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FOR BOARD OF HEALTH USE ONLY Permit# Issued
FOOD ESTABLISHMENT PERMIT APPLICATION ;' 4Vuy
(Application must be submitted at least 30 days before the planned opening date)`019
Establishment Name L�'� � �,-
EstablishmentAddress 7(;% IW-f
Establishment Mailing Address (if different) ''0,4-r^ I:
Establishment Telephone No f-, 11-f?. ?-'
Applicant Name & Title: �`r'�- !l <-_'if �
Applicant Address C 6. r'1; �✓ F Uf % r 'v°'' � � �" R �l'f �
Applicant Telephone No 75 rJ?eT—'7/2`7" 24 Hour Emergency No.: �c�/_S-�?
Applicant Email
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
l An Association
partner.
VA Corporation
Name Title Address
r
O An Individual
�,P G/1'�v'!) .f/' y;::old,-; i-/, 7,r
i e ! � ' ! !
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L,rt l r %?.n { r n lac y t P kxr
0 A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title fir✓t�«/r,x ,�✓'>)� 9
Address:
Telephone No: ' , r 71 t 24 Hour Emergency No:
FAX: r C
E-mail:
Alt E-Mail: 7 r k'67(< r z r' ✓i f%. /-
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: Ter'L �-,
SEWAGEDISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS: 0 rl,
1I� ��
; y
• 1�
Name of Person(s) In Charge Certified in Food Protection Management:z;�„
.I l>>
1
Name of Person(s) In Charge Certified in Allergen Awareness Training l ,
Lr,f ✓ �, °. r
Name of pest control company routinely inspecting the premises for evidence of pests "-_ =Y y-
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.
of Permit:
Establishment Type:
,�Leength
I� Annual
[jrRetail Food $125.00
[ Mobile Food Consession
F] Temporary
[A Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
0 Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00
$25.00/1'reezer
Temporary End Dale:
Food Service up to 201 + $300.00
D Pushcart $50.00 # of Pushcarts:
Temporary Time:
E] Supermarkets $400
D Residential Kitchen $100.00
Rain Date:
0 Milk &Cream $10.00
0, Caterer $35.00
Food Operations: Deffnitlons:PHF - Potentially hazardous food (timeRemperature controls required)
(Check all that apply): Non-PHFs -non-potentially hazardous food(no fime/temperature controls required)
RTE - ready-toeaf foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs [ PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
El Sale of Commercially Pre -Packaged PHFs J Preparation of PHFs For Hot And
for More Than a Single Meal Service
(] Delivery of Packaged PHFs Cold Holding For Single Meal Service
E] PHF and RTE Foods Prepared For Highly
j] Sale of Raw Animal Foods Intended
Susceptible Population Facility
El Reheating of Commercially b
to be Prepared y Consumer
Use of Process Reqindi Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Planlan (including bare hand
E] Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
P
Ed Offers Raw Or Undercooked Food Of
�] Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
[] Vacuum Packaging /Cook Chill
F] Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
D 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, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Social Security Number or Federal to:
Signature of Individual or Corporate Name; !'r C �JY,7` %� �" J�!'''-� ` "-" ''/,i �'I (r r 0!
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
is
Business/Organization Name i'-
Address: 1 �t v,
City/State/Zip: � ,(f / a' t O�L { „1 l Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with 7 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 (met. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We 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]* 11.❑Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 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 m n an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: rt>- f` r G .- � ^� z / t C f- /i� sv; L
I
Insurer's Address: '�' =v✓="t 1 rd "?
City/State/Zip: �(fii
r l f
Policy # or Self -ins. Lic. # I"> t` __ £'' `5 � Expiration Date: /
Attach a copy of fire 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 trite and correct
Date: I
� cif✓ .. � _S
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.mass.gov/dia
(Policy Provisions: WGUUUUUUU)
j INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: The Hartford Insurance Co of the Midwest
ONE HARTFORD PLAZA HARTFORD CT 06155
low
NCCI Company Number: 20605
Company Code: G
Suffix
_ LARS RENEWAL
POLICY NUMBER: 76 WEG GG3568 ��
Previous Policy Number: 176 WEG GG3568
1. Named Insured and Mailing Address: OLD COUNTRY STORE & EMPORIUM, INC.
(No., Street, Town, State, Zip Code) 26 OTIS STREET
MANSFIELD MA 02048
FEIN Number: 27-1270212
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: All Other General Merchandise Stores
Other workplaces not shown above:
2. Policy Period: From 01/29/19 To 01/29/20 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: HARTFORD FIRE INSURANCE COMPANY
55 FARMINGTON AVENUE
HARTFORD CT 06105
Producer's Code: 76250805
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877)287-1316
Total Estimated Annual Premium: $1,588
Deposit Premium:
Policy Minimum Premium: $260 MA (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by elm" If Cave, 12/20/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 12/20/18 Policy Expiration Date: 01/29/20
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.
Signature of Individual or Corporatee Name
2_-7
"*Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatonj, 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.
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