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HomeMy WebLinkAboutDunkin Donuts 11/01/2016Commonwealth 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 SNACK 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:. ANITA SCHULTZ, PRESIDENT Whose place of business is: BIG FISH PROMOTIONS DBA DUNKIN DONUTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: FRAN KNIGHTS, GENERAL MANAGER Permit Expires: November 01, 2016 License Number: S-25 Food Fee: $100.00 BOARD OF HEALTH MichaeCylcCCean, Chairman FOR BOARD OF HEALTH USE ONLY i Date received: Date Inspected: Approved By: Permit # Issued i S-25 I� - FOOD ESTABLISHMENT PERMIT APPLICATION - (Application rnusf5b suUni ftedat-least 30 days before the planned opening date) 1) Establishment Name BIG FISH PROMOTIONS DBA DUNKIN DONUTS @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 80 COMMERCE STREET GLASTONBURY, CT 06033 i 4) Establishment Telephone No (860) 633-4400 5) Applicant Name & Title: ALICIA MARTINO, PROJECT MANAGER 6) Applicant Address 80 COMMERCE STREET, GLASTONBURY, CT 06033 7) Applicant Telephone No.: (660) 633.4400 24 Hour Emergency No.: (660) 969-1016 (sso) 633-4400 (aso) 922- i 9009 8) Owners Name & Title ANITA SCHULTZ, PRESIDENT I 1 9) Owner Address (If different from applicant) 80 COMMERCE STREET, GLASTONBURY, CT 06033 Owner's telephone number 8606334400 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association [or partner. ❑ A Corporation I Name Title Address V An Individual - ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) j Name &Title: �FRAN KNIGHTS, GENERAL MANAGER Address: I80 COMMERCE STREET, GLASTONBURY, CT 06033. Telephone No: (860) 633-4400 24 Hour Emergency No: (860) 989-1016 (860) 633-4400 (sso) 922- 9009 FAX: (860) 633-4482 E-mail: IFKNIGHTS(cD,BIGFISHPRONIOTION.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name &Title: ALICIA MARTINO, MAIN CONTACT Address: 80 COMMERCE STREET, GLASTONBURY, CT 06033 'Telephone No: (860) 633-4400 24 Hour Emergency No: (203) 379-8511 CELL FAX: (860) 633-4482 E I�lall: AMARTINO@BIGFISHPPOMOTION.COM Food Establishment Information 1 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees 5 17) DAYS/HOURS: BASED ON EVENTS, TIMING VARIES ! 18) Name of Person In Charge Certified in Food Protection Management: ALICIA P. MARTINO 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 JONATHAN CANARIO certificate AMY LYNN RENCZKOWSKI 19) Person Trained in Anti Choking Procedures (If 25 Seats or more): ❑ 20) Location ❑ Permanent Location 22) Establishment Type �❑ Caterer $12.50 Moblie Moblie Start Date: ^�lt�r� y )D V,, ❑Detail ( Sq. Ft) ❑ Milk & Cream $5.00 Moblie End Date: K)C v Food Service up to 100 or I❑ Mobiie Food & Consession $37.50 ! Moblie Comments: up to 10' PHF display $62.50 --- - - - - Manufacture Frozen Desserts/Ice Cream r] $12.50/freezer 21) Length of Permit: ❑ Food Service up to 101 -200 ❑ Annual or up to 25' PHF display $75.00 Pushcart Food Service u to 201 + E]Residential Kitchen O $50.00 ushcarts: Fp � Seasonal 1 ❑ ❑ or 25+ PHF display $137.50 ❑Retail Food $50.00 ! Seasonal Dates: MAY 1 - NOV 1, �(X rood Service - InstitutionI Retail Snack Food $12.50 ❑ Temporary --- Meals/Da 1 ❑ ( ❑ Temporary Start Date: y) j❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: ii Rain Date: j Definitions: PHF - Potentially hazardous food (time/temperature controls required) 23) Food Operations 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) jle of - Commercially - ck Non-PHFs for More Than a Single Meal Servi e ❑ Sale of Commercially Pre -Packaged PHFs [ j P eparat ondof PHFs For Hot And +To Order❑ Hot PHF Cooked an 9Cooled or Ho Held ----- - - --- -- - ----- --- - -- Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly EJ Delivery of Packaged PHFs--_-.----.---.--- - -----.------------- Susceptible Population Facility --- - - -- - --- -- ------ - [ I Sale of Raw Animal Foods Intended --_ ❑ Reheating of Commercially i to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _ I-- -- - A Varian e - - Use of Process Requiring ❑) Customer Self -Service of Non PHF and Non- r ❑ Customer Self -Service I and/or HACCP Plan (including bare, hand Perishable Foods Only- - contact alternative, time as a public health [_) Ice Manufactured and Packaged for 0 -/Preparation of Non PHFs 1 Retail Sale control) - - -- - - - --- - - - -- --- - — - Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin FOOD SERVICE -NON PROFIT SAMPLES❑Prepares Food/Single Meals for [) Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -: or Reconditioned Food To be completed by the Board of Health I Total Permit Fee: $100.00 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 law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant:l�llRt� 1� Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties 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: 06-1633731 26) Signature of Individual or Corporate Name:. 