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Home My WebLink About5 Hampshire Cafe - 12/31/20206c5Z.q -1�3 a5•�`' FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATIONuv (Application must be submitted at least 30 days before the planned opening date) ! Establishment Name .J 403tnO r� C(A_ Establishment Address r l}o mfr�tlilr e Establishment Maili Address (if different) O t r(c�p gO Illdua>i1, Establishment Telephone No �ctq-oc uo Applicant Name & Title: Applicant Address t%� &Y\d Lar folnr R4 o)5,0 Applicant Telephone No.:'174/o WN-31 24 Hour Emergency No.: Applicant Email 'K%dV,7,, @ 1 PMVt1 Owner Name & Title (If different from applicant) 2 CjI t/ p tl� Owner Address Two k)QLAiD �' A6Q,a53WA�Ir�}�n Si-, S1N�2 300 ��tn�dr)hY HW Owner telephone number (DIi)- 7aU-0RI0�- J Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. A_-_1A Corporation �Name Title Address ❑An Individual �iVri(A��U_�Idi PVI - �j (.11,aYi _fuI- L A Partnership Y�--�- '•\9 _',2WA-)Yl�� O�—D�-fy�-- ❑OtherlegalEntity �9tuue� lXJcts�_W �l Q �t— , � lX(fip0l6ik, Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Geral � �L V a)iskc;T `)� ka e r Address: nTT�� /J l J �/"- j Telephone No: 1 1- " I (OO gQ;L0 24 Hour Emergency No: 9r% - q(00 - / 0"D FAX: E-mail: Jr,ceIbI�" Alt E-Mail: ►C�o.rrar @ +j0i�'iV � ! <(om District Or Regional Supervisor (if applicable) Name & Title: Address: ``,, Telephone No: c�� y�d� ('c' (i FAX: �rl�- rihl E-mail:jface �Qyf\ C11co11P7 24 Hour Emergency No: qrl _ qW _ g0dD WATER SOURCE: DEP Public Water Supply No: (If applicable) Food Establishment Information SEWAGE DISPOSAL: No. of Food Emplo DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: G�rind Pad. Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests I-LO 16C 0 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 , I Does this establishment require a FOG permit? AJ If yes, please attach the FOG permit application. Length of Permit: Annual ❑ Temporary Temporary Start Date: Temporary End Dale: Temporary Time: Rain Date: Establishment Type: VRetail Food $125.00 ❑] Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 ❑ Food Service up to 101 -200 $250.00 ❑ Food Service up to 201 + $300.00 ❑ Supermarkets $400 ❑ Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $50.00 8 of Pushcarts: ❑ Residential Kitchen $100.00 ❑ Caterer$35.00 Food Operations: Definitions:PHF - Potentially hazardous food(line/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous foodfnotime/lemperature controls required) RTE - ready-lo-eat foods (Exr sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Nan-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs R1 Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs old Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Customer Self -Service I Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers RTE PHF in Bulk Quantities L ] Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Susceptible Population Facility ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Vacuum Packaging / Cook Chili ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comp with 105 CMR 590,000 and all other applicable law. I have been instructed by the board of health on how to otjt4i copies of 105 CMR 59QDg0 and Ibe radgM Fond Corte. Signature of Applicant: Pursuant to MGL Ch.02C, 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 N T (J „ r p Signature of Individual or Corporate Name: V✓� l"� �` TAX CERTIFICATION FORM 1 certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Q-- Signahn-e of Individual or Coi porate Name By: C< poste oh -er (r%tonAntay, i/'Aplalicnble) "Social SeCUtity No. (Voluularld or Federal Idenlificalim( 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 %Arhether you have met tax filing or tax payment obligations. Licensees livho 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. (':AI l,vcntaleiteADe,IUopAtiuuYs Doom lei I9SiallI ishnie k-'IcmpPI AX (I'RI'II I( A IION I'-ORNI doe The C'mmnonivealth of Bda.ssac•hasetts _ Depetantent of ]nclnstrial Acciden/s _ Office q Investi;ations 600 Washington Smeet _ = Boston, MA 02111 wivtv,n as.s.gov/dia Wroi-.crs' Compensation hisut•ance Affidavit: General Businesses Applicant ln1'ot•mation Please 13usincss/Organization Nantc: �l._NAiiIPSILt`C_� Address: .7 C itylSftt /%ip:_�I�(($ leL�t_ f}py-o�F:___ I>l — --- - - �Aleyot Icmplo}u'Check theappropurkbox: one it: ----q �j�-��) `06GO - - Business Type (required) - I un , employ et yvit11 - �_ S� employees (full mul/ - ❑ Reuid of pub -lime) 2.