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Home My WebLink AboutDunkin Donuts - 377 Chauncy - 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:. WILLIAM DONOVAN & KEVIN DONOVAN Whose place of business is: DUNKIN DONUTS @ STOP & SHOP 377 CHAUNCY STREET PERSON(S) IN CHARGE: CHARLES JACKSON, GENERAL MANAGER Permit Expires: June 01, 2010 License Number: FS-16 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: WILLIAM DONOVAN & KEVIN DONOVAN having a place of business at: DUNKIN DONUTS @ STOP & SHOP 377 CHAUNCY 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 No.: FS-16 Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY (U Date received Date Inspected: Approved By: Permit # Issued FS-16 FOOD ESTABLISHMENT PERMIT APPLICATION (Aoolication must be submitted at least 30 days before the planned ooeninq date) 1) Establishment Name: DUNKIN DONUTS @ STOP & SHOP 2) Establishment Address 377 CHAUNCY STREET T _ 3) Establishment Mailing Address (if different) P.O. BOX 312 MANSFIELD, MA 02018 APR 1, 7 2009 4) Establishment Telephone No: 3y 5) Applicant Name & Title WILLIAM DONOVAN & KEVIN DONOVAN 6) Applicant Address 195 DEERFIELD LANE, HANOVER, MA 7) Applicant Telephone No.: (781) 953-6925 24 Hour Emergency No.: (781) 953-6925 8) Owners Name & Title WILLIAM DONOVAN & KEVIN DONOVAN 9) Owner Address (If different from applicant): 195 DEERFIELD LANE, HANOVER, MA 10) Establishment Owned By: ❑ An Association ❑ A Corporation ❑ An Individual, ❑ A Partnership U Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address j�v .�� y> �p c� — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: Address: - Telephone No: --� rc ,i97 ;u�- 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 5 17) DAYS/HOURS: 7 DAYS 6:00 AM -10:00 PM 18) Name of Person In Charge Certified in Food Protection Management: CHARLES JACKSON If more than 3 individuals are certified, complete list is on file. Required 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): 20) Location: Permanent Location 22) Establishment Type ❑ Bakery $25 ❑ Mobile Mobile Start Date: ❑ Retail ( 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 Ci Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: Annual or up to 25' PHF display $100 Food 01 + Service up to 2 or 25PHF display 1 ❑Food Service -Institution ( Meals/Day) ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Dessertslice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: ❑ Retail Snack Food $10 Temporary Time: ❑ Tobacco Products No Fee Rain Date: - - 23) Food Operations (Check all that apply): Definitions: PHF- Potentially hazardous food hime4emperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) 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 for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs -- ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service -. ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility --- -- - ---- ❑ Delivery of Packaged PHFs - ---- _. -- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer -- - ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill — - -- ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand _ ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board alth ofHe$75.00 -------------"._-- --"-- Total Permit Fee: 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 col yx)h 105 CMR 5v40.0Q0 and all other applicable law. I have been instructed by the board of health on how to obt m c d s of 105 taf�ft 590.®00 and the federal Food Code, 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under p naItie of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. �A �1 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate N 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: DUNKIN DONUTS @ STOP & SHOP ADDRESS: 377 CHAUNCY STREET TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: WILLIAM DONOVAN & KEVIN DONOVAN TELEPHONE OF OWNER: (781) 953-6925 FEDERAL ID/SS NUMBER: 04--3513535 FEE: $2.00 PERMIT NUMBER: FS-16 SIGNATURE: DATE: 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) ** 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 o Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization/Name:L&2 Address: 2'7 7 ('lnl4i/n/c t-4 /vt City/State/Zip: c ` Phone#: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with: employees (fill: and/ 5. EUAetail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inch. 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officc;s 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 tlmt is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 .-3 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 www.mass.gov/dia Phone a� 333 S Wabash Chicago, Illinois 60604 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - RENEWAL OF WC 2 84382102 WC 2 843821021 08/01/08 08/01/09 INATL FIRE INS. CO. OF HARTFORD 1045558120 Named insured llnill pddIn $ Agent , DONOVAN SERVICES INC FRED C. CHURCH INC 72 SHARP STREET UNIT A-7 41 WELLMAN ST--CONNECTOR PARK HINGHAM, MA LOWELL MA 01851 02043 ** N A M E A N D A D D R E S S S C H E D U L E ** SCHEDULE PAGE 4 LOCATION ENTITY `-� ...... .-.-....,, ENTITY NAME AND ADDRESS 019 004 SECOND Q LLC\� 377 CHAUNCEY ST l MANSFIELD , MA 02016 J FEIN=043513535 020 001 DONOVAN SERVICES INC--736 CAMBRIDGE STREET BOSTON , MA 02135 FEIN=043000008 021 001 DONOVAN SERVICES INC 72 SHARP STREET HINGHAM , MA 02043 FEIN=043000008 022 001 DONOVAN SERVICES INC 220 GREAT ROAD LITTLETON , MA 01460 FEIN=043000008 , S 023 007 AYLIT LLC 25 KING STREET LITTLETON , MA 01460 FEIN=043324426 s DATE OF ISSUE: 06/18/08 POLICY ISSUING OFFICE: NEW ENGLAND WC000001 P-33398-E (ED. 6/87) TNRTTR P..T) U d a