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HomeMy WebLinkAboutMansfield Adult Day Health Center - 12/31/20204�',' ,__ FOR BOARD OF HEALTH USE ONLY Permit #Issued NUP'OWTSTABLISHMENT PERMIT APPLICATION __(AppficaAon must e submitted al least 30 days before the planned opening date) Establishment Name MANSFIELD ADULT DAY HEALTH CENTER Establishment Address 300 Branch Street Establishment Mailing Address (if different) 300 Branch Street, Mansfield, MA 02048 i Establishment Telephone No (508) 339-2119 Applicant Name & Title: Dawn Sullivan, Director of Clinical Services/COO I Applicant Address 10 Emory Street, Attleboro, MA 02703 Applicant Telephone No.: (508) 222-0118 24 Hour Emergency No.: (508) 695-0359 Applicant Email dsullivan@communityvna.com Owner Name & Title (If different from applicant) HEALTHCARE OPTIONS, INC Owner Address 10 Emory Street, Attleboro, MA 02703 Owner telephone number (508) 222-0118 Owner email: f Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or U An Association partner. O A Corporation Name Title Address J O An Individual'Ne�O �P/3Aa v/ GAS A Partnership O Dther legal Entity tiGGfx✓ �� 6 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Karen C. Amado, Program Director Address: 300 Branch Street, Mansfield, MA 02048 Telephone No: (508)339-2119 24 Hour Emergency No. FAX: (508) 339-3820 E-mail: kamado@mansfieldadhc.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Dawn Sullivan, Director of Clinical Services/COO Address: 10 Emory Street, Attleboro, MA 02703 Telephone No: (508) 222-0118 24 Hour Emergency No.- o.FAX: FAX:(508) 226-3573 E-mail: dsullivan@communityvna.com J Food Establishment Information WATER SOURCE: TOWN SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable)I No, of Food Employees: 1 rDAYS/HOURS: Mon - Fri 7:30am to 4:30pm ._............. _-1_____--____'____- ---- ---- --------- Name of Person(s) In Charge Certified in Food Protection Management: Richard Keefe, Food Service Coordinator Karen C. Amado, Program Director ! Name of Person(s) In Charge Certified in Allergen Awareness Training Richard Keefe, Food Service Coordinator I _ 1 Name of pest control company routinely inspecting the premises for evidence of pests Braman If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. O Yes -- ..... -- ..... ------ ------_-------- Does this establishment require a FOG permit? NO If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual 0 Retail Food 5125.00 Q Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 O Manufacture Frozen Desserts(Ice Cream Q Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: 1761 Supermarkets $400 0 Residential Kitchen $100.00--- Rain Date: Q Milk &Cream $10.00 Q Caterer $35,00 — Food Operations: Definitions:PHF- Polenfially hazardous food (hmeAemperaWm confrots required) (Check all that apply): NomPHF's-rrompotentially hazardous foadpo BmeRempemlum controls required) RTE - ready -to eat foods (Ez+ sandwiches, salads, mu/fins which need no furtherp ocessing) Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service �V Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hol And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Q Sale of Raw Animal Foods intended 21 Reheating of Commercially to be Prepared by Consumer (]' Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand Q Customer Self -Service of Non PHF and Non Customer Self -Service contact alternative, time as a public health Perishable Foods Only Q Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale t� Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities Prepares FoodlSingle Meals for Retail Safe of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, 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 1¢,e feppai Food Code. Signature of Applicant: 11 — ----I __✓ `^---- Pursuant to MGL Ch.62C, sec. 49A, i certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid slate lazes required under law. Social Security Number or Federal to: 22-2543620 Signature of Individual or Corporate Name: ���—/%���7�C%�yPT/���>�� /�✓G- __ 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 Individual or Corporate Name By: Corporate Officer (Mandatory, f Applicable) ')a-asy36c�-o "*Social Security No. (Voluntary) or Federal Identification Number *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. QUlsersislcite\Desktop\Scott's