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HomeMy WebLinkAboutHoneydew Donuts 12/31/2018a Commonwealth 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:, STEPHEN PROVAZZA, OWNER Whose place of business is: HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS 99 COPELAND DRIVE PERSON(S) IN CHARGE: STEPHEN PROVAZZA Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-35 BOARD OF HEALTH AichaeCMcCCean, Chairman Milk & Cream V 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. STEPHEN PROVAZZA, OWNER having a place of business at: HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS • d 9 I [ 0 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-35 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred ,:, cp i �f FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-35 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS 99 COPELAND DRIVE _r 3) Establishment Mailing Address (if different) 284 PRESIDENT AVENUE s'✓ PROVIDENCE, RI 02906 4) Establishment Telephone No TBA 5) Applicant Name & Title: STEPHEN PROVAZZA, OWNER 6) Applicant Address 284 PRESIDENT AVENUE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 561-0618 24 Hour Emergency No.: (508) 561-0618 8) Owners Name & Title STEPHEN PROVAZZA, OWNER 9) Owner Address (If different from applicant) 284 PRESIDENT AVENUE, MANSFIELD, MA 02048 Owner's telephone number (401) 861-0308 (508) 561-0618 10) Establishment Owned By: L= An Association L I A Corporation An Individual ❑ 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: ISTEPHEN PROVAZZA Address: 1284 PRESIDENT AVENUE, MANSFIELD, MA 02048 Telephone No: (401) 861-0308 24 Hour Emergency No: (508) 561-0618 FAX: E-mail: ISPPCAT(a�AOL.COM Alt E Mail: SPR059@AOL.COM 13) District Or Regional Supervisor (if applicable) Name & Title: ITANYA ANDREWS Food Establishment Information 14) WATER SOURCE: TOWN I 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: MON-SUN 4-10 18) Name of Person In Charge Certified in Food Protection Management: TANYA L. ANDREWS 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 STEPHEN PROVAZZA (RHODE ISLAND certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ] 20) Location: [] Permanent Location [_ J Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual [] Seasonal Seasonal Dates: [] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type [_] Retail ( 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) ❑ 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 (trmeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timartemperature controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- f Co --- ac ed — -- - t And for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And — - --------- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑, Delivery oof f Packaged PHFs Susceptible Population Facility 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 to be Prepared by Consumer i,_� Vacuum Packaging /Cook Chill [_ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health - Customer Self -Service - - Ice Manufactured and Packaged for Retail Sale control ❑ 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 Retail Sale of Salvage, Out -Of -Date ------ or Reconditioned Food To be completed by the Board of Health Total Permit Fee $125 00 Payment is due with application [--I wawed 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 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590-000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MOILCh.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: 04-3312078 `,Q/ �/].�� 'q 26) Signature of Individual or Corporate Name: J+yivl �OJf - 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: HONEY DEW DONUTS - SPCAP, INC. HONEY DEW DONUTS ADDRESS: 99 COPELAND DRIVE TELEPHONE AT LOCATION: TBA FAX NUMBER: OWNER OF BUSINESS: STEPHEN PROVAZZA, OWNER TELEPHONE OF OWNER: (401) 861-0308 (508) 561-0618 FEDERAL ID/SS NUMBER: 04-3312078 FEE: $10.00 PERMIT NUMBER: FS-35 SIGNATURE: si�'/Y-vi' , DATE: //-11 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 Qy 3 S 1 �-v .7 **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. RA\Health\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts 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 PERMITTINGAUTHORITY. Applicant Information Please Print LeeblV Business/Organiz�ationnName: `J �GP �� L ' yJ� �✓+�> #� c k u Address: a City/State/Zip: 00 4:)-/d6 Phone#: V, /' n®- "? Are you an employer? Check the appropriate box: Business Type (required): I. EZIA am a employer with —�=employees (full and/ 5. ❑ Retail or part-time).