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Home My WebLink AboutDunkin' Donuts 12/31/2018 (2)Commonwealth 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 wlichaet McCCean, 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, 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 MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred , U J 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.: (508) 612-9184 (401) 624-3634 24 Hour Emergency No.: (608) 397-6538 (508) 612-9184 8) Owners Name & Title EDWARD ANDRADE, VICE PRESIDENT 9) Owner Address (If different from applicant) 141 FAIRWAY DRIVE, ATTLEBORO, MA Owner's telephone number (508) 612-9184 (401) 524-3634 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. L A Corporation �tN_a�m"�e�_��f�� J T��itle�, Address Qe�1c�Oc ❑ An Individual �St7�c�T►1+ e4!�Li3, 7(_FAQ Wew �, - - =- ❑APartnership -�� lf,Qq�, ,ti(1 �2WaM N7, 1$ IPIOdc _ ❑ Other legal_ Entity- W. 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title KIM GREIGE, MANAGER Address: Telephone No: FAX: E-mail: t1\ii*uE11 STEARNS AVENUE, MANSFIELD, MA 02048 1) 337-6730 1)316-3482 24 Hour Emergency No: (508) 397-6538 (508) 612.9184 13) District Or Regional Supervisor (if applicable) Name & Title: �CARLOS RAPOSO, GENERAL MANAGER Address: I2 BELLA WOODS DRIVE, REHOBOTH, MA Telephone No: '(508) 243-0958 24 Hour Emergency No. (508) 612-9164 - --- - ---- r -- -- - - -- FAX: I(774)643-6235 E-mail: DEBERCY@AOL.COM CARLOS.RAPOSO@NATIONALDCP.NET 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No If applicable) I 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) ❑ N AI 20) Location: L Permanent Locahon 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date L Retail ( 1,850 Sq. Ft) [J] Milk & Cream $10.00 Mobile End Date: [/] Food Service up to 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/freezer - 21) Length of Permit: [] Annual or up to 25' PHF display $150.00 (] Pushcart $25.00 # of Pushcarts: 0 Seasonal i_J Food Service up to 201 + ] Residential Kitchen $100.00 Seasonal Dates: or 25'+ PHF display $275.00 ❑ Retail Food $100.00 Temporary ❑ Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: _ - Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food thme/tempemture controls required) Non-PHF's - 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) ill Sale of Commercially Pre Packaged Non PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held — -- -- - --- Sale of Commercially Pre Packaged PHFs ---- L Preparation of PHFs For Hot And for More Than a Single Meal Service -- - ------ - ---- [ ] Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly - ------ ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑_ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _ - ------ --- — -- -- L Customer Self -Service of Non PHF and Non- ❑Use of Process Requiring A Variance and/or HACCP Plan (including bare hand L Customer Self -Service Perishable Foods Only �❑ Ice Manufactured and Packaged for contact alternative, time as a public health ❑ Preparation of Non-PHFs Retail Sale contra Other Food Operations ❑ Juice Manufactured and Packaged for (❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin [ ] 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 L] 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 9o.0 0 Ltd �e fede oc g0e 24) Signature of Applicant: / 2!? w 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 so 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: 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: �a DATE: —-- �Q • �D- ,'2G/% 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. r► PCw3Qie(J � s ZL Signature of Individual or Corporate Name 0L/- 3aa0/8Y **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:\Hw1th\J=e's Doc=ents\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 PERMITTING AUTHORITY. Applicant Informationn (n� - I IaJ1 PIease Print Lg-gjb M�BN�ly Business/Organization Name: D,-,clk Address: Phone #: ,gr,8- 33%'67,30 Are you an employer? Check the appropriate box: Business Type (required): I. l am a employer with employees (full and/ S. (] Retail _�S[_ or part-time).