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HomeMy WebLinkAboutDunkin Donuts @ Stop & Shop 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:. WILLIAM DONOVAN & KEVIN DONOVAN Whose place of business is: DUNKIN DONUTS @ STOP & SHOP 377 CHAUNCY STREET PERSON(S) IN CHARGE: RICARDO ABRANTES & KEVIN DONOVAN Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-22 BOARD OF HEALTH wlichaefMcCCean, Chairman Milk & Cream O Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that. WILLIAM DONOVAN & KEVIN DONOVAN having a place of business at: DUNKIN DONUTS @ STOP & SHOP 377 CHAUNCY STREET 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-22 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred '1 FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-22 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the plannepe�nte}Kk V 1) Establishment Name DUNKIN DONUTS @ STOP & SHOP 2) Establishment Address 377 CHAUNCY STREET O' b/ rate• --- 3) Establishment Mailing Address (if different) DONOVAN SERVICES, Inc. 72 SHAl2PE STREET UNIT A-7, HINGHAM, MA 02043 4) Establishment Telephone No 5) Applicant Name & Title: WILLIAM DONOVAN & KEVIN DONOVAN 6) Applicant Address 72 SHARP STREET, UNIT A-7, HINGHAM, MA 02043 7) Applicant Telephone No.: (617) 528-1406 24 Hour Emergency No.: (Off) 628h405 (781) 223-0213 (KEVIN DONQ VAN 831iG-�cf)/L�J a 8) Owners Name & Title WILLIAM DONOVAN & KEVIN DONOVAN 9) Owner Address (If different from applicant) 72 SHARP STREET, UNIT A-7, HINGHAM, MA 02043 Owner's telephone number (781) 331-1599 10) Establishment Owned By:11) If a corporation or partnership give name, title, and home address of officers I _ i An Association or partner. 'A Corporation Name Title Address L_J An Individual 'A Partnership j 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: iJASCIIN&EEN & KEVIN DONOVAN Address: 172 SHARP STREET, UNIT A-7, HINGHAM, MA 02043 TelephoneCA o (619 5 781) 223-0213 FAX: E-mail: Alt E MaiL r - 13) District Or Regional Supervisor (if applicable) Name & Title. (SECOND Q LLC KEVIN DONOVAN I Address: 24 Hour Emergency No: 617) 5>?> "#59 (781) 223-0213 (KEVIN )ONOVAN 339_ y59- 83to RcLO Telephone No 24 Hour Emergency No (781) 223-0213 f � FAX: Email: - Food Establishment -Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 7 DAYS 6:00 AM 10:00 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 5 18) Name of Person In Charge Certified in Food Protection Management: JAG-eN4L.-GREEN �I Lfl If more than 3 individuals are certified, complete list is on file. Required as of 101112001 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): V /V 20) Location: [y] Permanent Location [. I Mobile Mobile Start Date: Moblie End Date: Mobile Comments: 21) Length of Permit: yl Annual Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) n 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 $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275,00 ❑ Food Service - Institution ( Meals/Day) c) /1 b r"_1 es ❑ Caterer $25.00 W Milk & Cream $10.00 I 1 Mobile Food & Consession $75.00 �] Manufacture Frozen Desserts/Ice Cream $25.00/1'reezer Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: Definitions. PHF - Potentially hazardous food (time/temperatum controls required) 23)Food Operations I Non-PHFs- non -potentially hazardous food(no time/temperature controls required) .Check all that apply): I RTE- ready -to -eat foods (Ex. sandwiches, salads, mums 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 ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only IdJ Preparation of Non-PHFs Other Food Operations PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held - - - ] Preparation of PHFs For Hot And 1 for More Than a Single Meal Service - __-_-_____-_ Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly J Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer [ ] Vacuum Packaging / Cook Chill ---------------------- Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) I- I 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 or Reconditioned Food To be completed by the Board of Health -_-- - _- _-- - - - - To Permit Fee: 4'125 0 � Payment is due with apphc tionJ waived I, the undersigned, attest to the accuracy of the information provided in t i application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all o 5Applicable law. I have been instructed by the board of health on how to obtain copies of 105 C R 5 .000 an effideral Food Code. 24) Signature of Applicant: ram/ 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: 04-3513535 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 December 31st of each year. NAME OF BUSINESS: DUNKIN DONUTS @ STOP & SHOP ADDRESS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: WILLIAM DONOVAN & KEVIN DONOVAN TELEPHONE OF OWNER: (781) 331-1599 FEDERAL IDISS NUMBER: 04-3613535 FEE: 0.00 PERMIT NUMBER: FS-22 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 "*Social Security No. ([voluntary) or Federal Identification Number 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 delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. RAHIthVane's DocumentSTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth ofAfassachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information --// Please Print LtgiblY Business/Organization Name; -i0ii%V/i ia �F2//2(/J/�Sl % �I ll J1 ���1� Areyouan employer? Check the appropriate box: 1. L,1 I am a employer with _ employees (full and/ or part-time).* 2.0 lain 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. LNo workers' comp, insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req j Phone#: /X/ —33/ — Business Type (required): 5. ❑Retail 6, estaurant/Bar/Eating Establishment 7. Q Office and/or Sales (inel. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing I I. El Health Care 12.❑ Other *Any applicant that checks box #1 most also filI 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 #1. lam an employer that is providing workers' compen ation insuran(�/ four my q em [o ees. B w is the ,[igcy information. Insurance Company Name: '/ YI C1790 0/ U U-- ,%( 15 Insurer's Address:rz("J /Vt [///ff x-c*-fY/fi,)C City/State/Zip: Z� a E& 94 -,- a// / T Policy # or Self -ins, Lie. #- uj� /;Ja oz �-6 O / Expiration Date: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify, under th pains and [ties ofperjury 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 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person W W W.IIIE 1,,. 11 WG Phone CERTIFICATE OF LIABILITY INSURANCE 110/24/ p (MM/ppIYYYY) 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 endorsermar ). PRODUCER Fred C. Church, Inc. 41 Wellman Street Lowell, MA 01851 (800)U2 1865 INSURED Donovan Services, Inc. DBA Dunkin Donut. 72 Sharp Street, Unit A-7 Hingham, MA02043 COVERAGES Mary Ann Horgan, CISR I `erinuas<• mhorgan®hedochumh.com I Insurance Company REVISION 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. INSR LTR TypE OFINSURANCE DDL SUBR POLICYNUMBER POLICY EFF MM/DO 'POLICY EXP MMIDD LIMITS GENERAL LIABILITY GENERAL LIABILITY CLAIMS -MADE F—IOCCUR EACH OCCURRENCE $ -DAMMCOMMERCIAL E I ETOe TIED 5 Ea occurrence) E MED EXP Anyoneperson) $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE POLICY LIMIT APPLIES PER: PRO' LOC JECT PRODUCTS -COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO AOSCHEDULED AUTOS AUTOS NON-OWHIRED AUTOS AUTOS NED COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ OII BODILY INJURY Per accident ( ) $ Par accident)AMAGE $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORJPARTNEWEXECUTIVE OFFICEWMEMBER EXCLUDED? (Mandatary In NH) U rs. describe under DE8 RIPTION OFOPERATIONS below N/A WCI00725601 8/1/2017 e/1/2016 X WC STATU- IT TRH - E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1.000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Location: 377 Chauncey Street, Mansfield, MA CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Client # 2 Met # 63202 CertHolder # 511 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD t I