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Home My WebLink AboutDec's Donuts 333 School 12/31/2018Commonwealth 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 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:. EDWARD ANDRADE, DIRECTOR Whose place of business is: DECS DONUTS INC. 333 SCHOOL STREET PERSON(S) IN CHARGE: SHAWN TAVARES, MANAGER Permit Expires: December31, 2018 Food Fee: $125.00 License Number: FS-20 BOARD OF HEALTH MichaeCMcCean, Chairman Milk & Cream CLl Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: EDWARD ANDRADE, DIRECTOR having a place of business at: DECS DONUTS INC. 333 SCHOOL 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-20 Board of Health wlichaeINcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 7 FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-20 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name DECS DONUTS INC. 2) Establishment Address 30.FSCHOOL STREET 333 3) Establishment Mailing Address (if different) 86 D-1 WASHINGTON STREET 4) Establishment Telephone No PLAINVILLE, MA 02762 284-4064 5) Applicant Name & Title: EDWARD ANDRADE, DIRECTOR 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703 7) Applicant Telephone No.: (608( 612-9184 24 Hour Emergency No.: (508) 226.8697 8) Owners Name & Title EDWARD ANDRADE, DIRECTOR 9) Owner Address (If different from applicant) 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703 Owner's telephone number (508) 612-9184 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers L I An Association or partner. Corporation Name Title Address El AnIndividual i - [ 7 A Partnership Other legal Entity__ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: SHAWN TAVARES, MANAGER Address: III2 PROVIDENCE AVENUE, RIVERSIDE, RI 02915 Telephone No: (401) 241-2788 24 Hour Emergency No: (508) 226.8697 FAX: (774) 643 6235 E-mail: DEBERCYPAOL COM Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: ]CARLOS M. RAPOSO Address: 2 BELLAWOODS DRIVE, REHOBOTH, MA 02769 Telephone No: 'I(508) 243-0958 24 Hour Emergency No: (506) 243.4806 I FAX: i (774) 643-6235 I E-mail: DEBERCY@AOL.COM 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: ` 4 AM - MIDNIGHT Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18 18) Name of Person In Charge Certified in Food Protection Management: SHAWN TAVARES If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 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) 20) Location: ] Permanent Location 22) Establishment Type 1, Moblie Moblie Start Date: [ ] Retail ( Sq. Ft) Moblie End Date: ] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: ❑ Food Service up to 101 -200 IJ! Annual or up to 25' PHF display $150.00 _I Seasonal Seasonal Dates: _] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: J Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ] Caterer $25.00 Milk & Cream $10,00 ] 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 (..... minerature controls required) Non-PHFs - non -potentially hazardous food(no tlme4empereture controls required) (Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) _i.. [] Sale of Commercially Pre -Packaged Non-PHFs _] Sale of Commercially Pre -Packaged PHFs I Delivery of Packaged PHFs [I 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 ❑ PHFCooked To Order ] Preparation of PHFs For Hot And Cold Holding For Single Meal Service --� [-I Sale of Raw Animal Foods Intended to be Prepared by Consumer �(] Customer self -Service j] 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 L. Juice Manufactured and Packaged for ij Offers Raw Or Undercooked Food Of Retail Sale Animal Oricin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for I Catered Events or Institutional Food Service (i ] Retail Sale of Salvage Out-Of-Dat� "._ __ _.. or Reconditioned Food To be completed by the Board of Health — --_-- - — - _-- ""-" "- Total Permit Fee: $125.00 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�ME,2 590.000 and all oth apple law. I have been instructed by the board of health on how to obtain copies o'4 5 C R§90.9p0 aqd- a fe old Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 4914,4-1�6rtify under the pertalres 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: 75-30179291, r 26) Signature of Individual or Corporate Name: lv&sAli �tne 