Food Employees I
-
1 17) DAYS/HOURS: 11 AM -12 MIDNIGHT SUN-THURS 11 AM -2 AM FRI-SAT
j 18) Name of Person In Charge Certified in Food Protection Management: KERI SHUNSTROM
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
j certificate ALYSSA L. GOMES
9) Person Trained in Anti -Choking Procedures (If 25 Seats or more). ❑
❑ Caterer $12.50
20)io ❑tePermanent Location
22) Establishment Type
F-1Moblie Moblie Start Da
0 Retail ( 1,500 Sq. Ft) ;
F1Milk & Cream $5.00
Moblie End Date:
❑ Food Service up to 100 or
❑ Mobile Food & Consession $37.50
Moblie Comments:
up to 10' PHF display $62.50
!
❑ Food Service up to 101 -200
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
21) Length of Permit:
Annual
or up to 25' PHF display $75.00
❑ Pushcart $12.50 # of Pushcarts:
❑ Seasonal
❑ Food Service up to 201 +
❑ Residential Kitchen $50.00
or 25'+ PHF display $137.50
0 Retail Food $50.00
Seasonal Dates:
❑Food Service -Institution
1
❑Retail Snack Food $12.50
-- -
I F] Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $12.50
' Temporary End Date:
Temporary Time:
Rain Date:
)Definitions:
23 Food O erations
Potentiallycontrols U
Definitions:Non econtrols
II(Check all that apply):
potenfiallyha�ardtimeltemperature
hazardous food(no time/temperatu required)
PHFs
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
0 Sale of Commercially Pre -Packaged Non-PHFs
u PHFCooked To Order
- -- ---
! ❑ Preparation of PHFs For Hot And
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
_ _ - --- __- __ _ I
-- -- — --- ----E--
[� Sale of Commercially Pre -Packaged PHFs
--- --- --- - --- - -I
Cold Holding For Single Meal Service
I E]PHF and RTE Foods Prepared For Highly
0 Delivery of Packaged PHFs_—
- -- -- --- - --
-_- - -_-- ---- -
❑ Sale of Raw Animal Foods Intended
Susceptible Population Facility
❑ Reheating of Commercially
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
E] Use of Process Requiring A Variance
Customer Self -Service of Non PHF and Non-
Customer Self -Service
and/or HACCP Plan (including bare hand
Perishable Foods Only
- g
❑ Ice Manufactured and Packaged for
contact alternative, time as a public health
❑�/ Preparation of Non-PHFs
Retail Sale
control)
Other Food Operations
❑ Juice Manufactured and Packaged for
E]Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
I, the undersigned, attest to
establishment operation wi4i
board of health on how t_ of
24) Signature of Applicant:
Pursuant to MGL Ch.62C, se . 49A, Iicert
and paid state taxes require under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate N
-----------
Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
! _ Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date - -
- - - "---- - f -- -,
or Reconditioned Food To be completed by the Board of Health
Total Perm Fee: $50.00
Payment is due with application ❑ waived
f the information provided in this application and affirm that the food
)5 CMR 590.000 and all other applicable law. I have been instructed by the
105 CMR 590.000 fned the federal Food Code.
ill . - _ _ ,
perjury that I, to my best knowledge and belief, have filed all state tax returns
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 Indivi ual or
Corporate Name (Mandatory)
** 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: ,! � i C wa htfr
Address:
City/State/Zip: f YMOLOLMhone #:
Are you an employer? Check the appropriate box:
1. ❑ 1 am a omployer 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. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
IL F1 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' compensation insurance for my employees. Below is the policy information,
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins, Lic. # uB . L ems_ 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. and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $2 av against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investi ions of DIA for insurance coverage verification.
I dolkereby c j f finder the pains and penalties of perjury that the information provided above is true and correct
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#! 42094 DOMINI
ACORD. CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDD
10/09/2015
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE MARKETING AGENCIES
306 MAIN STREET
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Worcester, MA 01608
POLICY NUMBER
508 753-7233
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Dufficy Enterprises Inc DBA Dominos
PO Box 707
Franklin, MA 02038
INSURER A: Travelers Property Casualty Com 25658
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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 CONTRACT OR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
PDATE (EFFDONY1
POLICDDATE EMXPIDD TION
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILIT(
DAMAGE TO RENTED $
CLAIMS MADE F� OCCUR
0
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS -COMP/OPAGG $
POLICY jEa LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
BODILY INJURY
$
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
BODILY INJURY
$
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
OTHERTHAN EAACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR FICLAIMS MADE
AGGREGATE $
$
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION AND
7PJUB2E47409215
09/30/15
09/30/16
X TORY WC LIMIT ER
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $500,000
ANY PROPRIETORIPARTNER/EXECUTIVE
E.L. DISEASE - EA EMPLOYEE $500,000
O EXCLUDED?
yFFICER/MEMBER
USPdescribe under
ECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT $500000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Evidence of Insurance DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
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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
applicantwho 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. *'A here a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (Le. 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-MASSAFE
Fax # 617-727-7749
www.mass,gov/dia
Form Revised 5-26-05