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HomeMy WebLinkAboutOld Country Store - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. CHRISTOPHER D. BAKER Whose place of business is: OLD COUNTRY STORE AND EMPORIUM, INC. 26 OTIS STREET PERSON(S) IN CHARGE: LAURYN S. BAKER, VICE PRESIDENT Permit Expires: December31,2019 Food Fee. $175.00 License Number: FS-59 BOARD OF HEALTH AichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Perrnit#lssue* r FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening t NOVI Gk 2018 Establishment Name: 'J" Establishment Address: Establishment Mailing Address(if different): 0 Establishment Telephone No.: 5"e- Applicant Name & Title: oi,, k isir -tx Applicant Address: iA� i� Applicant Telephone No.: 24 Hour Emergency No.: Applicant E-mail: (,')(4 Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. IKA Corporation 11 An Individual Name Title Address N�k-? 5*-v kQ, PV0_( IrIloy-J, 1�4'a" El A Partnership 1-1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) �7 J0, r- Name & Title: L �L u �"- ` " - -, - k- - V, r, C _;, I Address: 2 rr' VV 0(:)"y Telephone No: 7 ' -' Z O'l �5 24 Hour Emergency No: 7b/1-4- FAX: 5-0 _t' E-mail: Of4c Aft E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATERSOURCE: toLVn DEP Public Water Supply No: (If applicable) DAYS/HOURS: lt16^� " . eLt' (0 "- (, SEWAGE DISPOSAL:y f C No. of Food Employees: if(' n �t Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. [Person Trained in Anti Choking Procedures (If 25 Seats or more): ❑ - -_ - Location: Permanent Location Establishment Type ❑ Caterer $35.00 ❑Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: aLj Food Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: Food Service up to 101 -200 $250.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer Annual ---- ---- ---- ------ ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Seasonal ❑Residential Kitchen $100.00 Seasonal Dates: ❑ Supermarkets $400 Retail Food $125.00 El Temporary ❑Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date:.. -- Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltempemture controls required) :heck all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) 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 of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Hight) ❑ Sale of Raw Animal Foods Intended Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours to be Prepared by Consumer _-Susceptible ___-- ❑Vacuum Packaging /Cook Chill -.... Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations Customer Self -Service Ice Manufactured and Packaged for Retail Sale and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin Retail Sale of Salvage, Out -Of -Date Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health -"-"-" _---- -"-- - Total Permit Fee: Payment is due with application ❑waived 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 590.000 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. Signature of Individual or Corporate Name:Zoo' Social Security Number or Federal ID: .f --_y _- ? Z _7 r 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. !'1' /i. ^s Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ) ~ \Y \ §\E7 41, ( d 0:&2! \Ov _. )j0 . ; } A tI \ WE �Mmi � z � z 0 ro-a � � � � n W o 0 F�yj 3 � aQ p+ O p O N 0 iD CD - a) a) cy) o chi N O o_ Z (D n m x N N -0• U)i' W OD v O N N CD O N O v CD X (0O o m n o r: 1 10 (OD' N CD 'n- CD ;� ao a o- 0 D o c o CD CD CD C � N Xm o -4 a -n °° <: a co u 0 - m Vl N OD V Q V �^ U OD cf) a - a 3 CD -n :E o 3. o w o -n n© a Cloo ceD cu m n eo Ds -4 _ 3' en it 0 p B `1 It a i ne a innionrveatta aI inassaenusetts 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: Vid C, Address: City/State/Zip: M- l,' ?- ((,-i ) l4 rl Phone #: Are you an employer? Check the appropriate box: f Business Type (required): +M 1. I am a employer with employees (full and/ 5. Retail or part-time).* 6. ❑ RestaurantBar/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. S• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 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' ci mp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fill out the section below shoving 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 arm an employer that is providing workers' co,(nspensation insurance for my employees. Below is the policy information. Insurance Company Name: f1;�'/T l+�rrt ;t�t'L`✓{'fZ�f � rf Insurer's Address:t:...i ,^ City/State/Zip: Z-c t��.r,- r t—f,%✓�' '� �fi 1t n � } Policy# or Self -ins. Lie. # ��, bti�= � �^� �� � �L� � Expiration Date: � f�� 7 l f t 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, under the pairs and penalties ofperjury that the information provided above is true and correct. // //f,> %lb Phone#: s-( t?, - >3 9 — e'; r' 31 t/ Official use only. Do not write in this area, to be completed by city ar 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 66 (Policy Provisions: WC 00 uu uu 35 Gc. INFORMATION PAGE WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 20605 Company Code: G POLICY NUMBER: 76 WEG GG3568 Previous Policy Number: 176 WEG GG3568 HOUSING CODE: 76 1. Named Insured and Mailing Address: OLD COUNTRY STORE & EMPORIUM, INC. (No., Street, Town, State, Zip Code) FEIN Number: 271270212 State Identification Number(s): UIN; 26 OTIS STREET MANSFIELD, MA 02048 The Named Insured is: CORPORATION Business of Named Insured. GENERAL STORE Other workplaces not shown above: 26 OTIS STREET MANSFIELD MA 02048 2. Policy Period: From 01/29/18 To 01/29/19 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: HARTFORD FIRE INSURANCE COMPANY PO BOX 33015 SAN ANTONIO, TX 78265 Producer's Code: 250805 Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (877) 287-1316 $1,739 Total Estimated Annual Premium: Deposit Premium: $216 MA Policy Minimum Premium: Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Suffix LARS RENEWAL 04 �uaan� C�a� 12/16/17 Countersigned by Date Authorized Representative 1 Printed in U.S.A. Page 1 (Continued on next page) Form WC 00 00 01 A () policy Expiration Date: 01/29/19 Process Date: 12/16/17 ORIGINAL