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HomeMy WebLinkAboutJuice on Main - 12/31/2020FOR 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 Establishment Address 7-6 Establishment Mailing Address (if different) Establishment Telephone No "-2 % y- 2 j' t Applicant Name & Title Applicant Address Applicant Telephone No.: y`i a j Ely 24 Hour Emergency No.: 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 7 An Association partner. A Corporation Name Title Address 4y An Individual t �,� "k ,c t r _ - ra � ? v r 51', A Partnership LJ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: J Y- Z i ?) 24 Hour Emergency No: z 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: SEWAGE DISPOSAL: No. of Food Employees: j DEP Public Water Supply No: (If applicable) i DAYS/HOURS: Name of Person(s) In/Charge Certified/in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training f 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. O Yes z_114 Does this establishment require a FOG permit? /V= If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual FFt Retail Food $126.00 [d]] Mobile Food Consession Temporary 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/freezer Temporary End Date: Food Service up to 201 + $300.00 0 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Fg Residential Kitchen $100.00 Rain Date: F� Milk &Cream $10,00 [] Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (HmeRemperature controls required) (Check all that apply): Non-PHFs- non-potentally hazardous/ood(no time/temperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no furtherprocessing) n Sale of Commercially Pre -Packaged Non-PHFs I] PHFCooked To Order [U Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly []J Sale of Raw Animal Foods Intended �] Reheating Commercially Susceptible Population Facility of to be Prepared by Consumer Processed Foods for Service Within 4 Hours 0 Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand r:5 Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Retail Sale [i Preparation of Non-PHFs lk Juice Manufactured and Packaged for ]j Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations Retail Sale G`1 Vacuum Packaging / Cook Chill I„1 Offers RTE PHF in Bulk Quantities ]u] 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 with 105 C�4R 690.000 and all other applicable law. I have been Instructed by the board of health on how to obtain copies of 105 CM¢( 0.00 nd the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify tang 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. 'J Social Security Number or Federal ID: --r .- Name: Signature of Individual or Corporate Na 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. i Signature of Individual or Corporate Name By: Corporate r fficer (Mandatory, if Applicable) i "Social Security No. (Voluntary) or Federal Identification Number *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\cleite\Desktop\Scott's DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc 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 Business/Organization Name: JI Address: City/State/Zip: ✓P l v .<f I Phone #: j ,; . 7 J� is - "I ) Are yoy an employer? Check the appropriate box: Business Type (required): 1TT'I am a employer with % t ` 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] 8. ❑ Non-profit 3.0 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information, Insurance Company Name: r f i Insurer's Address: s m� 4 cr '..' l/ r- r c 1 v r , i , � J 7, 21 / City/State/Zip: j' c �d.% r v I't V11 `/ Policy # or Self -ins. Lic. Expiation Date: 2 12. 112, 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, underI fie rains and penaltles ofperjury that the information provided above is true and correct. Signature: '(-^ Date: Z .f 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 www.mass.gov/dia Phone #: i� JUICE-5 OP ATE 01/19 O01/1812(MWDY019 AcoRO" CERTIFICATE OF LIABILITY INSURANCE 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 endorsement(s).. PRODUCER 888.467.3330 c JACT Dane Meister KapatoesInsurance Services LL 725 Primera Blvd Suite 115 PHONE 888.467-3330 FAX 888-463-5755 AIC, No, EXt : A/C, No), E-MAIL ane00 KIS I I C.Com Lake Mary, FL 32746 Dane Meisler INSURER 3 AFFORDING COVERAGE NAIC # INSURERAMESCO INSURANCE CO 25011 INSURED Juice on Main LTD Jon Coppolino 240 N Main St. INSURER B: INSURER C INSURER D: Mansfield, MA 02048 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR TYPE OF INSURANCE ADDL INSO SUB VIVO POLICY NUMBER POLICY EFF POLICY E%P LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE DAMAGE TO RENTED MED EXP (My oneperson) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jeo LOC OTHER GENERAL AGGREGATE PRODUCTS - COMP/OPAGG AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS W Ep AUTOS ONLY WOKS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY WarPerson) BODILY INJURY Per accident PROPERTY DAMAGE Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED I I RETENTIONS A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ OMded3RIM EMBER E%CLUOED9 story HMI II yes, describe under DESC ION O OPERATIONS below NIA WC3394016 0212712019 02/27/2020 I PER X OTH- E.L. EACH ACCIDENT 500,000 E.L. DISEASE - EA EMPLOYEE $OO,000 E.L.DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance at - renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Fenn Revised 5-26-05 / \ J. v \ (\\\ & Z2 0, � /(/ \ \ >� 'Ro ( % ( \ 0 \ � 7 0 § 0, / \ ƒ \ \ «d/ § ® / � z tl7l CA CA � � z � z 0 I G _ ^ S O c � a n O O � �• r 1 O n w 0 � S 0 3 o D N 3 m � Y m �a a � � o m o � � n o a� z w d w � m D Z Ln m O n. n 0 � o m ro m m �, o � a o m 0 � � o a � m ro ^ ^ a O O O fn n v v 3 ti / ; j\g / - \(}E \ \ \ eb§ƒ ,a\ \/{ Ea!{§�q� - [ , § � @ � � r-M, t7i � � z '\ WE tom z � � � � z � z C) � � t7l 0 �lm