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Home My WebLink AboutDunkin' Donuts 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 ESTABLISHMNET 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, VICE PRESIDENT Whose place of business is: MANSFIELD DONUTS INC. dba DUNKIN DONUTS 45 CHAUNCY STREET PERSON(S) IN CHARGE: KIM GREIGE, MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-44 BOARD OF HEALTH -%4ichaeCwlcCCean, Chairman Milk & Cream ❑� 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, VICE PRESIDENT having a place of business at: MANSFIELD DONUTS INC. dba DUNKIN DONUTS 45 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-44 Board of Health MichaeCwlcCCean, 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-44 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD DONUTS INC. dba DUNKIN DONUTS 2) Establishment Address 45 CHAUNCY STREET 3) Establishment Mailing Address (if different) 45 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-6730 5) Applicant Name & Title: EDWARD ANDRADE, DIRECTOR 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 7) Applicant Telephone No.: (608) 612-9184 (401) 624-3634 24 Hour Emergency No.: (508) 397-6538 (508) 612-9184 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number EDWARD ANDRADE, VICE PRESIDENT 141 FAIRWAY DRIVE, ATTLEBORO, MA (508) 612-9184 (401) 524-3634 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers LI An Association or partner. Ll A Corporation dName / , Title Address 1-1 An Individual �3t9vcm F ❑ A Partnership rl m"A 12) Person Directly Responsible For Daily Operations (owner, Name & Title KIM GREIGE, MANAGER Address: 440 Telephone No: 1(508 FAX: E-mail: lJ . STEARNS AVENUE, MANSFIELD, MA 02048 in charge, supervisor, manaqer 337-6730 24 Hour Emergency No: (508) 397-6538 (508) 612.9184 Alt E-Mail: 13) District Or Regional Supervisor (if applicable) — - --- —- — — -- . _ _-.-_ Name &Title. ,CARLOS RAPOSO, GENERAL MANAGER Address: 12 BELLA WOODS DRIVE, REHOBOTH, MA Telephone No: 1(508) 243-0958 24 Hour Emergency No. (508) 612.9184 FAX: (774) 643 6235 E-mail: DEBERCY@AOL COM CARLOS.RAPOSO@NATIONALDCR NET 14 , YWVS- Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 18 17) DAYS/HOURS: 7 DAYS PER WEEK _ 18) Name of Person In Charge Certified in Food Protection Management: KIMBERLY M. GREIGE 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): ❑ `' �., All _..__._. 20) Location: ❑./ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: Retail ( 1,850 Sq. Ft) [] Milk & Cream $10.00 Mobile End Date: r] Food Service upto 100 or ❑Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream 25.00 reezer 21) Length of Permit: n Annual or up to 25' PHF display $150.00 ❑ Pushcart $25.00 # of Pushcarts: 0 Ej Seasonal ❑ Food Service up to 201 + ❑ Residential Kitchen $100.00 Seasonal Dales: or 25'+ PHF display $275.00 11 Retail Food $100.00 (._) Food Service - Institution ❑ Retail Snack Food $25.00 -1 Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: - ------ ----.__..- _-- 23) Food Operations Definitions: PHF- Potentially hazardous food (tfineRemperature 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 furtherprocessing) n Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- - -- -- -- PHFs— -- — ---__ Sale of Commercially Pre -Packaged PHFs IV]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 — Susceptible Population Facility ----------------- -- ❑ Sale of Raw Animal Foods Intended — [_„J 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 Customer Self -Service of Non PHF and Non- �� Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health _ [_] Ice Manufactured and Packaged for Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin -- - - title - _"- [ J Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities - I 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: $126.00 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 CMR 590 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CM 90.0 0 Wd tj)e fede ggle,,, 24) Signature of Applicant: (1/`fir Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3220184 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Town of Town of Mansfield - Board of Health 6 Pak Ro ransfield 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: MANSFIELD DONUTS INC, dba DUNKIN DONUTS ADDRESS: 45 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 337-6730 FAX NUMBER: (508) 643-7997 OWNER OF BUSINESS: EDWARD ANDRADE, VICE PRESIDENT TELEPHONE OF OWNER: (508) 612-9184 (401) 524-3634 FEDERAL ID/SS NUMBER: 04-3220184 FEE: $10.00 PERMIT NUMBER: FS-44 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 0q- 3aa-0/00)P' **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. R:\Hm1thVme's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORMAOC The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 ' www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH TEE PERMITTING AUTHORITY, Applicant Information (n� Please Print Legibly Business/Organization Name: memgV iA DJk Address: Phone #: -G8' 337-�o730 Aree you an employer? Check the appropriate box: Business Type (required): 1, t am a employer with employees employees (full and/ 5. ❑ Retail ' or part-time).* 6. �estaurant/Bar/Eating Establishment 2. [J I 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. El 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. insuranceeq.] 12,❑ Other *Any applicant that checks box #1 roost also fill out the section below showing their workers' compensation policy information. **if the corporate officers have exempted thcraselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #]. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Insurer's City/State/Zip: Policy # or Self -ins, Lie. #- 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 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 S. Selectmen's Office 6. Other Contact Person www.rnms.govldia Phone 110--fr!• 17419 MANSFDON ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (M 12017, 10/11/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPONTHE 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 an ADDITIONAL INSURED, the policylles) 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 certlilcate does not confer TlgVris to the certificate holder in lieu of such endorsementis). PRODUCER - - Starkweather & Shepley PO Box 549Ap Providence, RI 02909.0549 401 435.3600 NMETffy Kristin M..Stone, ACSR PHOI�e 401 435.3600 �L�-g399 ySess: kstone@starshep.com _ INSURER(S)AFFORDING COVERAGE NAICtl INSURER A: Hartford Ins Group 19682 _ INSURED Mansfield Donuts Inc. 86 D•1 Washington Street Plainville, MA 02762 INSURER O: `- INSURER C: INSURER D; - ' INSURER E: INSURER F: COVERAGES - CERTIFICATE NUMBER: REVISION NUMBER: 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 LTRTYPE OF INSURANCE IA,ySDL31l—pR POLICY NUMBER MMIPOYW_ MMIOD EXP UMW A X COMMERCIAL GENERAL LIABILITY ClAIM3-MADE OCCUR 028BAKN9406 7101)2017 07101120it SJDori 00D oEEpAp,C��HHp GOEECTTCURRENCE PREMISES�EeEoNaarti an. 51,901)000 WED EXP(Anyarebarspn) 810,000 _ PERSONAL & ADV INJURY S 1 000 000 _ GEN'L AGGREGATE LIMIT APPLIES PER: RO- POLICY ❑ JECT X LOG OTHER: GENERALAGGREGATE $2000,000 PRODUCTS -COMPIOPAGG_.s2,000,000 "-- AUTDMOBILE LIABILITY ANY AUTO v ALL OWNEDVAUTOS --- HIREO AUTOS O COMBINED SINGLE LIMIT En eccWdnl_ $ BODILY INJURY (Per person) S BODILY INJURY(Paracddent) $.. j uOnER donUMBRELLA LIAB LIARMADE EACHOCCURRENCEEXCESS AGGREGATE DED RETENTIONS'$ -- A WORKERS COMPENSATION T AND EMPLOYERS' LIABILITY ANY PROpRIETpq/PppTNER/EXECUTNE Y IN OFFlCEIUMEMBER EXCLUOED4 ® (Mandatory In NH) It ea,deacdbo Under DESCRIPTION OF OPERATIONS below NIA 02WECEK3227 11710112017 07)01120it X PAT ER OTH• E.L EACH ACCIDENT SSOO OOO E.L. DISEASE -EA EMPLOYEE $500 000 E.L. DISEASE• POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD UM, AddlBonal RomaAs Sohad,As, may bo rNodeee0 mma apaco55 Itudmd) Locations: 45 Chauncy Street, Mansfield, MA 0204% Town of Mansfield 6 Park Row Mansfield, MA 0204B 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 REPRESENTATIVE 0) 4ARR.201A ACORD CORPORATION. All A.Ink reserved ACORD 25 (2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #51016082W016076 SCK / ( \ k } ® 7 z § } , § ® U. z $ . `\ w § a0 W:^7 u { § \ £ k f e ( / ) . <4 o w w « \�^w 7 2°§ 14 k§ E ( \ �D�c \ ) ƒ $ i . . � k k En z k w . IL \ k I U \� « \\ LO « � � «?I� y . V H ilM i r. cd V k—j 1 Q � y`llj tLStd 0 Yv P: 4h ^O y iN cs u U d o p