The URL can be used to link to this page

Home My WebLink AboutFour Corners Convenience - 12/31/2020An FOR BOARD OF HEALTH USE ONLY Permit # Issued - FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name '-. -\ - 0 e" s Lcy-)v Establishment Address (� CjC i V\ MG S �'� r //�AA U2 Establishment Mailing Address (if different) Establishment Telephone No 0 j j Applicant Name & Title: G 2(t Applicant Address �-\ C) \ Applicant Telephone No.: �U _� `fit 7 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: ❑ An Association CA-kcorporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �✓0� e,\ Address: k�\ TelephoneNo: -� 52—Yv7 24 Hour Emergency No: Cjv—;}- FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: LNF0GE DISPOSAL: /V/N DEP Public Water Supply No: (If applicable) Od Employees' DAYS/HOURS:(i) Srn(_N\ _�' - (n 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. ❑ Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. th of Permit: Establishment Type: Annual I(J/ Retail Food $125.00 ❑ Mobile Food Consession ❑ Temporary ❑ 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: ❑ Food Service up to 101 -200 $250.00 $25.00#reezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Su ermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions: PHF-Potentially hazardous food (time/temperature controls required) Non-PHFs- non -potentially hazardous tood(not'meRemperafure controls required) (Check all that apply): RTE - ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot or More Than a Single Meal Serviceeld [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 ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ 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 ❑ ❑ Customer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health Perishable Foods Only (�Crce Manufactured and Packaged for control) El Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of ice Manufactured and Packaged for Animal Origin Other Food Operations etail Sale ❑ Vacuum Packaging / Cook Chill ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for ❑ 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 590.000 and the federal Food Code. Signature of Applicant: 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 stale taxes required under law. E � —0 c Social Security Number or Federal ID: 2-U �' Signature of Individual or Corporate Name: �� `6 f'� 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. Su\C�) LcN�cm; Cur Signature of Individual or Corporate Name `L U�1- G � —'A &-o L **Social Security No. (Voluntary) or Federal Identification Number By: orporate 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\Scott's Docoments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc p \ Inv l unlrnur we"e Ln uI IVA"aa L nua.".] _ Department of Industrial Accidents t z (vi Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly CnYI1� Business/Organization Name: � <JOVh CY Address: LA SUJ Mn MC1NI-\ St City/State/Zip: (3lt%vf1S�i'�' ��M ��/UZ � Phone #: 65U8, — 33 -2 Are you an employer? Check the appropriate box: Busiues Type (required): 1. ❑ I am a employer with employees (full and/ 5. l U", etail or part-time).* 6. F1 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. g. ❑ Non-profit o workers' comp. insurance required] 30 We are a corporation and its officers have exercised 9. F1 Entertainment their right of exemption per c. 152, § 1(4), and we have 10.Q Manufacturing no employees. (No workers' comp. insurance required]* 1 LQ Health Care 4.❑ We area non-profit organization, staffed by volunteers, 12.E] Other with no employees. [No workers' comp. insurance req.] *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 provt ng wor ers' compensation insurance for my a iployees. Below is the policy information. Insurance Compact, _ a e: / " ` , ` L��, PUL VW, S W Insurer's Address: + U 1�)C x 5 q 22_2 -OoZ 2_ aCity/State rU t(\ ee I.1� 1\ / U2 �� S Policy # or Self -ins. Lic. # 1 U w;(] 3-V U \ \ Expiration Date: T / U 1 / Z l) \ ,1 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 Phone #: 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 Person: Phone #: www.u. .., . VASUCO1 . ia. � " CERTIFICATE OF LIABILITY INSURANCE �� DATE 1012 12019 Y) 10/22/2018 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(les) 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 . PROWLER 508-947-1818 J.K. Olivieri Ins. Agency _ 84 East Grove St. Middleboro, MA02346 Kenneth W.Oiivleri cINT,,ArT Kenneth W. Olivieri FNDNE 508-947-1818 i FAX Alc No fiX4• .I(W,No): . AFFORDING COVERAGE NAICN _INSURERISI INSURER A: NGM Insurance Co. 14788 INSURED Vasudev �orporation dba Town News8ck8tAgency Mansfie , Md 6SS2b48 INSURER 11 : Technology Insurance Co. INSURER C: INSURER D: _ INSURER fi NSURER F ��.. ..�,.e,e'n•-'se u'measen. RFVIRIffA1 NUMBERS V V Y FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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. INSR TYPE OF INSURANCE AOOL IN SUB IN.COMMERCIAL pOUCY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY CLAIMS�MAOE a OCCUR Business owners BPF1371Y 11/30/2018 11/30/2019 EACH OCCURRENCE $ 1,000,000 DAMAGETOR - IENTED MED EXP (Any onePerson) 500,000 10,000 X PERSONAL &ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMITAPPL[ES PER: pp�� X POUCY Eljp07 E] LDC GENERALREGATE It 2,000,000 PRODUCTS- CMPIOP GG 2,000,000 OTHER LE LP1R AUTOMOBILE LIABILITYItEa ANYAUTO INJURYPer rson Per accident AGE RAGGREGA AL�prr�O��S ONLY AU��TN11OSWWULNNEEEO Al sONLY AUTOJONLY UMBRELLA LIAR OCCUR ENCEEXCESS LIAB CLAIMS -MADE DEO I I RETENTIONS WORKERSCOMPELIADON RNGS PLOYERS'DAEILITY �''� tiI ANYPRRIMEMBOR ARTNERRIE EC�� LJ (Mande cry lnl ). VgdeI;C&0taYlm R!EIION OFERA I N Business Owners Liquor Liability X PER OTH- [B' A NIA C3776493 BPF1371Y 03/13/2019 W30/2018 03/1312020 11/30/2018 E.LEACH CCIOENT 500,000 E.L. DISEASE -EA EMPLOYE 600,000 S DISEASEPOLICY 600,000 See Limits Belo DESCRIPnON OF OPERATIONS I LOCATIONS IVEHICLES (ACORO 101, AddlNonal Remarhe Schedeb, may be attached RMN spa" Is ngelred) Liquor Liability Coverage: Each Common Cause Limit 11,000,000 2,000,000 Aggregate Limit Town of Mansfield 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. REPRESENTATIVE ACORD25 (2016/03) , '" .,...,.... """' _1-- The ACORD name and logo are registered marks of ACORD