* 6. E]RestaurantBar/EatingEstablishment 2: ❑ 1 am a sole proprietor or partnership and have no 7, ❑ 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]* 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 #1 must also fill out the section below showing their Workers' compensation policy informati(n. **lf the corporate officers have exempted thcrosdves, but the corporation bas other employees, a workers' compensation policy is required and such an organization should check box 91. !am an employer that is providing workers' compensatiion insurance for my employees. Below is the policy information. Insurance Company Name, �i7x xoz- /rG z A.f:eiL{,I/ wey< Insurer's Address: /' e)' �d)� �5 � � a ' / � z), 2 City/State/Zip: &-a t dl 6-'e'-e- , S Policy#or Self -ins, Lie.#- o1.y000 J 61Yd &I J Expiration Date: /' 1'-/ d 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. f do hereby certify, under thelpgins and penaldes 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 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person Phone NOTICE TO EMPLOYEES NOTICE im EMPLOYEES The Commonwealth of. Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS I Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - littp://www.state.nia.tis/dia As required by Massachusetts General Law, Chapter 152., Sections 21, 22 &c 30, this will give you notice that I (we) have provided for payment to our injured employees tinder the above -mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, 02185 ADDRESS OF INSURANCE COMPANY 014000501929117 01/0 1 /2017-01 /01 /2018 POLICY NUMBER EFFECTIVE DATES HUB NE Association Proerams NAME OF INSURANCE AGENT ADDRESS PHONE # Honey Dew Donuts 194 Wheeler Street Rehoboth, MA 02769 EMPLOYER ADDRESS EMPLOYERS'S WORKERS' COMPENSATION OFFICE (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS ,.__—, DONUTSH004 AVOINER Aco/ZL7" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOIYYYY) 1 11/09/2017 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 policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsement(s). PRODUCER License # 1780862 NQAJACT HUB International New England 299 Ballardvale Street _JAIC,,No Ed)(978)_657 5100 (A/c Np) (978) 988.0038 _ Wilmington. MA 01887 ADDAIL RESS: _ IINSURER A Merchants Mutual Insurance Company _ 123329___ LIN INSURED NSURER D: ) Honey Dew Donuts INSURER C SPCAP, Inc. DBA 284 President Ave. r--- ---- --- -- -- - -- Providence, RI 02906 INSURER E: r GOTrC,rn I. u„nneco. CcvlclnKf ul lnnCco• 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. IN$R TYpE OF INSURANCE A SD ISUBRI POLICY NUMBER POLICY EFF POLICY EXPILTR LIMITS A I COMMERCIAL GENERAL LIABILITY 11 $ 2,000,000 CLAIMS MADE (OCCUR iIncluded BOPID76939 D5/01 /2D17 0510112018O RENTEDEa occunence) _$ I 5,000 rHURRENCE nyone person) $ 4,06 000 GEN L AGGREGATE LIMIT APPLIES PER: GGREGATE _$ POLICY', pRp :LOC ECT I PRODUCTS-COMPIOP AGG $ 4,000,000 OTHER: $ LE LIMIT AUTOMOBILE LIABILITY (Ea acradene _. $ (Eaawd.nt) ANY AUTO � �, BODILY INJURY (Per person) $ SCHEDULED {� AUTOS ONLY �I, BODILY INJURY (Per aWdent)_$ -, HIRE N3N-OWNED pp p EE.Ride t)AMAGE $ ' AUTOS ONLY AUTOS ONL Y (Pe'e Ali $ UMBRELLA OCCUR EACH OCCURRENCE '. $ _ EXCESS L ABIAB CLAIMS MADE AGGREGATE $ _ BED RETENTION$ !WORKERS COMPENSATION AND EMPLOYERS' LIABILITY (PER OTH STATUTE._ ER _ II YIN ANY PRRO/�PREIETgO�RR �II(Mantlalory E L EACH ACCIDENT $ _ EXCLNERIE%ECUTIVE OFFICER M M EXCLUDRIE in NH) - i N l q '., E.L.DISEASE - EA EMPLOYEE( _$ If yes, under ' Res0b. "DESCRIPTION OF OPERATIONS below E.L. DISEASEPOLICYLIMIT $ A .BUS Pass Owners Poll 1 ISOPI078939 0610112017 j 0510112018 (Contents $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) COVERING LOCATIONS: 99 Copeland Drive, Mansfield, MA r ArJrCI I ATlnnl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall Mansfield, MA 02048 AnUTnHORIZED REPRESENTATIVE V ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD