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HomeMy WebLinkAboutDunkin Donuts - 4 S. Main- 6/1/201001 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 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:. DECS DONUTS INC Whose place of business is: DECS DONUTS INC dba DUNKIN DONUTS 4 SOUTH MAIN STREET PERSON(S) IN CHARGE: KIM THRASHER GREIGE Permit Expires: June 01, 2010 license Number: FS-15 Food Fee: $75.00 Milk & Cream L7 BOARD OF HEALTH Dr. Raymond Martin, Chairman 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: DECS DONUTS INC having a place of business at: DECS DONUTS INC dba DUNKIN DONUTS 4 SOUTH MAIN 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 June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 License No.: FS-15 Scott L tt , Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-15 FOOD ESTABLISHMENT PERMIT APPLICATION /dnnliontinn mutt ha cuhmittarl at 1Aa.at.nn dave hafnra tha nlann®rl nnenino date) 1) Establishment Name: DECS DONUTS INC dba DUNKIN DONUTS 2) Establishment Address 4 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 86B WASHINGTON STREET PLAINVILLE, MA 02762 4) Establishment Telephone No: (508) 339.6229 5) Applicant Name & Title: EDWARD ANDRADE — 6) Applicant Address 141 FAIRWAY DRIVE, ATTLEBORO, MA 02703 7) Applicant Telephone No.: (508) 612-9184 24 Hour Emergency No.: (508) 612-9184 8) Owners Name & Title DECS DONUTS INC 9) Owner Address (If different from applicant): 86B WASHINGTON STREET, PLAINVILLE, MA 02762 10) Establishment Owned By: ❑ An Association W A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, or partner. Name Title yv(q,g,P_t ?Iecs L4o and home address of officers Address G w 1�1_1 rp � �f FFpy�UtCw , 12 12) Person Directly Responsible For Dailv Operations (owner, person in charge, supervisor, manager etc.) RIM mml Name & Title: �lM'J'P�✓L-t l�'°lf>C,B 2 Wt�%� �✓Z Address: 5q Su,Ae.�t sT N. %wtSTGyt V'�►►'�- oa3St� Telephone No: 3301 . � CS( 24 Hour Emergency No: SO8 .3Ot'j _ &`�3& FAX: jG0' &q3 -�9q I 13) District Or Regional Supervisor (if applicable) Name &Title: _s'J eUi ice Address: �S 2G�isa$6�tUG. i�pcv�uC�ei •� 03rvol Telephone No: , aLA OC6R 24 Hour Emergency No: j08-')e.(3 _006T FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 12 17) DAYS/HOURS: 7 DAYs 5 AM - 12 AM 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. 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,P 20) Location: [ Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: Retail ( 600 Sq. Ft) Mobile End Date: Food Service up to 100 or Mobile Comments: up to 10' PHF display $75 21) Length of Permit: ❑d Annual ❑ Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ 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 $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHF's - 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 V PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs W Preparation of PHFs r Hot And Cold Holding For SingleMeal 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 Perishable Foods Only Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accuracy of the information provided in this establishment operation will comply wit CMR 590.000 and all other ar board of health on how to obtain copies of 05 CMR 590.000 and the fader ] Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged f Retail Sale ❑ Offers RTE PHF in Bulk Quantities ❑ 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 Oriain ❑ 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: $75.00 Payment Is due with application ❑ waived and affirm that the food '. I have been instructed by the 24) Signature of Applicant: . `""'" "`---'- Pursuant to MGL Ch.62C, se AI c , certify under the penaltie perjury that I, to my best knowledge and belief, have filed all state lax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 75-3017929 26) Signature of Individual or Corporate Name: t'S 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 June 1st of each year. NAME OF BUSINESS: DECS DONUTS INC dba DUNKIN DONUTS ADDRESS: 4 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6229 FAX NUMBER: (508) 643-7997 OWNER OF BUSINESS: DECS DONUTS INC TELEPHONE OF