The URL can be used to link to this page

Home My WebLink AboutDec's Donuts 905 S. Main 12/312018Commonwealth 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. 905 SOUTH MAIN STREET PERSON(S) IN CHARGE: ALEIDES CONCEICAO, MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-21 BOARD OF HEALTH .Mic aeCMcCCean, Chairman Milk & Cream W 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: EDWARD ANDRADE, DIRECTOR having a place of business at: DECS DONUTS, INC. 905 SOUTH MAIN 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-21 Board of Health -%1ichaeC9b1cCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit# Issued FS 21 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 905 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 905 SOUTH MAIN STREET I) 6Oa MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-3800 5) Applicant Name & Title: EDWARD ANDRADE, DIRECTOR 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703 7) Applicant Telephone No.: (508)612-9184 24 Hour Emergency No.: (401)663-7637 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 1 An Association or partner. I- l A Corporation Name \ Title Address ❑ An Individual 1 A Partnership 1 Other legal Entity ---- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ALEIDES CONCEICAO, MANAGER Address: 136 GEORGE STREET APT. #12, PAWTUCKET, R.I. 02860 Telephone No: FAX: E-mail: Alt E-Mail: 339-3800 643-6235 24 Hour Emergency No: (401) 663.7537 13) District Or Regional Supervisor (if applicable) Name & Title: IC RAPOSO, GENERAL MANAGER - _ I -- — - -- Address: 2 BELLA WOODS DRIVE, REHOBOTH, MA Telephone No: 1(508) 243-0958 24 Hour Emergency No: (508) 612-9184 •I. DEBERCY@AOL.COM FAX (774) 643-6235 14) WA I LK SUUKUL: Food Establishment Information 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: 7 DAYS 5:00 AM - 12:00 AM 18) Name of Person In Charge Certified in Food Protection Management: 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): FVI ►Jwr 20) Location: [] Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: ] Annual I Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 'VI 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 I-J Food Service up to 201 + or 25'+ PHF display $276.00 ❑ Food Service - Institution ( Meals/Day) ALCIDES CONCEICAO ❑ Caterer $25.00 Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer i Pushcart $26.00 # of Pushcarts: 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 timeAemperature controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) l 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 Preparation of Non-PHFs Other Food Operations ❑) 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 ] 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 L J PHF and RTE Foods Prepared For Highly Susceptible Population Facility / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin RTE PHF in Bulk Quantities I ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service i_. i Retail Sale of Salvage, Out -Of -Date --------- ----' or Reconditioned Food To be completed by the Board of Health I - - - ---- - — - - Total Permit Fee: $126.00 i_� 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 CM; 59 00 and all other applicable law. I have been instructed by the board of health on how to obtain copies, 105 C 590. OO�nd federal e/ 24) Signature of Applicant: [ -- Pursuant to MGL Ch.62C, sec. 49A, 1 certify under the p and paid state taxes required under law. 25) Social Security Number or Federal ID: 75-3017929 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit 1 hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: DECS DONUTS, INC. ADDRESS: 905 SOUTH MAIN STREET TELEPHONE AT LOCATION FAX NUMBER: OWNER OF BUSINESS: (508)339-3800 (508)339-8097 EDWARD ANDRADE, DIRECTOR TELEPHONE OF OWNER: (508) 612-9184 FEDERAL ID/SS NUMBER: 75-3017929 FEE: $10.00 PERMIT NUMBER: FS-21 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. It -DmuS _l. C_4 - K� Signature of