HomeMy WebLinkAboutHoney Dew Donuts12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
---- - --- --
Permit to Operate a Food Service Establishmen
Type: FOOD SERVICE 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:.
STEPHEN PROVAZZA, OWNER
Whose place of business is:
HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS
99 COPELAND DRIVE
PERSON(S) IN CHARGE
STEPHEN PROVAZZA
Permit Expires: December 31, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee: $67.50
License Number: FS -93
Milk & Cream W
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
STEPHEN PROVAZZA, OWNER
having a place of business at:
Town of Mansfield
6 Park Row
Mansfield, MA 02048
HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS
99 COPELAND DRIVE
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 12/31/2016
License No.: FS -93
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
I
-- FOOD ESTABLISHMENT PERMIT APPLICATION
- pp rca ion mus esu mi e a eas ays e o; e t e p anne open�rg are
Fstablishment Name D 8
EF-Jiblisinment Address
Establishment Mail*4
Address (if different)
`) Establishment Telephone No V J 0
5`1 Aprlica:rit Narne & Title: �G,�C
t:) AoPlic antAddress f��s� � � U-�- p�AoiJ�k, e -e— ►2 0Q-5;
" 7t licant Te,ephone No. , 24 Hour Emergency No.. G /
8 Oviners Name & Title
&,vner Address (if different from applicant)
Owner's telephone number d
s i :;blishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association or partner.
oruoration Nam%e® Title Address
-!� :ndividua, /r'S — -_
A P?rfnership Po
legal Entity - -
2` Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
J
Telephone i�lo: � __i 24 Hour Emergency No: � 77-... �> — 0
i`irstric:t Cir Regional supervisor (if applicable)
11.=rYIE� & Title.
1c, 0 qa P t, i) � e
el
-:AX:
�t
E-mail:
24 Hour Emergency No:
�clq
`k:` VVA I EF; SOURCE:
DEF Public Water Supply No: (If applicable)
Food Establishment Information
15) SEWAGE DISPOSAL:
16) No. of Food Employees:
l) DAYS/HOURS: lir Suit A��
and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for
Is) Name of Person In Charge Certified in Food Protection Management:
Retail Sale
I" more than 3 individuals are certified, complete list is on file.
Juice Manufactured and Packaged for
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
Retail Sale
c,a,lificate
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
1 Person Trained in Anti -Choking Procedures If 25 Seats or more): --
—
20) i ccation: [�manent Location
22) Establishment Type
To be cornpleted by the Board of HaalM
[—I Caterer $12.50
Mobli_e Moblie Start Date:
Retail ( Sq. Ft)
LVMilk & Cream $5.00
Mioblie End Date:
Food Service up to 100 or
❑ Mobile Food & Consession $37.50
fdoblie Comments:
up to 10' PHF display $62.50
h Manufacture Frozen Desserts/Ice Crearn
$12.50/freezer
2 1) Length of Kermit:
E] Food Service up to 101 -200
nuei
or up to 25' PHF display $75.00
[ Pushcart $12.50 9 of Pushcarts:
Seasonal
_ Food Service up to 201 +
! ;Residential Kitchen $50.00
or 25'+ PHF display $137.50
Retail Food $50.00
Seasonal Dates:
- --
El Food Service - Institution
u!, Retail Snack Food $12.50
_ eincora�y
-i en lora y Start Date:
( Meals/Day)
[ Tobacco Products $12.50
Temporary End Date:
Temporary Time:
_
I Rain Date:
23) Food Operations ( Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non-potenfially hazardous food(no time/temperature controls required)
C;-'eck all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Cr:stomer Self -Service of Non PHF and Non-
- Pe>isiiable Foods Only
P`paration of Non-PHFs
Otrer Food Operations
n PHFCooked To OrderL J Hot PHF Cooked and Cooled or Hot Held
-- - - for More Than a Single Meal Service
Preparation of PHFs For Hot And - --
Cold Holding For Single Meal Service [ PHF and RTE Foods Prepared For Highly
- — Susceptible Population Facility
Sale of Raw Animal Foods Intended -
to be Prepared by Consumer Vacuum Packaging / Cook Chill
Li Use of Process Requiring A Variance
L Customer Self -Service
and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for
contact alternative, time as a public health
Retail Sale
control)
Juice Manufactured and Packaged for
I [ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
-
or Reconditioned Food
To be cornpleted by the Board of HaalM
Total Permit Fee:
Payment is due with application waived
I, d -ie undersigned, attest to the accuracy of the inform provided in this application and affirm that the food
=stebiishmeit operation will comply with 105 CMRP560.00 0and all other applicable law. I have been instructed by the
board of health on how to obtairlfcopie$ of 105 GM9600 and the federal Food Code.
