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Home My WebLink AboutDomino's Pizza - 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: RETAIL FOOD 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:. DUFFICY ENTERPRISES, INC. Whose place of business is: DOMINO'S PIZZA 235 CHAUNCY STREET PERSON(S) IN CHARGE: CORYNTHIA SIMPSON Permit Expires: June 01, 2010 License Number: RF-110 Food Fee: $50.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF-110 FOOD ESTABLISHMENT PERMIT APPLICATION (Aoolication must be submitted at least 30 days before the ,planned ooenino date) 1) Establishment Name: DOMINO'S PIZZA f• 2) Establishment Address 235 CHAUNCY STREET 3) Establishment Mailing Address (if different) 2 MILL STREET APR 2 Z 009 FRANKLIN, MA 02038 4) Establishment Telephone No: (508) 339-1000— o® 5) Applicant Name & Title: JEFFRY P. DUFFICY 6) Applicant Address 2 MILL STREET, FRANKLIN, MA 02038 7) Applicant Telephone No.: (508) 520-1000 24 Hour Emergency No.: (508) 854-7783 (774) 210-0293 8) Owners Name & Title DUFFICY ENTERPRISES, INC. 9) Owner Address (If different from applicant): 2 MILL STREET, FRANKLIN, MA 02038 10) Establishment Owned By: ❑. An Association ❑O A Corporation El An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation,or, partnership, give name, title, and home address of officers or partner:. r �' Name Title Address n�v y 2r 01i,f 2 ryliL,( sf Zv3Y 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: /2� (..06 n�1(7 Address: Telephone No: 24 Hour Emergency No: 5ozi. 777. it7U�� isC�T.£'x� v931 FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: �,/v JCR va Z 0 Address: Z M t L Telephone No: 'u� 52,C, -I o00 24 Hour Emergency No: 7i 5�73 i S FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 2 17) DAYS/HOURS: 11 AM-12 MIDNIGHT SUN-THURS 11 AM-2 AM FRI-SAT 18) Name of Person In Charge Certified in Food Protection Management: 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 ALY DIENE JEFFREY P. DUFFICY JOSEPH MCKENNA 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: W Permanent Location 22) Establishment Type ❑ Bakery $25 ❑ Mobile Mobile Start Date: W Retail ( 1,500 Sq. Ft) ❑ Caterer $25 Mobile End Date: ❑ Food Service up to 100 or Food Delivery $25 Mobile Comments: up to 10' PHF display $75 ❑ Food service up to 101 -200 ❑ Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: ❑� Annual or up to 25' PHF display $100 ❑ Mobile Food Temporary $25 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: ( Meals/Day) ❑./ Retail Food $50 Temporary End Date: ❑ Retail Snack Food $10 Temporary Time: ❑ Tobacco Products No Fee Rain Date: 23) Food Operations Definitions., PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous tood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑d Sale of Commercially Pre -Packaged Non-PFHs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑d Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ❑ 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 Customer Self -Service of Non PHF and Non - Perishable Foods Only of Non-PHFs Other Food Operations I, the undersigned, attest.tdfhe+ establishment operatiy will cofr board of health on how to obtain 24) Signature of Applicant Customer Self -Service Ice Manufactured and Packaged for Retail Sale and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Orioin RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ——t or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $50.00 Payment is due with application ❑ waived f the information provided in this application and affirm that the food )5 CMR 590.000 and all other applicable law. I have been instructed by the 105 CMR 590,000 and the federal Food Code. Pursuant to MGL Ch.62C, s 49A, ( certify under the pe ies of p rj that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes requirea under law. 25) Social Security Number or Federal ID: 04306284 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. %,U1Nv1aLo IYQI110 krvianuaw'y! (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 Legibly Business/Organization Name: PIyrr"c� E�vi 1z i Al�c fig/} �orvl;na� T I Z Z Address: .13 5 Cat A cc n Q.)ootiF Phone#: 335- 10e)6 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 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 4. ❑ no employees. [No workers' comp. insurance required]* We by I1.❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers', comp. insurance req.] 12.❑ Other *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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below Is the policy information. Insurance Company Name: Tn PeLp5 ; M1.54 A'2t1c C m Insurer's Address: �[ om` e Ave- a i.( -e City/State/Zip: �Q Q Ix, N �+ Policy # or Self -ins. Lic. # lU L i-%13 Ll1,2 D Expiration Date: q 3o n4"C `) 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 anor 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 g inst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investiatil s 6i tTiA DI or insurance coveraee verification. I do heryby certify,) ndikithe 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: 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.moss.gov/dia CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDPMY) 10/13/2008 PRODUCER (603) 432-6414 FAX: (603) 432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Financial Insurance Services Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 950 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POI_ICIFs BFI nw 03053 INSURED Dufficy Enterprises, Inc. PO Box 707 Franklin MA 02038 INSURER E: CO THE POLICIES OF INSURANCE LISTED BELOW 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L LTR INSRO TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE MMIDD/YY POLICY EXPIRATION OATS MMIDDNY LIMITS GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCUR ROP8093340 12/1/2007 12/1/2008 EACH OCCURRENCE 1, $ 000,000DAMAGE TORENTED ISES Ea occurrence $ 50,000 ME,EXP(Anyone arson $ 5,000 PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG$ 2,000,000 PRO_ X POLICY JECT LOC AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X A ALLOWNEDAUTOS SCHEDULED AUTOS BA9663221 10/23/2007 10/23/2008 BODILY INJURY (Per person) $ HIREDAUTOS NON-OWNEDAUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) $ GARAGE LIABILITY ANYAUTO AUTO ONLY, EA ACCIDENT $ OTHERTHAN EAACC $ EXCESSIUMBRELLA LIABILITY AUTO ONLY: qGG $ OCCUR CLAIMS MADE E CHO URRE CE $ 2,000,000 AGGREGATE $ 2,000,000 $ B DEDUCTIBLE X RETENTION $10,000 CUP9135739 12/1/2006 12/1/2007 - $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNERIEXECUTIVE lfyesOFFICER/Mbe and EXCLUDED? SPECALPR PROVISIONS SPECIAL PROVISIONS below WC9784120 9/30/2008 9/30/2009 O STATU- LOR $ E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 $1, 000, 000 O OTHER Hired Non Owned Auto Liability 06nmtzW9646 9/30/2008 9/30/2009 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CCOTinrnTo unr ,.�., SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE %CORD 25 (20011081 W ACORD CORPORATION 1988 Pons t nrI nc mm y d m m0 ONm o NON �No co�0) RM I m FAX NO. :s s a m Oct. r 2006 a:z n» d6 THE NATIONAL REGISTRY OF FOOD SAFETY PROFESSIQNALS® CERTIFIES MICHAEL MCABEE HAS SUCCESSFULLY SATISFIED THEIREQUIREMENTS FOR Notification of Test Result ID#: xxx-xx-8628 Scaled. Test Score: 91 Candidate Status: Pass Test Date: December 3, 2008 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. THE FOOD SAFETY MANAGER CERTIFICATION EXAMINATION l.nisn'rri:ie.l. ll7rc•!r ISSUE DATE: DECEMBER 3, 2008 CERTIFICATE NO: ZS20326156 TEST FORM: ZSF This certificate Is not valid for more than five yean from data of 0sm. National Registry of Food Safety Professionals) CERTIFIED FOOD SAFETY MANAGER MICHAEL MCABEE 1M Certificate No: ZS20326156 Issue Dale: December 3, 2008 MICHAEL MCABEE 95 DEXTER ST ATTLEBORO, MA 02703 Ensure Food Protection (You scored 91% correct). Mastered Purchase and Receive Food (You scored 82% correct). Competent Food and Supplies Storage (You scored 91 % correct). Mastered Foods Preparation, Service & Display (You scored 89%correct). Mastered Equipment & Facilities Maintenance and Cleanliness (You scored 69% correct). Competent Personnel Hygiene, Training and Behaviors Related to Food Safety (You scored 100% correct). Mastered Legal Compliance (You scored 100% correct). Mastered National Registry of Food Safety Professionals® 1 5728 Major Blvd Ste 750 1 Orlando, FL 32819-0000 I Plione: 407.352.3830 I Fax: 407352.3603