HomeMy WebLinkAboutDunkin' Donuts @ Xfinity 11/01/2018Commonwealth 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: XFINITY RETAIL FOOD PERMIT
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:.
ANITA SCHULTZ, PRESIDENT
Whose place of business is:
BIG FISH PROMOTIONS DBA DUNKIN DONUTS @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ALIX SLABINSKI
Permit Expires: November 01, 2018
Food Fee: $100.00
License Number: XRF-3
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Kateceived: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
pp ica ion mus a su m� e a eas ays a ore e p anne opernng a e
1) Establishment Name p„ '['fir 0` 1�
2) Establishment AddressEk) �� 'N c
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3) Establishment Mailing Address (if different)
4) Establishment Telephone No �L0°06`� r 1414 CC)
5) Applicant Name & Title: O �L l nJ I1 Q Q\� 1 1 IQ Ii�
6) Applicant Address COYYI CD _y C'�'(SI�Wr C T
7) Applicant Telephone No . 24 Hour Emergency No.-
8) Owners Name & Title Wny �a C
9) Owner Address (If different from applicant)
Owner's telephone number le6) (Q3 L.{ L{ 0
10) Establishment Owned By:
0 An Association
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
O A Corporation
An Individual
Name Title Address
Ed A Partnership
H Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title:
Address:
COM MefCe- S}-. CI4``%S%nb (u
Telephone No:
V ��lS� J2J `tI I 0 24 Hour Emergency No:
FAX:
E-mail:
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Alt E-Mail:
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13) District Or Regional Supervisor (if applicable
Name &Title:
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M'� CbWnS Cvna- n C6�a_1—
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Address:
Telephone No:
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G 3 24 Hour Emergency No: 3
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FAX:
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Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in
Food Protection Management:
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If more than 3 individuals are certified, complete
list is on file.
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Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
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19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) 0
20) Location: [g Permanent Location
22) Establishment Type
Caterer $25.00
(YMoblie Mobile Start Date:
® Retail ( Sq. Ft)
I� Milk & Cream $10.00
Mobile End Date:
0 Food Service up to 100 or
[Ed Mobile Food & Consession $75.00
Mobile Comments:
up to 10' PHF display $125.00
E Food Service up to 101 -200
O Manufacture Frozen Dessertslice Cream
$25.00/freezer
21) Length of Permit:
0 Annual
or up to 25' PHF display $150,00
Pushcart $25.00 # of Pushcarts:
M Seasonal
0 Food Service up to 201 +
Q Residential Kitchen $100.00
Seasonal Dates: �� 1120Ig - NOV • I
or 25'+ PHF display $275.00
El Retail Food $100.00
Temporary
❑] Food Service - Institution
[I Retail Snack Food $25.00
Temporary Start Date: rJ' t' t G
( Meals/Day)
LI Tobacco Products $25,00
Temporary End Date: U
Temporary Time:
Rain Date:
23) Food Operations 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 foods (Ex. sandwiches, salads, mums which need no furtherprocessing)
❑--i Sale of Commercially Pre -Packaged Non-PHFs ^-❑-i PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs E] 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
Q Sale of Raw Animal Foods Intended Susceptible Population Facility
❑`}' Reheating of Commercially Processed Foods for Service Within 4 Hours to be Prepared by Consumer Vacuum Packaging / Cook Chill
Customer Self -Service of Non PHF and Non-
0 rvi Customer Self-Sece
U Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
Perishable Foods Only
Ice Manufactured and Packaged for
Retail Sale
contact alternative, time as a public health
control)
_
Preparation of Non-PHFs
Other Food Operations
Juice Manufactured and Packaged for
Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
Prepares Food/Single Meals for
Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment Is due with application 0 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 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMFJ�-$90.00 gnd the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49V1 certify under the penalties of
and paid slate taxes required under law. /h
25) Social Security Number or Federal ID: r
26) Signature of Individual or Corporate Name:
that I, to my best knowledge and belief, have filed all state tax returns
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.
�a '�iSh 1 r6m�anS Yeah l� C�\�� n S
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
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"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.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: ( )O %YYl we ice 9-t '
Phone #:/ RWQ( (o.33-
Are ou an employer? Check the appropriate box: Business Type (required):
1. I am a employer with _Gemployees (full and/ 5. [:]Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I 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.