❑ I have G �Rcstuuant/Darn tting,Establishment tuna sole proprietor or partnership and no 7. Office tindloi Sales find. real estmc, auto, etc.) employees woikm - Ioi me m any capacity. II_ R Non-piof-it 111,uworkers comp insulmcerequiled] "R Wo are it corpol anon and ns officers line exercised 9. ❑ 6ntcitaunnent thin t I ht of ewnption per d I S2. § 1(4), and we have IO.Q Manofactul ing no employees. (No workers' comp. insurance requiNtij" d.AArc are organization, by I I.Q I`lc�alth Care a non-profit stalled volunteers, with no employees. I No workers' comp, insurance req,] I2.�(-<,,, (,44e " - _— Vac uppliennl IIW 1 checks has 11 I moral also Jill out the wCdon bellm shine uke their oojhos- compensation ponce inlimmdion_ ,.'II'IIw Cmp,Iare ulriver here cwnIpled Ihcm.eI,C, but Ilre Vol ll mWlotI II is other employee.. a ourkea' compemaIion policy is n:y I wd mid it nn olganvtl(wn should clieck hux 41- / am an empltger that rr providing wol-ke", compemsolion insnranc•e.loe my emydgpees. Below is the policy infarutnliot. Insurance Company N nic:.--- �1'�(J( ... 6E fo)-1'.j.. #Lte -CIL1.tt.K C, )Jc - C-koLq �T t-x • _..-- Insurer'sAddress:_ I '.�` k o x C249 -... c n\tSauvLJp Lbktt.- a-) - MAG 't �s (y -- -f Policy it or Se f-ins. LIc It_----- 01 T'_ 000 o`�`O I� 117 _ _ F:\puation Drle: -lRC\0 Attach a copy ol'the workers' compensation policy deeLu'ation pare (showing the policy number and expiration date). Pailloe to secure coverage as Iequined wider Section 25A ofMGL c. 152 emu lead to the imposition of criminal penalties of a line up to.$1,500.00 and/or one-year imps sonmcni, as well as civil I:icnaltics in the form of a S I Of' WORK ORDER and a fine of up to $250.00 a day against Cite violator. Be advised thal a copy of this statement may be I'mwarded to the Office of Investigations of, the DIA for insurance coverage verification. 1 tin hereby eertiji', ender the pains (nril)enalties of perjury that the information provided ohnve iy a -Ile and correct. by2o Qfficial use 0111p. Un not lvrite ill this oren,, to he completed kp city or lawn gfficial. City or Town: Permit/License it Issuing Autbovity (circle one): I. Board of, Health 2. Bililding Depadmeuf 3. City/Town Clerk 4. Licensing Board 5, Seledinen's Office O. Other Contact Person: I'huoc#r: wtrw.maeas,vwAt is ACORO® CERTIFICATE OF LIABILITY INSURANCE 16� onrE (MM ODr v ) 11121/2019 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 CONTACT Elise Flane NAME: Roger Keith & Sons Insurance Agency Inc. PHONE (508) 583-1106 FAX (508) 583-8478 A/C No Ext : A/C Na E-MAIL efano@rogerkeith.com ADDRESS: 1575 Main Street INSURER(S) AFFORDING COVERAGE NAIC N Brockton MA 02301 INSURERA: The Charter Oak Fire Insurance Company 25615 INSURED INSURER B : Travelers Property & Casualty Company ofAmerica 25674 LPM Holding Co. Inc. INSURER0: Federal Insurance Company 20281 dba Epicurean Feast INSURER D : MA Retail Merchants WC Group Inc. 580 Main Street; Suite 1 INSURER E: Bolton MA 01740 _ INSURER F: COVERAGES CERTIFICATE NUMBER: 2019 LPM/EPICUREAN REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOWNAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LTR TYPE OF INSURANCE ADDLSUBR INSD We POLICYNUMBER POLICY EFF MMIDD/YY1'Y) POLICY EXP (MMIDDlYYYYj LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGERENTED PREMISES Eaoccurtence $ 1,000,000 MED EXP(Any one person) ._ $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 A 630-6C830447 01/01/2019 01/01/2020 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑ JECOT 0 LOC GENERALAGGREGATE $ 3,000,000 PRODUCTS - COMPIOPAGG $ 2,000,000 LIQUOR LIABILITY $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea..Icah S 1,000,000 X BODILY INJURY (Per person) S ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS 810-7C399675 01/01/2019 01/01/2020 BODILY INJURY (Per aacidenQ $ PROPERTY DAMAGE P.,moident S HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 5 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 26,000,000 B EXCESS LIAB CLAIMS -MADE ZUP-91M48908 01/01/2019 01/01/2020 RETENTION $ C: EXCESS $ 35,000,000 --TOED A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN R/EXECUTIVE ❑ ANY PROMEMBER EXCLUDED? EXCLUDED? O Mandate, In NH) NH) (f yes, describe Dyes, describe under DESCRIPTION OF OPERATIONS below NIA UB-9H942545 01/01/2019 01/01/2020 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 WORKERS COMP & LIAB BI by Accident/Accident $1,000,000 D MASSACHUSETTS ONLY 01400502016119 01/01/2019 01/01/2020 BI by DlseasePoliCy Limit $1,000,000 BI by Disease/Employee $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be beached if mare space is required) POLICY LIMITS IN EFFECTAT POLICY INCEPTION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF MANSFIELD ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED REPRESENTATIVE MANSFIELD MA 02048 5a ✓ - ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD I � 11 EM14 � la � ( \ \ ) ( ) \ \ ® ± \ ( 0 \ U \ % -2 } §&\ \ y (ƒ\\ \ / ti 0 3 L'