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HomeMy WebLinkAboutCanoe River Campground - 12/31/2020,I FOR BOARD OF HEALTH USE ONLY Permit #Issued C rl/lrn COTAOI ICUh ACAIT [:3C6rAIT AOOI Ir`ATIrIAI (Application must be submitted at least 30 days before the planned opening date) 3 Establishment Name (, all 0 e 0 0-f I h Y1G Establishment Address 3 % SJ�� c ✓t-S 11 B C y) f% 140G , ' Establishment Mailing Address (if different) Establishment Telephone No n Applicant Name & Title: e wnq 6ronSq �✓f QS I n /�P Applicant Address 3 OY/ I l �S% f n✓� "�7 e/ r rS� t�1 Applicant Telephone No.: 0 / 524 Hour Emergency No.:L- Applicant Email O 7s�1 C6'GL C2 A 0- /�wp r& L#Al 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 El An Association partner, Liz'-AA Corporation El An Individual Name Title Q "rr Address 6;—oy?v/ �U�tsg/y©S J� CSGf ? • l / �S /� $ a 5) — _ S% El A Partnership _c-V- �2✓t e Ca f ram) i 5 r El Other legal Entity r✓y h Q tt rrri �° t �� o�OY� Y f iV� t Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: PA, j 10 o �_-Ooy—d / d /Yv.Pna �P3 � mQf �11 Address: �/3 M I I t s/ r, / Telephone No: >20 i� �i 3 1 (p F2 - 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: PbV Food Establishment Information WATER SOURCE: )� /Yt�'rfS�te SEWAGE DISPOSAL: /+7/Uy d �lgnS" No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: �u p u +J�f7 —' Q /D U�LP bo'K 2[ S Name of Person(s) In Charge Certified in F od rotecti n Management: � t l,, Ca.rra1I Name of Person(s) In Charge Certified in Allergen Awareness Training 09� Corf " Name of pest control company routinely inspecting the premises for evidence of pestsz'n 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. El Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: 4rnnual .Retail Food $125.00 E] Mobile Food Consession Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 anufacture Frozen Desserts/toe 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 D Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 E Residential Kitchen $100.00 Rain Date: milk & Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food(timefiempemtura controls required) (Check all that apply): Non-PHFs- non -potentially hazardous tood(no tlme/fempendare controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins Which need no fudherprocessing) / Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order 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 9 of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑� Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Q Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 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 EJ 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 0 Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for I 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 0.0 and all other applicable law. I have been instructed by the board of health on how to obtain "es of 105 CIy1 590,�t�0 and the fefleral Food Code. Signature of Applicant: — - - - `- - Pursuant to MGL Ch.62C, sec. 49A, I certify un er 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. Social Security Number or Federal ID: b — �r`4- Signature of Individual or Corporate Name: 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. �% ✓�r 11 �n Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number 441,,� 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:\lkerslslcite\Desklop\Scoffs Docnmcnts\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts 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 Leeibly Business/Organization Name: Address: ' 7 Are you an employer? Check the appropriate box: 1. Q 1 am a employer with employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.7 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #: 9t 9— Business Type (required): 5. D-Retail 6. ERI�estaurant/Bar/Eating Establishment 7. n Office and/or Sales (inct. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.Q Manufacturing 11.Q Health Care 12.n Other *Any applicant that checks box #1 must also fill out the section below showing thew 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 #I. I ana an employer that is providi►►g workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: �'_ ttN` t C r Insurer's Address:_ , 0' B 0 -) _,5-4 00 City/State/Zip: Policy # or Self -ins. Lic. # ® ` L7 S^9" Expiration Dater Attach a copy of the workers' compensation policy declaration page (showing the policy number and - 5A3 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 imprismunei t, as well as civil penalties in the form of a STOP WORK ORDER and a foie 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 ce ' y ndenr the - ua and pen ties ofperjury that the information provided above is true and correct. 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 M www. mass.gov/dia VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0495N75-0-19) RENEWAL OF (6ZZUB-0495N75-0-18) INSURER: AMERICAN ZURICH INSURANCE COMPANY 1 NCCI CO CODE: 17965 INSURED: PRODUCER: STARLIN, INC. DBA CANOE RIVER C & S INSURANCE AGENCY CAMPGROUNDS 190 CHAUNCY STREET 137 MILL ST MANSFIELD MA 02048 MANSFIELD MA 02048 Insured Is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05-13-19 to 05-13-20 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applles to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In Rem 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit e_ Bodily Injury by Disease: $ 100000 Each Employee C. OTHEF STATES INSURANCE: Part Three of the policy applies to the states, If any; !fisted hers: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 05-03-19 WC ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: C & S INSURANCE AGENCY 75W2J 017733 0 VDAC e� ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICYNUMBER: (GZZUB-0495N75-0-19) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTALANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC -CODE: 7349 NAICS: 561720 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 6616 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 72 TOTAL ESTIMATED PREMIUM 7026 TAXES AND SURCHARGES 253 DEPOSIT AMOUNT DUE 727-9 Minimum Premium: $ 280 DATE OF ISSUE: 05-03-19 WC OFFICE: ZURICH-ORLAN 809 PRODUCER: C & S INSURANCE AGENCY 75W2J A/R (WCIP) # ST ASSIGN: MA ZURRIICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0495N75-0-19) INSURER: AMERICAN ZURICH INSURANCE COMPANY 17965-MA INSURED'S NAME: STARLIN, INC. DBA CANOE RIVER CAMPGROUNDS RATE BUREAU ID: 000120957 EXP. MOD. EFFECTIVE DATE: 05-13-19 CLASSIFICATION LOCATION 001 01 FEIN 042375571 ENTITY CD 001 STARLIN, INC. DBA CANOE RIVER CAMPGROUNDS 137 MILL ST MANSFIELD, MA 02048 SIC CODE: 7349 NAICS: 561720 CLERICAL OFFICE EMPLOYEES NOC PREMIUM BASIS ESTIMATED TOTAL ANNUAL CODE REMUNERATION 8810 DATE OF ISSUE: 05-03-19 WC ST ASSIGN: MA 017734 IF ANY RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM WA SCHEDULE NO: 1 OF MORE L ZURICH CLASSIFICATION LOCATION 001 01 (CONT'D) BUILDINGS -OPERATION BY OWNER OR LESSEE. WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0495N75-0-i 9) PREMIUM BASIS ESTIMATED TOTAL ANNUAL CODE REMUNERATION 9015 240962 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION $ MERIT RATING/EXPERIENCE MOD: .95 MODIFIED PREMIUM TOTAL ESTIMATED ANNUAL STANDARD PREMIUM .00% ARAP MODIFICATION PROGRAM (0277) EXPENSE CONSTANT(0900) 0.0300 TERRORISM (9740) 3.83% MA WC SPECIAL FUND AND TRUST FUND TOTAL ESTIMATED PREMIUM DEPOSIT AMOUNT DUE RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM 2.89 6964 6964 6616 6616 NONE 338 72 253 7279 7279 DATE OF ISSUE: 05-03-19 WC ST ASSIGN: MA SCHEDULE NO: 2 OF LAST