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HomeMy WebLinkAboutThe Store (Kanku, Inc.) - 12/31/2020s- FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name Vp'g J. <ij IJC Establishment Address �-Of �" jai Establishment Mailing Address (if different) Establishment Telephone No 9 - _� 3 `? - V Applicant Name & Title: Applicant AddressI1,0 M tr1 Applicant Telephone No.: _50 F), Gf e) I - qa-.) A'' 24 Hour Emergency No.: Cd - If,o "a__-I� ApplicantEmail 1'4.e, 199-79,� e"�1,e,6" Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or : An Association partner. )� A corporation Name Title Address i_a An individual__- 7 A Partnership ---- -- ----- i' Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 14 ?q'�dv_r+a-1 Address: 110 /vP1t",'rA% 9 1-t A,,0A0Jy f /b9 Ole? lop Telephone No:24 Hour Emergency No:�t1 FAX: 1 E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX. E-mail: WATER SOURCE: , # DEP Public Water Supply No: (It applicable) DAYS/HOURS'. Food Establishment Information SEWAGE DISPOSAL: T-0 yj No. of Food Employees: Name of Person(s) In Charge Certified in Food Protection Management; Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests 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. � J Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: .nnuai Retail Food $125,00 i`) Mobile Food Consession . Temporary ( Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE 5100,00 FOOD TRUCKS $175.00 -� Manufacture Frozen Dessertsoce Cream Temporary Start Dale: [Food Service up l0 101 -200 $250.00 S25.000feezer Temporary End Date. Food Service up to 201 * $30000 Pushcart $50,00 !f of Pushcarts Temporary Time. [Supermarkets $400 ❑ Residential Kitchen$10000 Rain Date. Milk & Cream $10,00 [ Caterer $35,00 Food Operations: Do6nittons: PHF - Pohmrleuy hazardous food(timefremperatum WAaWs required) (Check all that apply); Non-PHFs-non-poten6elty hazardous(oodrno limettemperature controls required) RTE - ready-taeat prods (Ex. sandwiches, salads, muffins whichneadno funherprocessOlu V Sale of Commercially Pre -Packaged Non-PHFs [-) PHFCooked To Order Sale of Commercially Pre -Packaged PHFs [ Preparation of PHFs For Hot And Cold Holding For Single Meal Service Lj Delivery of Packaged PHFs Sale of Raw Animal Foods Intended (•: II Reheating of Commercially to be Prepared by Consumer Prorsssed Fonds for Service Within 4 Hours F Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations Customer Self -Service ] Ice Manufactured and Packaged for Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [j PHF and RTE Foods Prepared For Highly Susceptible Population Facility Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative. time as a public health control) Offers Raw Or Undetcooked Food Of j Juice Manufactured and Packaged for Animal Origin Retail Sale i,J Vacuum Packaging! Cook Chill _) offers RTE PHF in Bulk Quantities ,i1 prepares Food/Single Meals for i.. ] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, 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 590o00 and the federal Food Code. Signature of Applicant _ '� Z' " atk-f Pursuant to MGI. Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid slate taxes required under law. Social Security Number or Federal ID. L,r Signature of Individual or Corporate Name. TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. roc Signature of Individual or Corporate Name 0 u - .3<_'2 /IAIX "Social Security No. (Voluntary) or Federal Identification Number u A)<'Mc.4 PL-t� By: Corporate Officer (Mandatory, if Applicable) *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:\U,w"\slciteVJesktop\.Scott's DocumeNsUnod Estublishinents-'t'cmp\'IAX CERTIFICATION FORM.doc The Conunonwealth aj-Massachuselts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV ww"wnass.govIdia Workers' Compensation insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Natne:_(" K i) t_p 1,,.Gr�__ 92 Address:,.3Cl-�i'` City/State/Zip: Are you an employer? Check the appropriate box: L� i am a employer with employees (full and/ or pan -time),* 2. ❑ 1 and a sole proprietor or partnership and have no employees working for rue in any capacity. lNo workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees, lNo workers' comp, insurance required)' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. iNo workers' court). insurance real Phone 4: Business Type (required): S. ®Retail 6.