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HomeMy WebLinkAboutBig Fish/Dunkin Donuts - 6/1/2010Commonwealth 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: SNACK 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 COMCAST CENTER 80 COMMERCE STREET PERSON(S) IN CHARGE: FRAN KNIGHTS, GENERAL MANAGER Permit Expires: ,June 01, 2010 License Number: S-25 Food Fee: $10.00 BOARD OF HEALTH Dr. Raymond Martin, Cha7rXn FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-25 FOOD ESTABLISHMENT PERMIT APPLICATION /Annllnafinn must ha suhmitted at least 30 days before the planned opening date) 1) Establishment Name: BIG FISH PROMOTIONS DBA DUNKIN DONUTS @ THE COMCAST CENTER 2) Establishment Address 80 COMMERCE STREET CE STREET GLAURY, CT 06033 R �� 3) Establishment Mailing Address (if different) 80 C;633-4400 4) Establishment Telephone No: (860) �i 5) Applicant Name & Title: ANITA SCHULTZ, PRESIDENT 6) Applicant Address 80 COMMERCE STREET, GLASTONBURY, CT 06033 7) Applicant Telephone No.: (860) 633-4400 24 Hour Emergency No.: 8601888-1016 (860) 633.4400 8) Owners Name & Title ANITA SCHULTZ, PRESIDENT 9) Owner Address (If different from applicant): 80 COMMERCE STREET, GLASTONBURY, CT 06033 10) Establishment Owned By: ❑ An Association ❑ A Corporation O An Individual ❑ A Partnership ❑ Other legal Entity 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: y i 31 Y / (/ i.. `µ. t ii It \. �� i! A6Y {( J Address: C�iiC_ Telephone No: 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: - Food Establishment Information 14) WATER SOURCE: TOWN ( `lti:�'3'4tt rid¢ , (' 1"P15)SEWAGOE DISPOSAL: TOWNDEP Public Water Supply No: (If applicable) . of Fod Employees: 5 17) DAYS/HOURS: MAY 20-AUGUST 31 18) Name of Person In Charge Certified in Food Protection Management: KG- BUDRE-WICZ If more than 3 individuals are certified, complete list is on file. I ;to'li as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 119) Person Trained In Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location ❑ Mobile Mobile Start Date: 5/20/20OR Mobile End Date: 8/31/2009 Mobile Comments: 21) Length of Permit: ❑ Annual W Seasonal Seasonal Dales J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $75 ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution Meals/Day) ()! ❑ Bakery$25 ❑ Caterer $25 ❑ Food Delivery $25 ❑ Milk & Cream $2 ❑ Mobile Food & Consession $60 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑d Retail Snack Food $10 ❑ Tobacco Products No Fee 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, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ElSale of Commercially Pre -Packaged PHFs ❑ 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 ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non Perishable Foods Only Other Food Operations LJ Customer Self -Service ❑ Ice Manufactured and Packaged fc Retail Sale ❑ Juice Manufactured and Packaged Retail Sale ❑ Offers RTE PHF in Bulk Quantities or Reconditioned Food ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service I To be completed by the Board of Health Total Permit Fee: $10.00 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 590.000 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 f� '.=` ^- Pursuant to MC L Ch.62C, to. 49A. I certify under 91 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: 06-1633731 26) Signature of Individual or Corporate Name: 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 (Mandatory) By' C— or—` p icer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 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 Leeibly Business/Organization Name nth tx ' ' `{ k' �_ i i ` C �c bk� i . `(' {(a'iy }I (rt Address: City/State/Zip: (,ia )'t/ ! C 1_ Phone #: ��, a („y . • (C.tty l i Are you an employer? Check the appropriate box: Business Type (required): I Z I am a employer with (6 ,(> employees (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. g. ❑Npn-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]* I1.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. Other 'k ,' !)(,A') with no employees. [No workers'.eomp. insurance req.] f k + *Any applicant that checks box H 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#l. I am an employer that is providing workers' cotmpensadon insurance for my employees. Below is the policy information. Insurance Company Name: � 1��C W� l i tt t'�2 Insurer's Address:L'i ¢¢ i f( tri i(tL'C City/State/Zip.!' [V i 1 Policy # or Self -ins. Lic # Lk ? ``] (� > �... Expiration Date: 1?%' 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 the pains and penalties ofperjury 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: Phone www.mass.gov/dia 04/28/2009 12:09 8606334482 BIG FISH PROMOTIONS PAGE 03/05 Y 0 0 ■ / k _ d Z § W § $ 2 Ali v N � � ! \ § +xn39vd s !1OW o HSIAnm > e m vT maze/» . o / !{ $» , /• R!|t z_w. 9040 39vd s !10W a HSIJnm za�C9098 a m! _:alp _ r m u ©^\}.1wwk 22 . dk % �2la | )#E ) - . ��\ � \ a k k {r / \}\) j\\ 1 \ + \ D . , CO \\( R \ \\ � o ) +su 30Vd SNOI10HOdd HSIJ9IS ZBVPEE9098 a x! ne zee 04/28/2009 12:09 8606334482 SIG FISH PROMOTIONS PAGE 01/05 Fax Cover Date: 4/28/2009 Attention: Jane Company: Mansfield Health Dept Fax number: 508-261,7.425 Re: Sery Safe Certified Employees From: Marisa Crean Number of pages including cover: Notes: Hi Jane, Here are four certificates of people who could possibly be on site. Like I said on the phone all of our employees are Serv-Safe certified and will have their certificate on them when on the truck for sampling, Please let me know if you need anything else, Thanks! Marisa Crean Project Manager Big Fish Promotions • 80 Commerce Street • Glastonbury, CT 06033 • (860) 633-4400 • fax (860) 6334482