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HomeMy WebLinkAboutFamily Food Mart - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued ;:nn l f=QTARI IQI-IRAPKIT DGDRAIT ADDI Ir`ATInKl (Application must be submitted at least 30 days before the planned opening date) Establishment Name DIVyq AVI-IOND Tyo)T C-PP. c4ct. F_6/m)by r=a-T lY011 Establishment Address 660 FrAlc - 0 � 0 z-O l V Establishment Mailing Address (if different) Establishment Telephone No 5Di6_- 339 Applicant Name & Title: P11RN A V P r�A T r "L- 0 W t I (L Applicant Address 0114 S7 �ifiJ 1714md6ldcC %nA 02aA V Applicant Telephone No.: '141 . 24 Hour Emergency No.: q-ci' Applicant Email P--Iroi wv Pei k I e � t`1 ui � • (fi ^ 1 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 Ed An Association partner. [I] A Corporation Name Title Address 0 An Individual _ C] A Partnership IJ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Pik 6" kJ Pff � qA_ IOW 1`I PL(L Address: 0), I-t-Mw�h iI fj91 % • I01Qr"S ife-Icytr i Telephone No: a SiSI Z 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: To wiII SEWAGE DISPOSAL: T o w )JI DEP Public Water Supply No: (If applicable) of Food Employees: _t:No. DAYS/HOURS 00M SvI\J —r;.?D HM io io•0o-- 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. 0 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: IF] Annual Retail Food $125.00 n Mobile Food Consession E] Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service u to 201 + $300.00 p Q Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Q Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs- non -poser its lly hazardous lood(no time/tempera lure controls required) ATE - ready-lo-eal foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held Sale of Commercial) Pre -Packaged PHFs y g IJ Preparation of PHFs For Hot And for More Than a Single Meal Service i. Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Reheating Commercially Susceptible Population Facility of to be Prepared by Consumer Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance 0 Customer Self -Service and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only LJ Ice Manufactured and Packaged for control) 0 Preparation of Non-PHFs Retail Sale Q Offers Raw Or Undercooked Food Of I] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for El 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 690.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, 1 certif and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns — 311( - Li51 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. Signaturd of Individual or Corporate Name 41- 3 1 k -4I *"Social Security No. (Vohmtanj) or Federal Ideatifi'rntion Number RANt+V PaTCL_ 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\SCOWS Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwmmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Di V10 AVHOQID lyolr (-U- 4c(, A-0MART Address: 660 [ftV. i ST City/State/Zip: RNSF11-zl.I) p13+ 02oti f Phone #: 339 ' 6 �-cj 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. [No workers' comp. insurance required] g• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care urance with no employees. [No workers' comp. insreq.] 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 #1. I am an employer that is pro#ing workers' coarlpensapon insuraneoor nay employees. Below is the policy information. Insurance Company Insurer's Address: PO go A , H 16 r� W / City/State/Zip: / k" - 9ctyyr— 002 O Policy # or Self -ins. Lie. # D 1 r,l Co /y 4- 1 iS Expiration Date: 0 h) If 1 iy Z 0 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 hereby certify, under the pains and penalties of perjury that the information provided above is true and correct D I.-q Phone#: 711(- SS_i - 6 � z 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia FAMIF01 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 1012312 Y019 0/23/29 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 endorsemen s . PRODUCER 508-947-1818 J.K. 011vled Ins. Agency 64 East Grove St Middleboro, MA 02346 Kenneth W. 011vleri C NWACT Kenneth W. Olivier! PHONE 508-847-1818 FAX ac xo Eat : a° No): 2 AIL 1 9URER9 AFFORDING COVERAGE NAIL INSURER A 1 Guard Insurance INSURED Family Food Mart DI a Akhand Jyolt Corp 886�Eastt Street Mansfield, MA 02048 INSURER B: INSURER C q INSURER D: INSURER E : .., INSURER F: REVISION NUMBER: S 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. INSR1 TYPE OFINSURANCE ADDL SUB POLICY NUMBER POUCY EFP .POLH:Y EXP LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Business Owners DIBPO58622 05/1212019 06/12/2020 EACH OCCURRENCE 4 1,000,000 PWETFSO eREN�iED 6D,9QQ X MEo w An ono arson 6,000 ' PERSONAL AADV INJURY Included GENLAGGREGATE UMITAPX I SPER X POLICY ❑ jEp7 LOG GENERAL AGGREGATE 2,000,000 PRODUCTS-COMPIOPAGG 2,000,000 COMBINED SINGLE LIMB AUTOMOBILE LIABILITY BODILY INJURY Wor person) ANY AUTO BODILY INJURY P aetidml OWNED SCHEDULED AUTOS ONLY FA7l�iT�0p5yyryEp AUTOS ONLY AUrOB ONLY ��eE�R�aYnDAMAGE UMBRELLA UA6 OCCUR EACH OCCURRENCE AGGREGATE EXCESS LikB CLAIMS -MADE DEC RETENTIONS A A wONHERB cOMPBNSATION ANDEMPLOYERS'LUIBILITV Y N ANY PROPRIETORIPARTNERIEXECUTIVE O4FlCEAIM5M.W) EXCLUDED? N (ntandatafy in NN) R dedbuFdar IF N PERA S below Business Owners Liquor Liability NIA DIWC047518 DISP058622 04/15/2019 05/12/2019 04/16/2020 06/1212020 X PER OTH- E.L. EACHA CADENT 500,000 Ii E.L DISEASE EA EMPLOYE 600,000 EAS 500,000 See Limits Belo DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1e1, Additional Remarks Sehaduis, may be attached U more apace is required) Liquor Liability Coverage: t1,000,000 Each Common Cause Limit 2,000,000 Liquor Liability Aggregate Limit Town of Mansfield 6 Park Row Mansfield, MA 02048 MANST02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WnH THE POLICY PROVISIONS. I ARR-2015 ACORD The ACORD name and logo are registered marks of ACORD All rights reserved.