❑RestaurantBar/EatingEstablishmetn 7. ❑ Office and/or Sales (fuel. real estate, auto, etc.) 8. ❑Non-profit 9. ❑Entertainment 10.❑ Manulacturing I LFJ Health Care 12.❑ Other _ 'Any applicant that checks box If I must also fill out the section below showing their workers' compensation policy infommtion. "If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an or'Katization should check box N 1, ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:k! 11 jj n1 f /age nt^tA��/�S Insurer's Address: Q^j VA�jt City/State/Lip: () CA5;ltl 7 — Polity # or Self -ins, Lic. # l9 i ti 00 5O 3e-A 4 S t•i 119 Expiration Date: i2 f % L1 / � ✓1e) Attack 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 fit the form of a STOP WORK ORDER. and a line of up to $250.00 a day against die violator. Be advised that a copy of this statement may be forwarded to die Office of Investigations of the DIA for insurance coverage verification. I do herehl, cerlify, under the pains and penalties• of perjury that the information provided ahove is true and correct. Signature: 0' ,,_�'i 0 Date: Official use only. Do not write in this area, to he completed by city or town official. City or Town: PermidUccuse Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectinen's Office 6. Other Contact Phone www.mass.gov/dm /ate a® CERTIFICATE OF LIABILITY INSURANCE �10/181200 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 REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcypes) must 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 Ileu of such endorsement(s). c PRODUCER NAME jjFAN HUB NE Association Programs PHONE "- - - - IA/G I IAJc, Nol'. 300 Ballaidvale Street EMAIL Wilmington, MA 01887 ADDRESS _ -- - - INSURER(S)AFFORDING COVERAGE _- I NAICa u�„eGe A MA Retail Merchants WC Group Inc. INSURED INSURERS; Kanku, Inc. INSURER C. dlb/a The Store 213 South Main St. INSURER D - - Mansfield, MA02048 INSURER E. ". rconcrrnre .111"01=0. nnnni -- - REVISION NUMBER: 00001 a 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 POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ N6F' TYPE OFINSURANCE AUOC UBR T MF POLIC EXP LIMITS LTR I POLICY NUMBER 1 MMIDDIYW MWO I OENERAL LIABILITY EACH OCCURRENCE IS - DAMAGEYORENTED I I COMMERCIAL GENERAL LIABILITY PREMISES_LEa oaurrer2e) _i `+ _ CLAIMS MADE OCCUR 4 MILD UP (My one petwn) 5 _ _-- PERSONAL& AOV INJURY _ -IS GENERAL AGGREGATE GEI,LAGGREGATEPLIRMIT APPLIES PER'. ;COMB 5 O POLICY L.. T LOC S NCED MNOM11�rOP LIMIT ' AUTOMOBILE LIABILITY I BODILY INJURY (Pet person) IS BODILY INJURY (Peraaidani) 5 -�ANYALUG ALLOWNED SCHEDULED AUTOS _ AUTOS NON OWNED PRO EP Rn DAMAGE 5 HIRED AUTOS AUTOS (Pe,gcNdenl ._ I ' I 5 UMBRELLA UMBRELLA LIAR I OCCUR I EACH OCCURRENCE I EXCESS LIAB f CLAIMS-MA_D_E_ I AGGREGATE _ S ____ DED RETENT10145 S KER IT -- AND EMPLOYERS' LIABILITY y/N E LEEACH 100,000 AANNfl ROPS RtETORRWARTNERIEXECUTIVE OFTICE MAEMBER FXCLUDED'1 NIA ACCIEB�S Af , (Mandatory In NH) 014005032484119 1/01/2019 1/01/2020 EMPLOVEq 6 1001,000 II ,esd 'Ihe urcer ! f)SGRIPTION OF OPERATIONS helm EL DISEASE POLICY LIMIT r 1 5 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aeach ACORD 101, Additional Remarks Schedule, IT more space Is required) Town Or Mansfield ATTN:Jane Doucette 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD