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Home My WebLink AboutDomino's Pizza 12/31/2018Commonwealth 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 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:. DUFFICY ENTERPRISES, INC. Whose place of business is: DOMINO'S PIZZA 235 CHAUNCY STREET PERSON(S) IN CHARGE: JUSTIN LEVESQUE Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-99 BOARD OF HEALTH MichaeCMcCCean, Chairman 101t_. FOR BOARD OF HEALTH USE ONLY Permit # Issued FS 99 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address DOMINO'S PIZZA 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 6) Applicant Address 7) Applicant Telephone No. 2 MILL STREET, FRANKLIN, MA 02038 8) Owners Name & Title 9) Owner Address (If different from applicant) —(Ti't—� 24 Hour Emergency No.: CHRIS (508) 631-1602 DUFFICY ENTERPRISES, INC. 2 MILL STREET, FRANKLIN, MA 02038 Owner's telephone number _ 5085201000 10) Establishment Ownec I-_ !An Association A Corporation An Individual LI A Partnership 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: Jw-�tn J� Address: 1235 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (508) 339-1000 24 Hour Emergency No: CHRIS (508) 631.1602 FAX: ( 2 S 5�q (. C 0_00 E-mail: IOFFICE(a)DUFFICY.NET Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title. ICHRIS COURTEMANCHE, VP OF OPERATIONS Address: 2 MILL STREET, FRANKLIN, MA 02038 Telephone No (508) 520-1000 C (508) Hour Emergency No: (�es}2ss zs�a f50s) 631 1602 FAX: (508) 541-1000 i E-mail: OFFICE@DUFFICY.NET Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 2 17) DAYS/HOURS: S-THURS. 10:30 AM - 1:00 AM FRIISAT 10:30 AM - 2:00 AM I 18) Name of Person In Charge Certified in Food Protection Management: E If more than 3 individuals are certified, complete list is on file. Ih �1St� UG' Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of JEFFREY DUFFICY certificate CHRISTOPHER C. COURTEMANCHE 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑JI Permanent Location 22) Establishment Type ❑ Caterer $25.00 ' Moblie Mobile Start Date: Retail ( 1 500 Sq. Ft) ❑ Milk & Cream $10,00 Mobile End Date: Mobile Comments: 21) Length of Permit: J Annual Seasonal Seasonal Dates: i iemporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: [] Food Service up to 100 or up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $1 %00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 " """ -_-- ❑ Food Service - Institution ( Meals/Day) ❑ Mobile Food & Consession $75.00 �-� Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 (_] Tobacco Products $25.00 23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Wi Sale of Commercially Pre -Packaged Non-PHFs IJI Sale of Commercially Pre Packaged PHFs IV] Delivery of Packaged PHFs i i Reheating of Commercially Processed Foods for Service Within 4 Hours IJI, Customer Self -Service of Non PHF and Non - Perishable Foods Only IV] Preparation of Non-PHFs Other Food Operations ,V 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 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 EI Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or H.ACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities 1 ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food I To be completed by the Board of Health -- ----- ----_- --__-- Total Permit Fee: $12500 i ..- Payment is due with application i 1 waived I, the undersigned, attes o the accur the information provided in this application and affirm that the food establishment operati will comply 5 CMR 590.000 and all other applicable law. I have been instructed by the board of health on h to obtain c e 05 CMR 590.000 and the federal Food Code. 24) Signature of Pursuant to MGL Ch.62C, se ./4d, I c rtify 46eithe �enallies of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes regwr under law. 25) Social Security Num r or Federal ID: 04-3062841 26) Signature of Individual or Corporate Name: a_w F C't1 erJQ-1 is CS . -TA6c- TAX CERTIFICATION FORM 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. �:DU GY bVT awc Signature of Individual or Corporate Name o % 1 "Social Security No. (Voluntary) or Federal Identification Number *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 delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. R:\Hn1th\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Z Congress Sheet, Suite 100 Boston, MA 02II4-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERAIITTING AUTHORITY. Applicant Information Please Print Legibly, Bus iness/Organization City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I 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.] Phone #: Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/BatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment Io,❑ Manufacturing I L ❑ 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 cxemptcd themselves, but the corporation has other employees, a workers' compensation policy is required and such en organization should cbeck box #I. I am an employer that is providing workers, compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State Policy # or Self -ins, Lic. # / ��lO fJ _� � L�"1 �� I Expiration Date: q 1--2y /1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure cqQ erage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.g0 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a Fine of up to $25gAQa�JaV against the violator. Be advised that a copy of this statement may be. forwarded to the Office of for insurance coverage verification. 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 Z. Building Department 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.man.govldia AcoRble CERTIFICATE OF LIABILITY INSURANCE �' DATA (MMNO YYYn 11109/2017 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 pollcy(les) must be endorsed. N SUBROGATION IS WANED, 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 a . PRODUCER INSURANCE MARKETING AGENCIES INC 306 MAIN ST WORCESTER MA 01608 WCTKatie P Foley 50e 471-1164 Na: LAppFass; kpf@imaagency.wm INSURERIS) AFFORDING COVEMGE NAICs INsuRERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED DU(afICY ENTERPRISES INC DBA DOMINOS PIZZA PO BOX 707 FRANKLIN MA 02038 INBUIIER B: INSURER C: INSURER D: E; :N. COVERAGES CERTIFICATE NUMBER: 211195 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 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. IN SR I TypE OFIN8UPANCE pOIACVNUMBER IM DY AMIVAK LIMITS COMMERCUU GIUERAL LUUIIUTY EACH OCCURRENCE S ClA1M9�MADE ❑OCCUR (E M EM19ES Ee cmemnce) $ MEDEXP ono 4 PERSONAL& ADV INJURY 1 N/A GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS•COMP/OPAGG S POLICY❑ jECT r LOC $ OTHER: AUTOMOBILEUMBILIIY CO11 MBINED I E IT $ BODILY INJURY (Par poem) 4 ANYAVTO BODILY INJURY (Par acddanl) S ALL OWNED SCHEDULED AUTOS AUTOS EO HIREDAUTOS AUTOS NIA PPROPERTY DAMAGE S S UM8RELLALU1 OCCUR EACH OCCURRENCE S AGGREGATE e EXCESS LUB CLAIM84AADE N/A DEB I IRETENTION$�/$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AN PRORPIId T EREXCTWDEU ECUTNE WA (MandatMIn Nl9 WA WA 7PJUB2E47409217 09/30/2017 09MO12016 X PSTE I E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE• EA EMPLOYEE 1 500,000 E.L. DISEASE• POLICY LIMIT $ 500,000 If yyeeae,, d.Wbe undm DESCRIPTION OF OPERATIONS bel- N/A DESCRIPTION OFOPERATIONS / LOCATIONS I VEHICLES (ACORD 101. AdtllSanal Rarnerlu eebaduu, maybe attached Nmen spas D raqulnd) Wodcers' Compensatlon benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was Issued (unless the expiration dale on the above policy precedes the Issue date of this certificate of insurance). The statue of [his Coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verificallon Search tool at www.mass.gov/Wdhvorkem-compensationMvesBgallons/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AITMORREDREPRESEWATNE 13 J C� Mansfield MA 02048 Daniel M.4rz y,CPCU, Vice President —Residual Market —WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserve ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Duo (W z I�1 z W z W z W W W d W W � jrv�V F r m W N -=i M .a 0 � z � o z o UJV) 8 0 v N W '^ tl NNa 4 $ri T4 tl � w �$ o * N