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Home My WebLink AboutDunkin Donuts 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD ESTABLISHMNET 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, VICE PRESIDENT Whose place of business is: MANSFIELD DONUTS INC. dba DUNKIN DONUTS 45 CHAUNCY STREET PERSON(S) IN CHARGE KIM GREIGE, MANAGER Permit Expires: December 31, 2016 License Number: FS -38 Food Fee: $67.50 Milk & Cream W BOARD OF HEALTH MichaeC-McCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: EDWARD ANDRADE, VICE PRESIDENT having a place of business at: MANSFIELD DONUTS INC. dba DUNKIN DONUTS 45 CHAUNCY STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 1213112016 License No.: FS -38 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 Inspected: Approved By: Permit # Issued i Date received: P FS -38 I FOOD ESTABLISHMENT PERMIT APPLICATION -- -- - -- -- -- p icp anion must -b mim ed —tT --t-aVdays-bemire tt epanned opening dared -- - 1) Establishment Name MANSFIELD DONUTS INC. dba DUNKIN DONUTS -- -1 2) Establishment Address 45 CHAUNCY STREET ' -- 3) Establishment Mailing Address (if different) 45 CHAUNCY STREET r MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-6730 j 5) Applicant Name & Title: EDWARD ANDRADE, DIRECTOR 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA _ _ --- - 184 7) Applicant Telephone No.: (506) 612-9164 (401) 524-3634 24 Hour Emergency No.: (508) 612-9 8) Owners Name &Title EDWARD ANDRADE, VICE PRESIDENT - -- - 9) Owner Address (If different from applicant) 141 FAIRWAY DRIVE, ATTLEBORO, MA Owner's telephone number (508) 612-9184 (401) 524-3634 -_ - - - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers l El An Association or partner. W A Corporation Name Title AddressMW ❑ An Individual- a - 0,"4a. ❑ A Partnership -- B--_ ❑ Other legal Entity -- -' supervisor, 12) Person Directly Responsible For Daily Operations (owner, person In charge, p ervisor, manager etc.). Name &Title: Krhy'MANAGER Address: �� L11 �fiW - ' -- -------- 4 Hour Emergency - Telephone No: No: � I FAX: 1(508)316 -3482- - E -mail: DEBERCYC&_AOL.COM --- — - - Alt E -Mail: -- -- 13) District Or Regional Supervisor (if applicable) Name & Title: ]CARLOS RAPOSO, GENERAL MANAGER Address: 12 BELLA WOODS DRIVE, REHOBOTH, MA Telephone No. (508) 243-0958 24 Hour Emergency No: (508) 612-9184 - - -- - - E-mail. DEBERCY@AOL.COM CARLOS. RAPOSO@NATIONALDCP. NET FAX: 1 (774) 643-6235 - 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18 17) DAYS/HOURS: 7 DAYS PER WEEK 18) Name of Person In Charge Certified in Food Protection Management:e 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): El 20) Location: V Permanent Location i 22) Establishment Type ❑ Moblie Moblie Start Date: I Retail ( 1,850 Sq. Ft) Moblie End Date: 0 Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: V Annual ❑ Seasonal Seasonal Dates: C ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: I Rain Date: 23) Food Operations (Check all that apply): ❑ 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) I ❑ Caterer $12.50 V Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ ii Residential Kitchen $50.00 i ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non -PRFs ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only �❑ Preparation of Non-PHFs Other Food Operations W PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer V Customer Self -Service Ice Manufactured and Packaged for 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) ❑ Juice Manufactured and Packaged for' ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ] Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date I__ -- or Reconditioned Food To be completed by the Board of Health — — - I 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 ap licable law I have been instructed by the board of health on how to obtain copies of 1 C R90.9 0.0 and t#e era}F d e. 24) Signature of Applicant:77 " Pursuant to MGL Ch -62C, sec. 49A, I certify under the penalti of 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: 04-3220184 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. NAME OF BUSINESS: MANSFIELD DONUTS INC. dba DUNKIN DONUTS ADDRESS: 45 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-6730 FAX NUMBER: (508) 643-7997 OWNER OF BUSINESS: EDWARD ANDRADE, VICE PRESIDENT TELEPHONE OF OWNER: (508) 612-9184 (401) 524-3634 FEDERAL ID/SS NUMBER: 04-3220184 FEE: $5.00 PERMIT NUMBER: FS -38 8 ren. 