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Home My WebLink AboutDec's Donuts 4 S. Main 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:. DECS DONUTS INC. Whose place of business is: DECS DONUTS INC dba DUNKIN DONUTS 4 SOUTH MAIN STREET PERSON(S) IN CHARGE: CARLOS RAPOSO SUPERVISOR Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-19 -•Gip • Michae[MCCtean, Chairman Milk & Cream [7 Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: DECS DONUTS INC. having a place of business at DECS DONUTS INC dba DUNKIN DONUTS 4 SOUTH MAIN 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-19 Board of Health MichaeCMcCCean, 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 FSFS19 I I L� FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name DECS DONUTS INC dba DUNKIN DONUTS 2) Establishment Address 4 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 5) Applicant Name & Title: EDWARD ANDRADE 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703 86 D-1 WASHINGTON STREET PLAINVILLE, MA 02762 7) Applicant Telephone No.: (508) 612-9184 8) Owners Name & Title 9) Owner Address (If different from applicant) 339-6229 24 Hour Emergency No.: (508) 612-9184 DECS DONUTS INC. 86 D-1 WASHINGTON STREET, PLAINVILLE, MA 02762 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 :An Association or partner. A Corporation Name Title Address 1 An Individual _] A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ICARLOS RAPOSO SUPERVISOR Address: I2 BELLA WOODS DRIVE, REHOBOTH, MA Telephone No: 1(508) 243-0958 FAX: 1(508) 643-7997 E-mail: DEBERCYAOL.COM -- Alt E-Mail: 13) District Or Regional Supervisor (if applicable) 24 Hour Emergency No: (509) 612-9184 Name & Title. n - - bo�D ►gem-�G - -- - - Address: i p 162 'ART.CTRC Ci' TAI NTON, MIA T._ o;2 NaGD� S -07rZ6, 40, MR� Q,1 70 3 - Telephone No: 1(508) 339-6229 24 Hour Emergency No: ( 7711—.2 l FAX: I (774) 643-6235 E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No of Food Employees: 12 17) DAYS/HOURS: 7 DAYS 5 AM - 12 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): [' i 20) Location: [] Permanent Location ' Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: v'I Annual [I Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type Li Retail ( 600 Sq. Ft) [f 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) 15 FELICIDADE REGO ❑ Caterer $25,00 [J Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream [- I $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100,00 ❑ Retail Food $100,00 ❑ Retail Snack Food $25.00 [ J Tobacco Products $25.00 23) Food Operations j Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) Check all that apply): RTE - ready -to -eat roods (Ex. sandwiches, salads, muffins which need no further processing) [J'i Sale of Commercially Pre -Packaged Non PHFs [VI PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -.- -_ --- -- - [ ] Sale of Commercially Pre -Packaged PHFs -� --- - -- - [J[ Preparation of PHFs For Hot And for More Than a Single Meal Service — -- -- Cold Holding For Single Meal Service [ PHF and RTE Foods Prepared For Highly [� Delivery of Packaged PHFs - - -- --- .-.-- — ---- - - ❑ Sale of Raw Animal Foods Intended .i Susceptible Population Facility ] Reheating of Commercially- to be Prepared by Consumer Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours --.---- ---------------- ------- --------- ❑ Use of Process Requiring A Variance [I Customer Self -Service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only ❑Ice Manufactured and Packaged for contact alternative, time as a public health [__IPreparationofNon-PHFs ___j -, "Retail Sale control) _ Other Food Operations i._] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities J ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date i or Reconditioned Food 1 To be completed by the Board of Health --_--- ----- "-- ----- Total Permit Fee: $125.00 Payment is due with application L ) waived 1, 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 0 and all other applicaI been instructed by the board of health on how to obtain copies of 105 C 90. 00 aPd tye fe Ie ood C e. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties o jury 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: 75-3017929 `\ L _ 26) Signature of Individual or Corporate Name: zoees Ky Town of Mansfield Town of'Maneiield - 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 31 st of each year. NAME OF BUSINESS: DECS DONUTS INC dba DUNKIN DONUTS ADDRESS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6229 FAX NUMBER: OWNER OF BUSINESS: (774)643-6235 DECS DONUTS INC. TELEPHONE OF OWNER: (508) 612-9184 FEDERAL ID/SS NUMBER: 75-3017929 FEE: $10.00 PERMIT NUMBER: FS-19 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 Office andatory, if Applicable) `7�- 3OI�i aq "*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:\FIealthVan&s DocmnentsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 021I4-20I7 r www.mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: �cS-bvt��sA Address: ( ,s-'�1 ✓Ltt�Fcyl �T City/State/Zip: VIAYAA&� . Phone#: SGq- ag Are you an employer? Check the appropriate box: Business Type (required): I. am a employer with 1 a employees (full and/ 5. ❑ Retail or part-time).* 6, estaurant/BarBating Establishment 2.0 1 am a sole proprietor or partnership and have no 7, Q Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. S. ❑ 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]* 11.❑ Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box tit most 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 41. I am an employer that is providing workers, compensation insurance for my employees. Belot the policy information. Insurance Company Insurer's Address: ,C) • -9cY Sq'` City/State/Zip: Policy # or Self -ins. Lie. # oaw�Cek 3a.1(p Expiration Date: 72 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, uncle e pa_ s aannad peennalKes of th information provided above is true and correct. Signature: '�`^✓` Date: ID •,�G ' iDl7 Phone.#•� ��a"' 9/" 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.uiuna,�cwu�a nFr-Snnwu unanum sxoao -------- ACORD,- CERTIFICATE OF LIABILITY INSURANCE Dnra(MMIoolrvrv) 10/11/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R1GH'IS llPONTHECERTIFIGATE 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), AUTHORI2ED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER - IMPORTANT. If the Certificate holder it, an ADDITIONAL INSURED, the policyiles) mustbe endorsed, If SUBROGATION IS WANED, ADINIs to0 t the terms and conditions of the policy, Certain policies may require an endorsement. A statement on this cerUOcate does not copier rightthe certificate holder in lieu of such endorsement(s), PRODUCER Starkweather &Shepley PO Box 549 TEAcr Kristin M. Stone, ACSR - _ p: �A"ic01}IE Bell: 401 436-3600 (AID Ne): 401 43.1-9399 nou"IEas: kstone@starshep.com _ Providence, RI 02901-0549 401 435.3600 INSURERS) AFFORDING COVERAGE NAICIt INSURER A: Hartford Ins Group 19682 _ INSURED Decs Donuts, Inc. 86D-1 Washington Street Plainville, MA 02762 INSURERS: INSURERC: INSURER D1 - INSURER Ej,_ — INSURER F: oeulelnM Ai11MRFR• _ COVERAGES UCKIIrRJHIC Iauanacn: LISTED BELOW HAVE BEEN ISSUED TOTHE ------ INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. CERTIFICATE NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, THE TERM INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TD ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY. PAID CLAIMS. LNSR a Type OF INSURANCE POLIO Y NUMBER POLICY Ell MM/OOIVYVYj 7/0112017 PO Doy yyl . (MMIDDIVYYV 07/011201 LIMRS A X COMMERCIALGENERAL LIABILITY 02SBAKN940O EACH OECTCURRENCE $1 001)000 PREMISES La aOineitca-).,� S9 000 000 �j I� X MEO E%P (Any one person) E1O,000 CLAIMS -MADE OCCUR PERSONALSADV INJURY $1000000 --- AGGREGATE $2,009,000 GEN'L AGGREGATE LIMIT APPLIES PER: .GENERAL ❑ JEC PRODUCTS-COMPIOPAGG $2,000,000 POLICY I I LOC OTHER: COMBINED SIG LIMB AUTOMOBILE LIABILITY Enuc dont BODILY INJURY (Par Pelaen) S - ANY AUTO ALLOWNED SCHEDULED BODILY INJURV (Pat ecddenU $ —_.. PROPERTY DAMAGE. S AUTOS AUT OWNED S _ HIRED AUTOS AUTOS UMERELLALIAB .00CUR EACH OCCURRENCE S AGGREOATEy. ,.. EXCESS LIAR CLAIMS•MAOE $ S OED RETENTIONS _ WORKERS COMPENSATION 02WECEK3216 7/0112017 -- 07I01/201 X PEa EORH A E.L. EACH ACCIDENT - 5500,000 AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEIMEMBER EXCLUDED? ® NIA E.L. DISEASE - EA EMPLOYEE $5Og000 (Mandatory In NH) Ifyea,tleactibaunder DESCRIPTION OF OPERATIONS below -- E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD jet, Addhlnnol Remarks Schedule, maybe ahachedWMOTOUpacala 101AM6) 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. M• a anco nnne nrnRn rnmonRArInIM All rinhtR raSSmed ACORD 25 (2094101) 1 of 1 The ACORD name and logo are registered marks of ACORD SCK 6S10160351M1016034 / ® y{ƒ§ ; \ \((G § mime / %z /k\ƒ / } 0 y 2C> \/ I .............. . __ _......_..... _ I 0 O m N m m 00 O n Nw a � m o a � C w � 3 �v d� a m m o. N o N w ; � s 6 ti. N O N 3 mn V1 T N e � e N d i V � m � o ry O � T � O 6 N A. 0 p � GI O M O 0 X n a � 3 >' o a M 0