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 December 31st of each year. NAME OF BUSINESS: DECS DONUTS INC. ADDRESS: 321 SCHOOL STREET TELEPHONE AT LOCATION: (774) 284-4064 FAX NUMBER: (774) 643-6235 OWNER OF BUSINESS: EDWARD ANDRADE, DIRECTOR TELEPHONE OF OWNER: (508) 612-9184 FEDERAL ID/SS NUMBER: 75-3017929 FEE'. $10.00 PERMITNUMBER: FS-20 SIGNATURE: DATE: 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. Signature of Individual or Corporate Name By: Corporate Officer datory, if Applicable) -IS• got-?gA9 **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:\I-IealthVane's Documentsu°ERMIT APPLICATIONSUAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts q Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 rt www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Business/Organization Name: \)l'S T,)^J✓1__ uysC Address: 733-3 S City/State/Zip: Are you an employer? Check the appropriate box: I. �I am a employer with I R employees (full and/ or part-time).* 2.0 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#: %7H Z$1} - 46(og Business Type (required): 5. ❑Retail 6. &?-estaurant/Bar/EatingEstablishment 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other tAny 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 sm ' organization should check box #1. lam an employer that is providing workers' eontp`ensagon insurance for my employees. Below is the policy information. Insurance insurer's Address; �•o • l.�,Ox City/State/Zip; p2Uvi de3 P t Policy If or Self -ins. Lie. # D a.w eCey-3,) 1p Expiration Date: 7 • i ' aiO i rC 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 $1,500.00 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 Investigations of the DIA for insurance coverage verification. I do hereby certify e hnd pen hat the information provided above is true and correct. Signa ure (/ —s 9 Date' IO - So Phone #; �Gb'' • (p I a - / /�� 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 nFr-Rnown ACO U, CERTIFICATE F LIABILITY INSURANCE 909/2H112017 DATEI 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 ALTERTHE 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 heen4orsed, if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement On this certlticate does not center TYgtdS to the certificate holder In lieu of such endorsemantls). PRODUCER Starkweather 8 Shepley PO Box 549 o TacT KristinM Stone,_A_CSR - N E; iA�CC . E t):401 435.3600 we Nai: 401 431.9399 _ E-MAIL kstale starshom _ ppRE93• @ e p•C— Providence, RI 02901.0549 401 435.3600 INSURERS) AFFORDING COVERAGE NAIC# INSURER A; Hartford Ins Group 19682 INSURED Dees Donuts, Inc. 86 D-1 Washington Street Plainville, MA 02762 INSURER B: INBURER C : INSURER 0: _ INSURERS: INSURER F: COVERAGE25 NGRrrf Nll.Ic nvmvu,y _ - - 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. gEXCLUSIONS N R N TYPE OF INSURANCE Iffomis I - n. lum VUBR � POLICY NUMBER p MMIDOPTYW 7101)2017 (MMIDON"I; LIMITS 07/01]201 E_ACHOCCURqRENCE___ 51,000Q00_,_ A JX COMMERCIAL GENERAL LIABILITY CIAIMS-MADE J OCCUR 02SBAKN9406 Pi EEaNtwbntej,_$1000000 MEDEXP(Anyoneperann) _ PERSONAL& ADV INJURY _$to.000 _ 510000(10 -- GENERALAGGREGATE E2,000,OOO GERL AGGREGATE LIMIT APPLIES PER: POLICY ❑ JET I I LOC PRODUCTS-COMP/OP AGG EZ 000,000 S OTHER: AUTOMOBILE LIABILITY __ - — EOfineld,01) LIMIT BODILY INJURY (Porparaon) S _ ANYAUTO AUTOSNED SCHEDULED NON•OWNEO HIRED AUTOS AUTOS BODILY INJURY(POr •Olden) S PROPERTY DAMAOE� Per o_gciyel�U 8 _.._ S m _..__L -UMBRELLA LIAR EXCESS LIAB M OCCUR CIAIMS•MADE EACH OCCURRENCE S _ F. - S A DED RETENTIONS WORKERS COMPENSATION EMPLOYERS'LIABILRY A1�VPROPpIETOR/PART ERIExECUrIVE YIN ®E.L. In NH) Rye. daecdbaundar SUIPT1ONOFOPERATIONSbeIOW NIAOFFICEfUMEMBEREXCLUOEDT 02WECEK3216 710112017 071JAGGREGAT-E — XPER OTH•AND E.L. EACH ACCIDENT $500000 DISEASE -EA EMPLOYEE 5500 B(Mandatory E.L. DISEASE -POLICY LIMITDE - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 1W, AddrM.1121 Remark- Strad.%may be aHadhodll more ewtb%IOWMMS) RE: 905 South Main Street, Mansfield, MA 02048 4 South Main Street, Mansfield, MA 02048 321 School Street, BLDG B, Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED _. coon one, ee.nnn nnoOnb AYIIIAI All ein6lu reromed ACORD 26 (201,1101) 1 of 1 The ACORD name and logo are registered marks of ACORD SICK o 7