* 6. MestaurantBar/Eating Establishment 2: 0 lam a sole proprietor or parhtership and have no 1, Q Office and/or Sales (inc1. real estate, auto, etc.) employees working forme 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 e. 152, § 1(4), and we have Ill ❑ Manufacturing no employees. [No workers' comp. insurance required]* I 1 ❑ Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance: 12. ❑Other *Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information. "If the corporate of fors have cxe opted themselves, but the corporation has other employees, a workers compensation policy is required and such an organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 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 e. 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, er he pales and pe es a p jury fiat 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 www.mws.gawwx Phone #: l:IinnHl 17413 MANSFDON ACORD.CERTIFICATE LIA ILITY INSU NCE DATE 101112 Al11/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE HDLDER.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 1NSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policylles) must be endarsed.lf SUBROGATION IS WAIVED, sUbject to the terms and conditions of the policy, certain policies may require an endorsement. Astatement on this DeTtlflcats does not corder fights to the certificate holder In lieu of such endorsementis). PRODUCER Starkweather & Shepley p y CO TqDy Kristin M. Stone, ACSR x E. �xol�E 401 5 3600 Clac, Now r 401 4313399 AIC o. EXU:. 43_ —Mna PO Box 549 ADDRESS• kstone@starshep.com Providence, RI 02901.0549 INSURERIS) AFFORDING COVERAGE NAIGO INSURER A: Hartford Ins Group 19682 401 435.3600 _ INSURED Mansfield Donuts Inc. 86 D-1 Washington Street Plainville, MA 02762 INSURER B: INBURERC: INSURER D: INSURERE: m INSURER F: T. COV5RAeca - CERTIFICATF NNMRFR: - - REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCELISTEDBELOW 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 By �Tq TYPE OF INSURANCE AIDS0I.SUBp POLICY NUMBER ypR��ELL�D1UCED MAUOOY/YE_ aPII,,AISy �CCpLLpAI_MS. MMI�OIYYVV LIMITS A X COMMSRCIALOENERALLIABIUTY CLAIMS-MADEOCCUR 02SBAKN9406 D710V2017 071011201E EACH OCCURRENCE S11000,Dot) ppgqW0.1pp1�EpTT ppENTEO PREMISEB�Eeoccunenrs s1000.000 MED EXP(Mycno Person) $10,006 PERSONAL&ADV INJURY S7 000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT ®.LOG OTHER: GENERAL AGGREGATE 52000,000 PRODUCTS-COMPIOPAGG s2,000,000 S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _-_ AUTOS ___ AUTOS NON -OWNED HIRED AUTOS AUTOS C00.1BIN-0 SINGLE LIMIT (En RaWOrd BODILY INJURY(P.1p..) S BODILY INJURY (Per pcdden) —_..._ pa�ndonlOgNNGE 1 8 - _— $ --- - -- _.. S UMBRELLA LIAR EXCESS LIAR OCCUR CLAIM&MADE _ EACH OCCURRENCE S AGGREGATE -.—S. ,S DED RETENTION S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AL��IYPRRrRIETOWPAppTtrJEERR//EEXEOUTf N OFFICERPMEMBER EXCLUOED9 N (MYYandidery In NH) DE9CRIPTON under F OPERATIONS below NIA 02WECEK3227 1710112017 071011201f GETA OTH- E.L EACH ACCIDENT 5500000. - EL. DISEASE -EA EMPLOYEE $500009 E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCAMONS (VEHICLES IACORD 1e1, ABdlfta .(Raft echD40-, may tb anachad M rnora apace h relrunbt) Locations: 45 Chauncy Street, 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. AUTHORIZED REPRESENTATIVE 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S10160021M1016076 SCK LT. W ..1 r 0 4N Zo 0 LL W S r 0 LL F Z W W a z Q w LL r w W to Q o o LL LL N W U U L N f0 Q s N Q U S G1 z z J H � fN d w w r r a as w_ A z 0 lz ar a 0 w U' z a w LL z 0 U w Q W u w V z F--a z 3 d S U K J � � N d d O d Y z Q Q � s O >[ M � 5 M 0 v zy R y tl A O d Q NE tl N tl Q H `Cl W Q ti v0 a V2S N A ryaM y d