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HomeMy WebLinkAboutWest Mansfield Variety - 12/31/2020a- o C� FOR BOARD OF HEALTH USE ONLY Permit#,Is�Ged FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name I� u�B� I vu J4e��p Establishment Address Establishment Mailing Address (if different) Establishment Telephone No 7-4 - 2S-4- �t392 Applicant Name & Title: N �_n �i-e l Applicant Address 6 Cu u n f Ct u1u tip`<i I�i d d F� n \� 2q 66 Applicant Telephone No.: 24 Hour Emergency No.: 5 0 `6- S-40, 9) q ) Applicant Email h Y2 r\ 31 Pq� C �m G •Caw\ 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 i An Association partner, X A Corporation Name Title Address An Individual A Partnership 1 Other legal Entity _ Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &'Title: Raid COl�nex� Address: 6 `ou��Y� C� u9 a �o�Tv✓ 024G6 Telephone No: Sd W - C6-tw C� 1 1 24 Hour Emergency No: i FAX: E-mail: h Gre n '� Pete\ ^ `j'w a c� , Cnv✓\ Alt E-Mail: District Oi Regional Supervisor (if applicable) Name & Title: Address. Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: 0 SEWAGE DISPOSAL: o, f DEP Public Water Supply No: (If applicable) No. of Food Employees: r DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: 7� Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests C 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. 1] Yes Does this establishment require a FOG permit? )IN 0 If yes, please attach the FOG permit application. Length of Permit: !Xi Annual [ ] Temporary Temporary Start Date: Temporary End Dale: Temporary Time: �kF717�1r� Establishment Type: FX Retail Food $125.00 r Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 n Food Service up to 201 + $300.00 [] Supermarkets $400 Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100,00 Ei Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 II Caterer$35.00 Food Operations: Definitions: PHF - Potentially hazardous food dimeAemperalure controls required) (Check all that apply): Non-PHFs � non -potentially hazardous repairs time/temperature controls required) RTE - ready-lo-eat foods (Fx. sandwiches, salads, muffins which need no further processing) X Sale of Commercially Pre -Packaged Non-PHFs [] PHFCooked To Order Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And L Delivery of Packaged PHFs Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended I;] Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours Customer Self -Service Customer Self -Service of Non PHF and Non-� Perishable Foods Only ❑ Ice Manufactured and Packaged for Preparation of Non-PHFs Retail Sale [;] Juice Manufactured and Packaged for Other Food Operations Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) [J Offers Raw Or Undercooked Food Of Animal Origin [J Vacuum Packaging / Cook Chill I] 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 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 CMyR�590.000 and the federal Food Code. Signature of Applicant: ___" - G) Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: _ c� Signature of Individual or Corporate Name: _ �' 3 2 2 S t I 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. \-A - R L L-le i Signature of Individual or Corporate Name /_f -/--3`i 22 S) "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\sleite\Desktop\Scout's Documents\Food Eslnblishmenls- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations tl 600 Washington Street Boston, MA 02111 w� y www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: W e5' Lnuv>54-el � \4j at'e Ll d,1�_ City/State/Zip: I Yq / oa04 16� Phone #: 4- zFs4 Ig392 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 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, g ONon-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* t LQ Health Care 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.0 Other .Any applicant that checks box NI 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 NI. I aen an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: l t�M s\/t e w \ Tv 5 Insurer's Address: C>kt (--�5t - City/State/Zip: -LA e (�i a t�©�3 Policy # or Sclf--ins. Lie. # Gl7 ( I S �y 9 Sf /� Expiration Date: St 2 0 2 0 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 a 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 lip 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 D1A for insurance coverage verification. 1 do hereby certify, evader the pains and penalties ofpeijury that the information provided above is true and correct, +e I Date, O� a 3 �) �i Sc1n— Q I I __ 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.gomma W ESTMAI A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 10/21 /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, sublect to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rl h[s to the certificate holder In lieu of such endorsement S . PRODUCER 508.947.1818 C N ACT Kenneth W. Olivieri J.K. Oiivierl Ins. Agency PHONE '— 64 East Grove St. IAIO, No, Eat 508-947-1818 jglC, Not; Middleboro, MA 02346 EMAIL - -- Kenneth W. Olivierl ADDRESS' —._—.. ... .._..--.— ,nouncn n: rluvlt IrIUWwI II 1J 41 aIIl" 4 U I`40Y Variety INsuRERe;The Norfolk &Dedham Group _.--111223965 r•.nvFeAr.Fs nvorinnnrc.,,,...,�.,. _. JU NUMBER: TFIIS 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 HE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS _AND CON DI'IION S_O_ F SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY EFF POLICY EXP T INSR AODL SUER POLICYimmirjr�vvi LIMITS A _ - COMMERCIAL S-MADE CLAIMS -MADE [ X] OCCUR - Business Owners BZS56927776 09/26/2019 09/2512020 EACH OCCURENCE $ 1,000,000 DAMAGETO RENTED 1,000,000 16,000 X EMISES fFesrlc[e MEDE%P An one arson PERSONAL INJURY 1,000 1100 ,_ .., _.__.... - -- - � GENERAL AGGREGATE 2,gg0 000 GEN'L x AGGREGATE LIMIT APPLIES PER POLICY �I LOC 1 JECT PRODUC S - COMP/OP AEG 2,000 000 3_ , OTHER' _AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT — _ _ _ ANY AUTO _ OWNED � SCHEDULED AUTOS ONLY AUTOS HIRED NON OWNED AUTOS ONLY F. AUTOS ONLY BODILY INJURY Per Person) BODILY INJURY Per amidenl gOPERTY DAMAGE per accitlanl _ _ UMBRELLA LIAB ;OCCUR EXCESS LIAR _ 7 CLAIMS_MAOE AC OCCURRENCE__ AGGREGATE DC-D RETENTION$ S q WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YN ANY PROPRIETORIPARTNERIEXECUTIVE I OFFFICEftRdEMe EXCLUDED? N (Mandatory In N If yea, describe under D DES RIPTION OF OPERATIONS below Business Owners NIA WE169098A BZS56927776 09/25/2019 09/26/2019 09/25/2020 09/2612020 PER OTH� x E.L. EACH ACCIDENT 1,000,000- E.L.OSEASE � EA EMPLOYEE 1,000,000 EL EASE -POLICY LIMIT 1,000 ,000 Included Liquor Liability DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If Moro space Is required) Liquor Liability Coverage Included L MANST62 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. U1VUB-2016 ACORD CORPORATION. All rinh(n Christopher George From: Hiren <hiren3lpatel@gmail.com> Sent: Tuesday, November 19, 2019 12:49 PM To: Christopher George Subject: Re: Mansfield Board of Health - Food Establishment Permit Application I will have Flynn pest control from Rehobth, MA Coming regularly for pest control at West Mansfield Variety Hiren Patel On Nov 14, 2019, at 1:58 PM, Christopher George <cgeorge@mansfieldma.com> wrote: To Whom It May Concern, You've recently submitted a Food Establishment Permit Application to the Mansfield Board of Health. We are unable to process your application until the following items have been remitted: • Name of Pest Control Company routinely inspecting the premises for evidence of pests. Please let me know if you have any questions. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. 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