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) By: Cor rate Officer (Mandatory, if applica le) ** Social Security Number (Voluntary) or Federal'ldentification 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 Business/Organization Name: < - - Address: City/State/Zip: Phone #: - ArFIan employer? Check the appropriate box: 1. am a employee 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 10.0 Manufacturing IL . ❑ 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#l. I am an employer that is providing workers' compensation insurance for my e _toes. Below is the policy information. Insurance Company Name: _ t Insurer's Address: C City/State/Zip: Policy # or Self -ins. Lic. # 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 Investieations of the DIA for insurance coverage verification. I do hereby certify, uncletheainand Phone #: that the information provided albo�ve is true and correct _. mate.. 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.goviaia Phone #: Client: 17413 MANSFDON -- DATE (MMronlvvvY) ACORD.CERTIFICATE OF LIABILITYINSURANCE 10/081201_5 THIS CERTIFICATE {S ISSUED AS A MATTER OF INFORMATI®W OWLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEWD, 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 INSURE®, thethe P011Cy(lils) nttlst 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 IleU of such endorsement(s), PRODUCER NAME Kristin M. Stone, ACSR —_- -- PNOtdE __-- [TAX 401431-9399 Starkweather & Shepley (AIG No, Ext) 401.435-3600_ tn�c, r o). ----— PO Dox 549 E MAIL kstone@starshep corn _ADtlREB8: ----- Providenc®, RI 02901-0549 INSURFRIs) AFFORDING COVERAGE 401435-3600 INsuRER A Selective Insurance 11867 INSURED Mansfield Donuts Inc. 45 Chauncy Street Mansfield, MA 02048 INSURER e I INSURER C: INSURER D INsuRERE: INSURER F 3OVERAGES CERTIFICATE WUMBER: 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, EXGL<JSIONS ANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ ---- -- — __ --- - r/O EFF POLICY EXP LI -_ MITS NSR TYPE OF INSURANCE - IN&13.IVYyP POLICY NUMBER YYY)DY___...._A X COMMERCIALGENERALLIABILITY 51965040 015 07/011201 EACH OCCURRENCE __ $1,000000 --_ _ ppppRR1gqGE77 RENTED S3OOt000 -_---�X) OCCUR pREF11SES�Ea occurrance� ._ CLAIMS -MADE ._ MED EXP (Any one person) GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT 49THER: LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED HEDULED AUTOSyPIED --TOS HIRED AUTOSTOS t UMBRELLA LIAROCCUR EXCESS LIAR CLAIMS_h COMP/OP AGG 5 BODILY INJURY (Por person) 1$ BODILY INJURY (Por accident) f S PROPGRTY DA A 0 $ Worarcidonl_ 5 EACH OCCURRENCE AGGREGATE — S A WORKERS COMPENSATION WC7955756 7/01/2015 7 ,—IRKTum AND EMPLOYERS Y / LIABILITY EACH ACCIDENT ANY PROPRIETOR/PARTNERIEXECUTIVE N N / A` — E.L OFFICER/MEMBER EXCLuUDED? N t EL DISEASE EA E_M_P_ (Mandatory In NH) I( es, descdba under 1 E.L. DISEASE- POLICY DESCRIPTION OF OPERATIONS below -'- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Locations: 45 Chauncy Street, Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE t ®1988.2014 ACORD CORPORATION, All rights resen/ed, ACORD 25 (2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #S7388031M738802 scat Lij (D W J LU m G P X 'N X u� y w a d O r— Ruj b N- a 0 m V i d V N 1 � O � � o Q � R Z O A � O F N :.z z X 'N X u� y w a LL a O O r— Ruj b N- a M W v LJ (M� z z 3 W W a I JLO q :x i. co O `# t � Cd � g U Q a 2 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 cavy 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 ial Accidents. Should you that the application for the permit or license is being requested, not the Department of Industr 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 burn 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