OWNER: (508) 612-9184 FEDERAL ID/SS NUMBER: 75-3017929 FEE: $2.00 PERMIT NUMBER: FS-15 SIGNATURE: ��' DATE: � -O� 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. jDCCS * Signature of Individual or Corporate Name (Mandatory) y: Corporate Office (Mandatory, if applicable) "7'�; - 3b 1 i`e;Lq ** 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 Le zibly Business/Organization Name: CS o n c Address: LA <�;• m iq I rl S( C_"i" City/State/Zip: Wtt"-Yn (t Ci M a- Phone #: 69`-1 Are you an employer? Check the appropriate box: Business Type (required): 1. [U-1 am a employer with 1O employees (full and/ 5. []Retail or part-time).* 6. estaurandBar/Eating Establishment 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 requ red]* 1 I. ❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no emplovees. rNo workers' coma. insurance real 12.© Other *Anv annlicant that checks box NI most Am 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 NI. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: On e — �Ec.-.T—tn S . Insurer's Address: p• % . t�C°y(Sq9 City/State/Zip: PA&vlcte�nee_ e�1_1 • Q Policy # or Self -ins. Lic. # Expiration Date: "7 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 I do hereby certs nder the pains and penaties ofperfuQ that the Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License above is true and correct. 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.mass.gov/dia Phone Client//- 32395 DEMON E ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/02/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Starkweather & Shepley ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 649 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Providence, RI 02901-0549 401 435.3600 INSURERS AFFORDING COVERAGE NAIC III INSURED Decs Donuts, Inc. INSURER A: ONEBEACON INS/DONUTS INSURER B: Chubb & Son 86B WASHINGTON STREET INSURER C: PLAINVILLE, MA 02762 INSURER O: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE SEE N ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING enry cFnl uaFeeFnlr TFGM na nnnlnlTlnN nF ANY rnN'-RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR " 7'"""""""""^"?DED BY THE POL CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH rULi4iES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE POL:OY NUMBER DATE(EFFE) ME DATE A)D DATE M DD PDA EIMMI OD(Y) LIMITS A GENERAL X LIABILITY COMMERCIALGENERALALLIABICU CLAIMS MADE OCCUR F62U033,16 07/01/08 07101109 EACH OCCURRENCE $ t o00 000 DAMAGE TO RENTED $300000 $5 000 FaijElL4fdblfY� MED EXP (Any one parson) PERSONAL S ADV INJURY 11,000,000 GENERAL AGGREGATE $2 OQO 000 GEN% AGGREGATE LIMIT APPLIES PER: POLICY PRO- E LOC PRODUCTS - COMP/OPAGG $2000000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEOULEDAUTOS HIREDAUTOS NON -OWNED AUTOS CO BINEDt'INGLE LIM(EdB $ BODILY INJURY (Per preen) $ BODILY INJURY (Per ecGtlenQ $ PROPERTY DAMAGE (Per eceltlent) $ A A GARAGE LIABILITY ANY AUTO EXCESSIUMBRELLALIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE X RETENTION $ 1000Q WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANV PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? It yes, describe under SPECIAL PROVISIONS below OTHER Employment Related Practices Liabili FB2UO3336 406022472 68028323 07/01/08 67/01/08 11/15 7 07/01/09 Q7/01/09 17 11/15/09 AUTO ONLY - EA ACCIDENT $ EA ACC AGO RRENCE $ $ $1000000 $j QQQ QQQ $ MACCIDENT$500,000 $ ATU- OTH- $ E.L.CIDENT $500000OFFICERIM,EMBER -EA EMPLOYEE $500000 E.L. DISEASE - POLICYLIMIT $1,000,000 Each Occur. $3,000,000 Aggregate $500000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES/ EXCI.USIO YS ADDED BY ENDORSEMENT / SPECIAL PROW SIGNS *10 days notice applies for non-payment of prer Tium Cancellation CERTIFICATE HOLDER ACORD 25 Town of Mansfield 6 Park Row Mansfield, MA 02048 OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION IF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYSWRITEEN THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE 1 of 2 iRS199518/M199 S16 RLS o ACORD CORPORATION 1988 k 2 ( U. � u c ■� � � ■� F ;0 kft 5� \\ \ { U. \\z \ \\a \\\ z ��( } - �\<k \ C:) D , / : % � : { d ■ : >\/ 4 z q C C,q �t � z