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FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION _F 'if .a.
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name Wines & More - Mansfield
Establishment Address 280 School Street, Suite 140, Mansfield, MA 02048
Establishment Mailing Address (if different) 1405 Douglas Ave.
North Providence, RI 02904
Establishment Telephone No 508-339-6900
Applicant Name & Title: Kathleen Haronian, President
Applicant Address 98 A Nipmuc Trial, North Providence, RI 02904
Applicant Telephone No.: 401-353-4400 24 Hour Emergency No.: 401-465-2527
Applicant Email license@wsretailers.com
Owner Name & Title (If different from applicant) Same as above
Owner Address "
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
O An Association
partner.
A Corporation
Name Title Address
FA An Individual
Kathleen Haronian President Same as above
12 A Partnership
R Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Kathleen Haronian, President
Address: 98 A Nipmuc Trail, North Providence, RI 02904
Telephone No: 401-353-4400 24 Hour Emergency No: 401-465-2527
FAX: 401-353-4469
E-mail: sal@wsretailers.com
Alt E-Mail: license@wsretailers.com
District Or Regional Supervisor (if applicable)
Name & Title: Craig Power, Vice President of Operations
Address: 40 Whitelock Street, New Bedford, MA 02745
Telephone No: 401-465-2527 24 Hour Emergency No: 401-465-2527
FAX: 401-465-4469
E-mail: license@wsretailers.com
Food Establishment Information
WATER SOURCE: Town
SEWAGE DISPOSAL: Town
No. of Food Employees: 16
DEP Public Water Supply No: (If applicable)
DAYS/HOURS: Mon. -Sat. 9 aml0pm Sun. 12pm-6pm
Name of Person(s) In Charge Certified in Food Protection Management:
N/A
Name of Person(s) In Charge Certified in Allergen Awareness Training
N/A
Name of pest control company routinely inspecting the premises for evidence of pests Big Blue Bug
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 N/A
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
N Annual
N Retail Food $125.00
Q Mobile Food Consession
Ep Temporary
RI Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
® Manufacture Frozen Desserts/ice Cream
Temporary Start Date:
€1t Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
n Food Service up to 201 + $300.00
® Pushcart $50.00 # of Pushcarts:
Temporary Time:
nu Supermarkets $400 -
® Residential Kitchen $100.00
Rain Date:
Fri]Milk & Cream $10.00
(] Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(fimefemperalure controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous lood(no timellemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs [711 PHFCooked To Order
i] Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs m Preparation of PHFs For Hot And
for More Than a Single Meal Service
(] Delivery of Packaged PHFs Cold Holding For Single Meal Service
i] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
0 Sale of Raw Animal Foods Intended
Q Reheating of Commercially to be Prepared by Consumer
® Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
" Customer Self -Service
and/or HACCP Plan (including bare hand
iB Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only r Ice Manufactured and Packaged for
control)
E0 Preparation of Non-PHFs Retail Sale
® Offers Raw Or Undercooked Food Of
Fo Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Ed Vacuum Packaging !Cook Chill
M Offers RTE PHF in Bulk Quantities
n Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Dale
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 with105 CMR 590.000 and all other applicable law. I have been Instructed by the
board of health on how to obtain copies gf 105 CMR 59Q.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I ertii
and paid slate taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
the penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns
GT Retail Inc. d/b/a Wines & More - Mansfield
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.
Y
i a r f Individual or Corporate Name
27-2176426
"Social Security No. (Voluntary) or Federal
Identification Number
Kathy Haronian
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:\Users\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Tile Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
If 600 Wasieington Street
Boston, MA 02111
Ivwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Basinesses
Applicant Information Please PrintLev_ibly
Business/Organization Name: GT Retail Inc. DBA Wines & More -Mansfield
Address; 280 School Street Suite 140 •
Are you an employ01-7 Cheldc the appropriate box:
I. rXI I am a employerwith 16 employees (full and/
or part-time).*
2, ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workera' comp, insurance required]
311 We, are a. corporation and its officers have exercised
their right of exemptionperc. 152, §1(4), and we have
no employees. [No workers* comp, insurance regdir6d'
4• n We are a non-profit organization, staffed by volunteers
with no employees. [No workers' comp. Insurancereq.
Business Type (requircd):.
5. Q Retail
6. - ❑ Restamant/Bar/Eating Establishment
7. ❑ Office and/or Sales (inch real estate, auto, cte,)
8• ]Non-profit
9. ❑ Entertainment
10,0 Manufacturing
ILO Health Caro
*Any applicnit that cheeks box 111 must niao tit Out Ole section below snowingmmr wmaem v.......... r••••-s ••--•-_.._..
**lfthe corpoune officers have exampled Ihomselves, but the corporation has other employee a Workers' compensation policy is required and such an
mgmilsai(on should cheek box Itl.
(anrall ejaployerlbat is prov/ding Ivarlrersr compensation insurance for Illy employees, Below is Ole pollcy lnfo+vdation.
insurance Company Name: MA RETAL MERCHANTS WC GROUP INC.
Insurer's Address: P.O. BOX 859222-9222
City/State/Zip: BRAINTREE, MA 02185
policy or Self -ins. Lie, #
014005032912119 Expvation Date: 1/1/20
Attach a copy of the wmdcers' compensation policydaclarnfion page (slioaying fie policy number and expifation date):
Failure to secure eciverage as reyuu•edunder Section.25A of MGLc. 152 can lead to the imposition of ctdminal penalties of fine tip to $1,.500.00 anrl/Orone
-year imprisonment, as well ascivll penalties in the form of a STOP WORT{ ORDHR and a fine
Of up to: $250.00 a day against the violator. Be advised that a Dopy of this statement may be forwarded tothe Office of
r....e..O, f;, ,n of thr. niA fnr. insurance COYCI'age verifcatiott
1 do
AM
!Ira! the tufnrnmtin+t provided above isirne and cor`recY.
OJ11tclal nse only. Do not write in this area, to be completed by dhr or lolvu off elal.
City or Town: Permit/Licensel{
Issuing Authority (circle one):
1. Bom•d of Health 2. Building Department 3. city/Town Cleric, 4. Licensing Board S. Selectmen's Office
6. Other
wsvw.mass.gov/dia