Om mentsWwd Establishments-'temp\TAX CGRTIpICA"I[ON FOR M.doc Information and Instructions Massachusetts General Laws chapter 152 requires all employers m provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written" An ernplover is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's uar., address and phone nufnbcr along with a certiftcaie of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Fan LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and In legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to 611 in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give its a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26.05 The Commonwealth of Massachusetts UTDepartment of lutfuslrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Bus iness/OrganizationName: '���� Olt'/lTa✓S, /��� Address: /6 %/'zd,�>Z City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): I.© I am a employer with employees (full and/ 5. Retail or part-time).* 6. Restaurant/BarlEating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. r] Office and/or Sales (incl. 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 theit ri Iit of exemption per e, i 52, $ t(4), and we ;lave i 0.Q Manufacturing no employees. [No workers' comp. insurance required]** 4.0 We are a non-profit organization, staffed by volunteers, I L�Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Ane annlicaut th:u checks hos N I must also fill out the section below showinz their workers' compensation notice information **If the corporate officers have exempted themselves, but the corporation has other employees, it workers` compensation policy is required and such an mgunizatiort should check box fl. I ant an employer that isproviding workers' co ipensation hrsurance for mp employees. Below is the police information, Insurance Company Name:_��%�% Insurer's Address: C� `Y IL15L,- �� pv�✓ � _ __ City/State/Zip: /J?OJ od- Policy # or Self -ins. Lic. # O 0 0% A� " CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDYYVYI 9/24/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh & Mclennan Agency LLC - New EnglandPHONE 100 Front St, Ste 800 Worcester MA 01608 CONTACT NAME: Daren Gedenberq — — FAX --- - 888-850-9400 A/c Ne : ass -795-8016 ADDRESS: MMA,NewEngland,CLines@marshmc.com INSURERS AFFORDING COVERAGE NAICR INSURER A: Philadelphia Indemnity Insurance Co. 180_58 10/1/2020 INSURED COMMUHEALT6 Community Health Systems Inc. 10 Emory Street----- INSURER B: Atlantic Charter Insurance Company 44326_ wsuRERc: Beazley Insurance Company,Inc. 37540 INSURER D: Attleboro MA 02703 INSURER E: DAMAGE TO RENTED PREMISES5100,000 INSURER F: S20,000 COVERAGES CERTIFICATE NUMBER: 119601405 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN LTR TYPE OF INSURANCE ADOL INRn SUER WVQ POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDWW LIMITS A GENERALLIABILITY PHPK2036134 10/1/2019 10/1/2020 EACHOCCURRENCE Sl.DW000 TXCOMMERCIAL CLAIMS -MADE � OCCUR DAMAGE TO RENTED PREMISES5100,000 MEL) EXP (Any one person) S20,000 essional Lia selMeleslatio PERSONAL&ADV INJURY $_1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE X PRO- POLICY ❑ JECTPRO- ❑LOC PRODUCTS-COMP/OP AGG _$3,000,000 $3,000,000 _ $ OTHER: • AUTOMOBILE LIABILITY PHPK2036129 10/1/2019 10/1/2020 COMBINED SINGLE LIMIT ire accident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED XSCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X HIRED x NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAR X OCCUR PHUB693138 10/1/2019 10/1/2020 EACH OCCURRENCE 55,000,000__ AGGREGATE $5,000,000 EXCESSLIAB CLAIMS -MADE DED X RETENTIONS in rinn $ B B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN WCA00301517 WCE00445600 1/1/20191/1/2020 1/1/2019 1/1/2020 X PER EORH E.L. EACH ACCIDENT $ 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBEREXCLUDED9 N NIA E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) It yes, describe Led r — DESCRIPTIONOFOPERATIONSbelow E.L. DISEASE -POLICY LIMIT $1,000,000 C Nelwark Security V19ABA190501 10/1/2019 10/1/2020 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Named Insured's Community Visiting Nurse Agency (CVNA) Healthcare Options, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Insured ©1988-2015 ACORD CORPORATION. All rights reserved. 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