24', Signature of Applicant: (Z V _ —
PUrSrant to MGL Ch.62C, sec. 49A, I certify under then Ities of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
26) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
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.
I �SA� , l
NAME OF BUSINESS: fe0j �/"� rl�
ADDRESS:
TELEPHONE AT LOCATION:
FAX NUMBER: (� . vx
OWNER OF BUSINESS:
TELEPHONE OF OWNER: S�J�
FEDERAL ID/SS NUMBER: ( D -r' -Z v
FEE: $10.00
PERMIT NUMBER:
SIGNATURE:
DATE: 3 !r�
I certify under the penalties of perjury that 1, 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
-7F
*'*Social Security No. (Volitntanj) or Federal
Identification Number
<�s�
By: Corporate Officer (Mandatory, if Applicable)
*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
det-JILquency 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\sIeite\Desktop\Scott's DocumentsWood Establishments- Temp\TAX CERTIFICATION FORM -doe
f
The Comnronsvettltlr of Mrrsscrc7;~usei+ts
_ Department of Tndustr'ial Accidents
1 Congress Street, Sulte 100
Boston, MA 02114-2017
www.nrass.govIdia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTII€)RITv,
a e ro In o anon Please Print lie -M
Btlsiezessf®rganization Name:
A cid,•ess: �q F�( A E'sd t�- "4Gl e- '
Cit;, Stale/ZiP:
74 pil o dek" - 6,)'?O (, Phone #: Wil— �7(, 14.3 6
Art; you ,in employer? Check the appropriate box:
iI am a employer with ---------employees (full and/
or part-time).*
1 ani a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3, lyde are a corporation and its officers have exercised
their right of exemption per c, 152, §1(4), and we have
na employees. [No workers' comp. insurance required]*"
4. F1n1e 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
%, O€lice and/or Sales (incl, real estate, auto, etc.)
8. Ej Non-pi•ofit i
9. [I Entertainment
10,D Manufacturing I
i
t1,[] }Health Care
''Any applicant that checks box#1 must also fill out the section belowshowing their workers' compensation pokey information.
'ylf 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 li I.
�I am an employer that is providing workers' compensation insurance for my employees, Below is the policy inforrnadon,
Insurance Company Name:
Insurer's Address:
Cih//Mata/Gip: � 1 rlJf� M 6
vol icy # or Self -ins. Lia #1 00�y��7 L� 3 Expiration Date:
At a copy of the workers' compensation policy declaration page (sl`kowing the policy number and expiration date' >
Failure to secure coverage as required tinder Section 25A of Iv1GL c. 152 can lead to the imposition of criminal penalties of a
tine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORT; ORDER and a fine
of up to X250.00 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 rlo here v cCerdfyy, render t erns and penalties of perjury that the information providle�d above is true and correct.
"�'Lell!21L-PAdYnt-o e— V)P.tf"'
—6C(It-0
gffcizal rise only. Do not write in this area, to be compleied by city or town offrciell
City or Town:
Permit/License #
Issuing Authority (circle one):
Board of Health 2. Building Department 3. City/Town Clerk 4; LieerisinG Board S. Selectrrnen's Crffice
6, Other
Contact S'ea'son:
w%'nv.mass.govXaa
Phone #:
~® CERTIFICATE LIABILITY I
DATE(MMIDD/YYYY)
9/15/2016
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 pblicy(ies) must be endorsed. 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 rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Association Benefits Insurance Agency
299 Ballardvale St, Suite 1
Wilmington, MA 01887
CO ACT
NA E:
PHONE VAX No:
WC No Ext•
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: MA Retail Merchants WC Group Inc.
INSURED
INSURER 8:
INSURER C:
SPCAP Inc.