[No workers' comp. insurance required] 8. ❑ Non-profit
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]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12U Other ?(Z'$'M6 b 8n.�
*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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: L� MMW `Sl �Mn
Insurer's Addr(
City/State/Zip:
Policy # or Self -ins. Lie. # W ul) 315 — Lo `1E31—n1 S 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, under thepains qldpenalties ofperjury that the information provided above is true and correct
3-
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.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Form Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
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(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: SEE ATTACHED ENDORSEMENT
NCCI Company Number: 10456
Company Code: 9
..g
":
I � • , • ,
Suffix
LARS RENEWAL
POLICY NUMBER: 131 WE AA70VY E--T—
Previous Policy Number: I New
1. Named Insured and Mailing Address: BIG FISH PROMOTIONS LLC
(No., Street, Town, State, Zip Code) 80 COMMERCE ST
GLASTONBURY CT 06033
FEIN Number: 06-1633731
State Identification Number(s): UIN: ME 0752035000 TIN: RI 2061633731
See Schedule of Operations if applicable
The Named Insured is: LLC
Business of Named Insured: Other Services Related to Advertising
Other workplaces not shown above: See Endorsement - WC990366
2. Policy Period: From 11/09/17 To 11/09/18 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: J P SVENDSEN AGENCY
PO BOX 3975
WOODBRIDGE CT 06525
Producer's Code: 31802564
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877)853-2582
Total Estimated Annual Premium: $28,954
Deposit Premium:
Policy Minimum Premium: $1,620 CT (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by 10/30/17
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 10/30/17 Policy Expiration Date: 11/09/18
INFORMATION PAGE (Continued)
Policy Number: 31 WE AA70VY
3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states
listed here: ME SEE ENDORSEMENT - WC 99 03 67
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily injury by Accident $1,000,000 each accident
Bodily injury by Disease $1,000,000 policy limit
Bodily injury by Disease $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here:
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES
DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
SEE ENDORSEMENT -WC 99 03 68
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
Total Standard Premium $28,168
Premium Discount -$841
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $182
Catastrophe (Other Than Certified Acts Of Terrorism) $177
Other Miscellaneous State Premiums $20
Estimated Annual Premium (before Surcharges) $27,706
Total Estimated Surcharges $1 248
*See the attached Schedule(s) of Operations for Location and State Level Premium Information
Total Estimated Annual Premium: $28,954
Deposit Premium:
Policy Minimum Premium: $1 620 CT (Includes Increased Limit Min Prem )
Interstate/Intrastate Identification Number: Refer to Schedule of Operations
NAICS: 541890
Labor Contractors Policy Number: SIC: 7389
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 10/30/17 Policy Expiration Date: 11/09/18
EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER
WORKPLACES
Policy Number: 31 WE AA70VY Endorsement Number:
Effective Date: 11/09/17 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: BIG FISH PROMOTIONS LI.0
80 COMMERCE ST
GLASTONBURY CT 06033
Item 1 of the Information Page is completed to include other workplaces of the named insured:
38 DELTA DR, PAWTUCKET, RI 02860-4555
NO SPECIFIC LOCATION IN STATE OF BOSTON, MA 02110
NO SPECIFIC LOCATION IN STATE OF FLORAL PARK, NY 11001
NO SPECIFIC LOCATION IN STATE OF NH
NO SPECIFIC LOCATION IN STATE OF PA
NO SPECIFIC LOCATION IN STATE OF ME
Form WC 99 03 66 Printed in U.S.A.
Process Date: 10/30/17 Policy Expiration Date: 11/09/18
EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED
Policy Number: 31 WE AA70VY Endorsement Number:
Effective Date: 11/09/17 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: BIG FISH PROMOTIONS LLC
80 COMMERCE ST
GLASTONBURY CT 06033
Item 3.A. of the Information Page is completed to include the following states:
Maine
ME
New Hampshire
NH
Massachusetts
MA
Connecticut
CT
Rhode Island
RI
New York
NY
Pennsylvania
PA
Form WC 99 03 67 Printed in U.S.A.
Process Date: 10/30/17
Policy Expiration Date: 11/09/18
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit f! Issyed,?
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FOOD ESTABLISHMENT PERMIT APPLICATION
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1) Establishment Name 4pin Y �C1r, ?mYYYA)-,(N,)U6
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3) Establishment Mailing Address (if different)
4) Establishment Telephone No. C2�qp) W,651 LH CD-
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No . 406 24 Hour Emergency No:
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8)Owners Name &Title
9) Owner Address (If different from' applicant)
Owners telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
r An Association or partner.
IJ A Corporation Name Title Address
t4An Individual
❑ A Partnership
— Other legal Entity
For Daily Operations (owner, person in charge, supervisor, manager etc.) 12) Person Directly Responsible
Name &Tille���
Address:
enc No: Telephone c� �' L I''\ 24 Hour Emergency No:
P_ V\�J?J
FAX:
E-mail:�`i\
Alt EMaii
13) District Or Regional Supervisor (if applicable
Name &Title: I ' l rCJ•'N 'Q'� CoWnS Q 'C'l h LUI i 1 Ct-CA--
Address: �.. COi1 miwct
Telephone No: 24 Hour Emergency No:
FAX: (C6t )1033 ^ LiyO bE-mall: W&W ns Viol - iSbvro rnotiCyn •cc� Y