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HomeMy WebLinkAboutTown News - 12/31/2020_arc; FOR BOARD OF HEALTH USE ONLY Permit # Issued LOC @ 721 2Q1a- -- - - -- FOOD ESTABLISHMENT PERMIT APPLICATION must be submitted at least 30 days before the planned opening date) Establishment Name Toujr\ Establishment Address \ (' 5 fi Cyr - Establishment Mailing Address (if different) Establishment Telephone No �� ) 5 = S} — 7 LA LA Applicant Name &Title: Applicant Address L-A Applicant Telephone No.: S� �` � 1- �6 24 Hour Emergency No.: �bS Applicant Email ' C - 4' 'c'��` Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: ❑ An Association CD -A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name \\ ICr,fl(^ Title A UL'g_ nt � 0 \fie �r - fi/� I\-, M Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: NO'P R Address:r,k C)<"\ b`tG �e� , fnc S t ic��M i Cl_Ul� Sc 9"32- '31 Qo Telephone No: r 24 Hour Emergency No: 5C) FAX: E-mail: �4� f CT 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: SEWAGE DISPOSAL: Nf"� DEP Public Water Supply No: (If applicable) No. of Food Employees: ^/` COV — t DAYS/HOURSa 1 v � Go m-cyprn ��jn 7m n, _ � Crh 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. Length of Permit: Establishment Type: Q'Annual ❑ -11111E] '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 Dessertslice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: 4KMilk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (timelfemperature controls required) Non-PHFs- non -potentially hazardous/ood(no lime/femperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno hatherprocessing) 6.Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service VI 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 Nan PHF and Non- Customer Self -Service contact alternative, time as a public health Perishable Foods Only '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 ❑ 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: VA,,l 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.� ii _ Social Security Number or Federal ID: o`L � 5 333 h 7 , ` t Signature of Individual or Corporate Name: `(�r I`J 13f11 `(i- 6' 1�1-�' V 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. tlC/\SvLA c�/ Cry, Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number 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\sleile\Desktop\Scotts Documents\Food Establisbmenis- Temp\TAX CERTIFICATION FORM.doc p � ine uontntonweatin ojmassacnuseus Department of Industrial Accidents Office of Investigations 600 Washington Street �ti yr• I�� Boston, IVIA 02111 www.niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print' Business/Organization Name: V � 7U� 'y Lcr Address:' �, ',; S t City/State/Zip: ,Mo1s,5 I C) Phone #: C>'6-- 6 7,A Are you an employer? Check the appropriate box: Busines Type (required): LEJ I am a employer with employees (full and/ 5. etail 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. g, ® Non-profit 3.❑yWo workers' comp. insurance required] e are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 L❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 12.❑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 ain an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: �TejL-n(-\U\b� co,vfx ,II 1-�\(- , Insurer's Address: 0C) ;UK(`1Cr \Cyr-\vn�I O NSUL t-1L-\ �1L- L t Expiration Date: / [ � % ��� 3 x Policy # or Self -ins. Lie. # P 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 ofperjury that the information provided above is true and correct Signature: �AD_ N'A - Date: ku —2' Phone # bCL6j Official use only. Do not write in this area, to be coinpleted 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 #: wwwan.,s .i, v".., SUSHLA1 ACORvCERTIFICATE OF LIABILITY INSURANCE DA10123 2019Y) 10/2312019 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 Ileu of such endoreemen a . PRODUCER 508-947-1818 J.K. Olivied Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W.OIlvleri c* Kenneth W. Olivied _ PHONE 506-947-1818 FAX _!_ Ro Eei : IArc Ro : _ INSURERAII AFFORDING COVERAGE INSURER A: Union Mutual Fire Ins. Co. 25860 INSURED $gub LaxRfD1i Inc. 44dba Oara6t1G8�II1Inct.B CltgO Mansfeld, MA 646 INSURER : Crum & Forster Specialty Ins INSURER C: Ma. Retail Merchants We Group23612 IRsuaER D : INSURER E: INSURER F: n..•.eewn_ee reorleI "C ul l uRFo• RFVIRirTN NI1MRER' 1. 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 0P INSURANCE AUDL1SUBR pDLIOy NUMBER POLICY EFF POLICY E%P LIMITS A COMMERCIAL GENERAL LIABILITY CLNMS•MNDE FX occua_ Business owners BOP0173646 07/14/2019 07114/2020 HOC OCCURRENCE 1,000,000 RNAOE oRENTED 600,000 X DE d1e 10,000 PE aADVI Y 1,000,000 1AGGR LppNIppR.� APPLIES PER: X POLICVjECT rLOC CE E A RE TE PRODUCTS •COMPOPA 2,000,000 2,000,000 AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEOULED AA11U�ppTeeODpS ONLY ANNUppT�1IOppSWWNN Dp AUTO COMBINED SINGLE LIMIT BODILYRV Per B D V P accM Y A LOAM UMBRELLA LIAB UMBRELLA EXCESS LIAR CUR OCCUR CLAIMS -MADE EACH ENCE EAFACCH OCCURRENCE O AGGREGATE DED RETENTIONS C g WGRRERS COMPENSATION ANDEMPLOYERB'LNBILITY ANY p�CPR�OR�PA1R¢IET�ORgR+ARTNER:EXECUTIVE (rnand t In NN)EXCLUDEDY N If 6039 beu(w ERIPTION OF OPERATIONS Pollution Liab Claims Made NIA 14006033710119 - STP124699 01/01/2018 11/28/2018 01/01/2020 11/28/2020 ERTUTE OTH- X SPTA ER E.L. EACHACCIDENT 100,000 E.L.DISEASE -EA EMPLOYE S 100,000 .L DISEASE POLICY LIMIT Aggregate Ded 500,000 2,000,000 6,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Suhadule, may he attached It Moro spaoa Is Mqulnd) Town of Mansfield 6 Park Row Mansfield, MA 02048 IL•\iF91i}� 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 a w........� ,nna eme• W The ACORD name and logo are registered marks of ACORD All rinhts reserved.