INSURER D
d/b/a Honey Dew Donuts
284 President Avenue
PERSONAL 8 ADV INJURY $
Providence, RI 02906
INSURER E:
INSURER F:
PRODUCTS - COMP/OP AGO $
i.w�nni+Ge PCOTICICATC M"MBPPI OUD13 KEV151UN NUMSCK: VVVV I
VV V Grtl1VLV
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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
— --- -
F INEXP
SURANCE
AMC
I
$ BR
POLICY NUMBER
MMIDDIYYI'F
M� Y YY
LIMITS
AUTHORIZED REPRESENTATIVE
rGENERAL
ENERAL LIABILITY
ADE 0 OCCUR
EACH OCCURRENCE $
PREMISES Ea urrence $
MED EXP (Any one person) $
PERSONAL 8 ADV INJURY $
GENERAL AGGREGATE $
GEML AGGREGATE LIMIT APPLIES PER:
POLICY PRO LOC
PRODUCTS - COMP/OP AGO $
$
AUTOMOBILE LIABILITY
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTO
HIRED AUTOS N p ED
C a acSlc deo NGLE LIMtT $
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
(Per accdder t
UMBRELLA LIAR
EXCESS LIAR
HOCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTIONS
$
AOFFICER/MEMBER
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY N
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN
EXCLUDED? ❑
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
014000501929116
1/01/2016
1/01/2017
X WCSTATU• OT -
O Y LIMIT ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEO $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
FI
CANCI ®TION
�.Crtlrrn.nrc nvi ucr�
— --- -
Town of Mansfield
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
6 Park Row
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Mansfirld, MA 02048
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORA I r0N. An ngn[s reserveu.
ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD
Jane Doucette
From: spro59@aol.com
Sent: Wednesday, September 14, 2016 7:00 PM
To: Jane Doucette
Subject: Re: Mansfield Honey Dew Donut Food Permit
Hi Jane,
I will get an insurance certificate for you, also the Rhode Island sery safe certificate is a multi state certificate.
The course is a two day course unlike MA that's just a one day class. The other managers in the store do have
certificates from MA. I can stop in anytime to drop off a check for the other permit and sign any documents you
need. Please let me know if you need any info on the RI food certificate.
Thank You
Stephen Provazza
Sent from my iPad
On Sep 14, 2016, at 5:02 PM, Jane Doucette <Jdoucette@mansfieldma.com> wrote:
Hi Stephen, I will need a workers' comp insurance certificate from you — do you have a sery-safe certificate from
Massachusetts? -when we charged you for the permit it was for a retail food permit but you needed a food service
permit — will need an additional $12.50.
Disclaimer
The information contained in this communication frorn the Town of Mansfield is confidential. it is intended solely for
rase by the recipient and others authorized to receive it. If you are not: the recipient, you are hereby notified that
any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly
prohibited and may be unlawful.
This email !)as been scanned for viruses and malware, and may have been automatically archived by Mimecast
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Name of Recipient- STEP— PROVAZZA
Certificate Number: 2141311
Date of Completion: 12"w"
Date of Expiration: 'x'-4'2121
is kere[Av iswed this cu2qirate
fo, rcunp(eung wi allrgin aware n ius
recognivdby A, DI-T—Vt efRiblic Hellftb-
inaivordance Trith 105 CAIR 590.009(G)06r).
T,is certffit-ate wiffbe (5)yewshrom dat—f—TIeti011
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Almuchustm Restaurant Assadaewn
333 Tamp R—d, Saiz 102
",udiborough, MA 01772
508-303-9%5
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RESTAURANT
ASSOCIATION
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10/13/2015
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Center Name Safety Program Consultants c(riC &A4688
TC PO Box 259 Rehoboth MA 02769
Info www.4spci.com 508-252-3049
Course
Location Pawtucket
Instructor Inst. ID #
Name Ken Marcotnaiano 09060168685
Holder's
O 2011 krm�j Hs�j Asso '- - T&-; va-sy win N5 card wd e—ft appearance. 90-1813
Ce:tter Name
Safety Program Consultants ci MAA4688
TC PO Box 259 Rehoboth MA 02769
Info vmwAspci.com 508-252-3049
Course
Lcccation Pawtucket — --
Instructor Inst. ID #
Name Ken Marcotngiano 09060168685
F+�s
90-1813 3/11