Individual or Corporate Name By: Corporate Office andatory, if Applicable) -7& • 301 41q � **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:Q ealthllan&s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth of Massachusetts Department of IndusttialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information rr Please Print Legibly Business/Organization Name: Z)6CS Address: CIDS '::�'AA& V,1A;n si City/State/Zip: 00`1"a 1M W- Phone #: �' S 3q - 3gno Are you an employer? Check the appropriate box: Business Type (required): 1. [9 Iouam a employer with I employees (full and/ 5. ❑ Retail or part-time).* 6. Q•Ae`staurant/BarBating Establishment 2. E] 1 am a sole proprietor or partnership and have no ?• Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑Non-profit [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* l l ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. ❑ Other with no employees. Wo workers' comp. insurance req.] *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 #I. I am an employer that is providing workers' conT5,wation insurance for my emp�Kes. Below is the policy information. Insurance Company Insurer's Address: b• x � City/State/Zip: Policy # or Sehf-ins. Lic. # o1 WejCP_'/ ' . 3k I(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 may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify, und%�ains and penalties o erjury chat the information provided above is true and correct. J Official use only. Do not write in this area, to be completed by city or town offciak City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person www.mass.gov/dia Phone 3239C nersrinnu ACOR& CERTIFICATE LIABILITY INSURANCE10/11/2017 GATE IMMIODfiYYY) 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is en ADDITIONAL INSURED, the policy(les) must be endorsed, If SUBROGATION 15 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(s). PRODUCER Starkweather $Shepley PO Box 549 Providence, 111 02901.0549 401 435-3600 li PKristin M. Stone, ACSR AlicDylo E,I : 401 435.3600 _ Nc y,1: 40`1 431-9399 g2AAIL kstono@starshep'com INSURER(S) AFFORDING COVERAGE NAICS INSURER Hartford Ins Group A: 19682 _ INSURED DISCS DODUlS, Inc. 86 D-1 Washington Street Plainville, MA 02762 INSURERS: INSURER C: INSURER D: INSURER E: INSURER F I 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, a J INSR LTft --�— -- TYPE OF INSURANCE INgB p POLICY NUMBER POLICYy EFF MMIDUIYYY�)M., PdLLIppY EXP DOIYYYY OMITS A X COMMERCIAL GENERAL LIABILITY 02SBAKNO406 D710112017 071011201E EACHOCCURRENCE S1000000�—_ pp^�T�rpqq��ff''rr pENTED� PIiEM16E5 Eo oeeurranw)-,� $1 000,000 �ClA1M9-MADE ®OCCUR MEDEXP(Any,nammeon) $10,000 PERSONAL&ADV INJURY $1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE s2000,000 PRODUCTS-COMPIOPAGG $2,000,000 POLICY ❑ JECOT EXI LOG OTHER: —'-- AUTOMOBILE LIABILITY "--"—"' -- - CpMSINEO SINGLE DMIT IE ccin 11 $ �. $ BODILY INJURY (Per person) S _ ANY AUTO AUTOSNED AUTOSULED NONOWNED HIREDAUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTYDAMAGE PeracciHoee $ —.—.-.— UMBRELLA LIAR .00CUR EACH OCCURRENCE S _ AGGREGATE._.._ —_.— S EXCESS LIAR CLAIMS -MADE — RETENTIONS S A DEO _ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROpRIETORIPARTNEMEXECUTIVE YIN OFFICER/ MEMBER EXCLUDED? NI (Mandatary In NH) NIA 02WECEK3210 7/0112017 07/01/201 X PER r oT+ E.L. EACH ACCIDENT _. $500,000 E.L DISEASE -EA EMPLOYEE $500000 E.L DISEASE-POLICYLIMIT $500,000 IrVyS9RI'adba under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO IN, Additional Remarks Schedule, may be armored 11 more apace, In me Ubad) 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. 0 40RRdnd6 Croon riahta ranamad ACORD 25 (2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #510160351M1016034 SCK xd so n= da x -r Z m'm m N Cd o O m uni S X 3 • T. Z s D d o v� ' b �- O � � Z p N d C � pp w � o y iNn �C R 00 d � O 0. N N S 0 m c 3 N m x D 3 X 3 2 O / E 5}/ [ / \2K w 4 fzr / G a 2 § /' § I I w ¥ -� i 0