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Home My WebLink AboutDec's 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: 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:. EDWARD ANDRADE, DIRECTOR Whose place of business is: DECS DONUTS, INC. 905 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOSE COSTA, MANAGER Permit Expires: June 01, 2010 License Number: FS-72 Food Fee: $75.00 Milk & Cream ❑O 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., EDWARD ANDRADE, DIRECTOR having a place of business at: DECS DONUTS, INC. 905 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-72 Scott Leite, 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 Food Establishment Permit Applicat (Application must be submitted at least 30 days before the plane o,�e�'riirt�laf+� 1) Establishment Name: Dom. ")CMl Vic sy „_ 2) Establishment Address: q 0 j vv A `y` Jr c e -- 3) Establishment Mailing Address (if different): rV1 A'nSQi e( V1.1 4 0 4) Establishment Telephone No: ► - S"ce"(a t D . q t g,q 5) Applicant Name & Title: COS' o lqVIO e— , 6) Applicant Address: v-41 FAlrt"J j>2 , iqtt(C-bCWC 14 7) Applicant Telephone No: ®g . G i �_ q ) �j 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): e 9) Owner Address (if different from applicant): CJ Pdm el 10) Establishment Owned By; ® An association A corporation • An individual m Apartnership • Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address �y Sri@0e" AnA e RtCS. -71 FAHMeW 40C ea eyywuaNLo et�wb2 U Ve�s I`it (satew�w i�rt. R4il��xuc 61.65 1gmdV--tde T#2CS . Clams w l lz4C� 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: Gse— CGS c) — VVInAVI {2 Address: M,i12,$ Del .. C Telephone No: Q - (® Fax: sog- (PLA33 -7q'1'7 Emergency Telephone No: LA ()l - `g(® (p 13) District Or Regional Supervisor rf applicable) Name & Title: S iLA j G - Address: "_�',s {✓i SB lItSOVi UC a9 U �C �'��1 Telephone No: - Fax:" (a`i 3 ' -7,9q% 39Uappnuhoa6-2.doc 1 Food Establishment Information 14) Water Source: 1-0 (AJ V\ 15) Sewage disposal: "-oc-.Jv"< DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: -1 ® Rat , i ® 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food P otection Management: �G 5 Required as of 101112001in accordance with 105 CMR 590.003(A) prea._ncn ma.�at . 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes XNo 20) Location: 22) Establishment Type(check ail that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery Permanent Structure ❑ Food Service - ( (g Seats) ❑ Residential Kitchen for Retail Sale ❑ Mobile 2� Food Service - Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service - Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) Annual 1 i l � ❑ Seasonal/Dates: ❑ Temporary/Dates/Time: Definitions: PHF- potentially hazardous food(dme4emperature controls required) 23) Food Operations: Hon-PHFs- non- potentially hazardous food (no dme/temperoture controls required) check al/ that a I ): RTE- reacipto-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre- 15 PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service. ❑ Sale of Commercially Pre Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Delivery of Packaged PHFs ❑ Sale Of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer. ❑ Reheating of Commercially Qr Customer Self -Service ❑ Use Of Process Requiring A Variance Processed Foods For Service And/Or HACCP Plan (including bare hand Within 4 Hours. contact alternative, time as a public health control Customer Self -Service Of Non- Ice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Oni . Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service U,' Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health ElRetail Sale of Salvage, Out -of Date Total Permit Fee: 1 i • ®G or Reconditioned Food Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I 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 10_5,C—M'P, 590.000 and the fe ral"Fo Cod . 24) Signature of Applicant: _ Ds Pursuant to MGL Ch. 62C, sec. 49A, I certify underpenalties 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: _7 S_ - 3Q 1 _79 261 Signature of Individual or Cornorate Name: 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 Indiv,Opat or Corporate Name -7S"- 301-792-9 "Social Security No. (Voluntary) or Federal Identification Nulnber By: Corporate Officer (Mandatory, iilApplicable) *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:\Scotts Documents\Food Eslablishments- 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: CS _ OPIU Address: ®<�_ U 6 Y—k VtAr+wt City/State/Zip: Miami�eI I VKl4 Phone#: �R'(01 Are yoy an employer? Check the appropriate box: Business Type (required): 1. I am a employer with i 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. 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 required]* 4. ❑ We by 1 I.❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other information. **If the corporate ofoers have exempted themselves, but the corporation has other employees, a workers' compensation policy is requited and such an organization should check box # 1. I am an employer that is providing workers' compensadon insurance for my employees. Below is the policy information. Insurance Company Name: G )V\C- (=icCOr•t C Insurer's Address: P • CG. !`ia City/State/Zip:—Pe cui 84?A=e_ - Policy # or Self -ins. Lic. # Expiration Date: ? - 1 -09 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 certifymetier the pains and penahies_9fj%adury that the information provided above is true and correct. I Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitiLicense # 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 w .mass.gov/dia ACORD,H DEcsnoNu _ , CERTIFICATE OF LIABILITY INSURANCE DATE (MMIODIVYYY) 'PRODUCER 10/U2/08 Starkweather & Shepley THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE PO Box 549 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Providence, RI 02901-0549 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 401 435-3600 INsuRED INSURERS AFFORDING COVERAGE NAIC # Decs Donuts, Inc, INSURER A: ONEBEACON INS/DONUTS 86B WASHINGTON STREET INSURER B: Chubb & Son PLAINVILLE, MA 02762 INSURER,: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 4NV RFrll IIq FR,iFMT TERM (1R rmin1TinN r1F ANY QnNI"-EAFFDRDED BY THE PLI F rOLiGiES`AuGFIEGATE LIMITS SHOWN MAY HAVE BEEN R `(3R ADD' _TR 9R TYPE OF INSURANCE PO A GENERAL LIABILITY FB2U03336 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JEC LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS GARAGE LIABILITY ANY AUTO IED TO THE INSURED NAMED ABOVE FOR THE POLK OR OTHER DOCUMENT WITH RESPECT TO WHICH TI IESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, JED BY PAID CLAIMS. IBER UATEY EFF%CTWE POLICY EXPIRATIO OA E MMIDO/YY 07/01/08 07/01109 ro<uV33J6 *XRETENTION OCCUR CLAIMS MADE D7/D7/D6 67%D7/61 DEDUCTIBLE RETENTION §10000RS COMPENSATION AND 406022472 ERS' LIABILITY 07/01/08 07/01/09OPRIETOR/PARTNER/EXECUTNERIMEMRER EXCLUDED? ecrlbe underL PROVISIONS belowEmploymentR802832311/15/07 11/15/O9 d PracticestV DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I9PECIAL PROVISIONS *10 days notice applies for non-payment of premium cancellation Town of Mansfield 6 Park Row Mansfield, MA 02048 u t MAY BE ISSUED OR AND CONDITIONS OF SUCH EACH COMBINED SINGLE LIMIT (Ea accldent) $ BODILY INJURY (Per Perecn) $ BODILY INJURY (Peraccident) $ PROPERTY DAMAGE (PeraccMenl) IS OTHERTHAN AUTO ONLY: $1,000,000 Each Occur. $3,000,000 Aggregate SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT "ALL —'RE To 00 SO SHALL MTPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESEN ATWE 'kt�94.w.Y 1 of #S199518/M19951c RLS O ACORD CORPORATION 1988 ON m \\ \\ 2— ) )\ \ \ ( \\� \ &{\ $ \ ) \\\ � / ) \\\ ) 22 f \ ] � k \