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. W\'Cs*�rYl- r * Signature of Individual or Corporate Name (Mandatory) 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. Genenal Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ,�- �,,�,\-\Cxy) `yi ocr( Address: &p 6,00)� r City/State/Zip: C.-7 U6g?3 Phone #:q W -- cn Are you an employer? Check11!� propriate box. 1. [�' 1 am a employer with employees (full and/ or part-time).* 2. ❑ 1 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.) & ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11. ❑ Health Care 12. Other \? M)Ql j( 7!!� *Any applicant that checks box # t must also fill out the section below showing their workers' compensation policy information. **lf 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 M. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: \ l %�N'ex!_ > C' ;7� 1 ` L ` M6 City/State/Zip; ,k_ ()17 0% /\ t`,.J q �� V VS Policy # or Self -ins. Lic. #�„1 ��� e�, L% �� "� 1 Expiration Date: 0 Attach a dopy of the worizerst;compenshtitin.pwiey declarration 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 02DER 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 DTA for insurance coverage verification. 1 do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Datw 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: Phone www.mass,gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 'Okqberty-Mutual. AR INFORMATION PAGEINSURANCE 175 Berkeley Street Boston, MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-6118:37-015 Issuing Office 0354 NEW BUSINESS NEW Issue Date 10-27-15 Account Number 1-611837 Sub Account 0000 1. Insured and Mailing Address BIG FISH PROMOTION'S LLC RISK ID 911833204 80 COMMERCE ST GLASTONBURY, CT 06033 Status 46 — LIMITED LIABILII,'VY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from i11-09-2015 to 11-09-2,016 12:01 A. M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CT NR B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The Limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: REFER TO RESIDUAL MARKET LIMITED OTHER STATES INSURANCE ENDORSEMENT WC 00 03 26A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 1,250 (CT ) Premium will be billed ANNUAL Producer 0004-178888 J P SVENDSEN AGENCY PO BOX 3975 WOODBRIDGE CT 06525-0975 Total Estimated Annual Premium $ 34,025 WC 00 00 01 A ©1987 National Council on Compensation Insurance,lnc. Ed. 07/01/2011 All Rights Reserved Insured Copy WC 00 00 01 B (CA) Page 1 of 1 aooa aea�j O J L) m CL E co C O O E O L a. U. m aoedg jajunoo anoge a6eaols ql!m slaupeo ossajosD /aannaa8 99:00 IoH mGJ9 aa}Jo:D 901 a� F a`) c � o Ws gsemPueH c E euiyoeW ao) U) c a M a) a) 0' sN3no x lauigeo a ca a� a� aooa aea�j O J L) m CL E co C O O E O L a. U. m P, June 30, 2016 Expiration Date TOWN OF GLASTONBURY 0 FOOD SERVICE LICENSE BIG FISH PROMOTIONS Is duly authorized to conduct a Food Service Operation in compliance with the requirements of the Public Health Code of the State of Connecticut. Anita. Schultz Owner/Operator License # F-93 C Director of Health Cb tb a1 M V4 W M m 40 W4 rl O ® z Z `U r qe u V ~ U. H a oe e g 0 w O w d U W-4 W v (4� z z W W r .;; Ve.?"t-;,. ; � �^�J.lt ;: ..,. s,:t. n.�:f"�: .r: "', ��i •��;' 1.: �.'�'�'a���{�1„ice "L: ,c y 4 n d' cT H M M O�0 000 N N a zt 1-7 v Q .;; Ve.?"t-;,. ; � �^�J.lt ;: ..,. s,:t. n.�:f"�: .r: "', ��i •��;' 1.: �.'�'�'a���{�1„ice "L: ,c y 4 n zt C R� i o "^. .;; Ve.?"t-;,. ; � �^�J.lt ;: ..,. s,:t. n.�:f"�: .r: "', ��i •��;' 1.: �.'�'�'a���{�1„ice "L: Big Fish Promotions, LLC 80 Commerce Street Glastonbury, CT 06033 PH 860-633-4400 FX 860-633-4482 Providence, RI May 3, 2016 To whom it may concern, Enclosed you will find an Application for a Food Establishment Permit Application for Dunkin' Donuts. Dunkin' Donuts will have a sampling truck set up at all of the concerts at the Xfinity Center again this summer. All the necessary paperwork and payment is enclosed. I will be the main contact if there are any issues and I can be reached by Phone at 860-633-4400 or cell after business hours at 203-379-8511, or by email at amartino@bigfishpromotion.com . If you have any questions please feel free to contact me. Thanks so much for your help and have a wonderful day! Sincerely, Alicia Martino Project Manager Big Fish Promotions 80 Commerce Street Glastonbury, CT 06033 (P) 860-633-4400 (F) 860-633-4482 amartino@bigfishpromotion.com www.bigfishpromotion.com we gel your brand into thelia K