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Home My WebLink AboutMansfield Service, Inc. - 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 Establishmen 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:. ELIAS KAZAN Whose place of business is: MANSFIELD SERVICE, INC. 189 CHAUNCY STREET License Number: FS -54 Permit Expires: December 31, 2019 Food Fee: $175.00 Milk & Cream BOARD OF HEALTH NichaeCHeaCey, Chairman Permit for the Sale of Tobacco Products - Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: MANSFIELD SERVICE, INC. 189 CHAUNCY STREET License Number FS -54 Permit Expires: December 31, 2019 BOARD OF HEALTH .rlichaeCHeaCey, Chairman I r FOR 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: Mansfield Service, Inc. Establishment Address: 189 Chauncy St. Mansfield, MA 02048 1 �F o 2 �..�43 Via• .. Establishment Mailing Address(if different): w- Establishment Telephone No.: 508 339-9054 Applicant Name &Title: 1 75fi El 1 S I Z J (fid Applicant Address: 18 Talbott Farm Dr. Mendon MA 01756 Applicant Telephone No.: 7745737465 24 Hour Emergency No.: 7745737465 Applicant E-mail: ewkazan@gmail.com 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 O An Association partner. J01 A Corporation Name Title Address El An Individual SamreaEBga ht 0 A Partnership 11 Other legal Entity — -- Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: rovV4 n 6 I MGyU/4 ser Address: 3G S v J vAw -l' S� . utn.1 �- 2- Co It �rn • 0 2-70 � I Telephone No: 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: Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 5 DAYS/HOURS: 24/7 Name of Person In Charge Certified in Food Protection Management Poula Abed If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): El Location: ® Permanent Location Moblie Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: Annual Eg Seasonal Seasonal Dates: iJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type tail ( Sq. Ft) ' ood Service up to 100 INCLUDING FOOD TRUCKS $175.00 El Food Service up to 101 -200 $250.00 EJ Food Service up to 201 + $300.00 0 Supermarkets $400 El Caterer $35.00 10011 Milk & Cream $10.00 E] Mobile Food Consession NO PHF PREPARED ON SITE $100.00 0 Manufacture Frozen Desserts/Ice Cream $25.00/1'reezer Q Pushcart $50.00 # of Pushcarts: E] Residential Kitchen $100.00 VRetail Food $125.00 El Retail Snack Food $50.00 N Tobacco Products $150.00 Food Operations Definitions:PHF- Potentially hazardous food (tima4emperature controls required) Non-PHFs - non -potentially hazardous tood(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs El PHFCooked To Order Sale of Commercially Pre- Packaged PHFs [:-i Preparation of PHFs For Hot And Delivery of Packaged PHFs Cold Holding For Single Meal Service Reheating of Commercially El Sale of Raw Animal Foods Intended Processed Foods for S W' h' to be Prepared by Consumer erwce it in 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations U Customer Self -Service Ice Manufactured and Packaged for Retail Sale El Juice Manufactured and Packaged f Retail Sale LJ Offers RTE PHF in Bulk Quantities ! Retail Sale of Salvage, Out -Of -Date 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 Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health El Offers Raw Or Undercooked Food Of Animal Origin 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 pq{ 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: 617 - Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. Signature of Individual or Corporate Name: / Social Security Number or Federal ID of perjury that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: Mansfield Service, Inc. LOCATION OF SALE OF TOBACCO PRODUCTS: 189 Chauncy St. Mansfield, MA 02048 TELEPHONE AT LOCATION: 508 339-9054 OWNER OF BUSINESS: Elias Kazan ADDRESS OF OWNER: 18 Talbott Farm Dr. Mendon, MA 01756 TELEPHONE OF OWNER: 774 573-7465 FAX NUMBER: 608 339-2074 If a corporation or partnership, give name, title, and home address of officers or partner. Same as owner * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 CT -3T NUMBER: 13 2 �3 D E 880 FEDERAL ID/SS NUMBER:—TI-1 — 3Z 3 SS SIGNATURE: DATE: I Z f o Ll` hoo/ 3 Commonwealth of MassachusettsLetter ID: L2077758080 q l s Department of Revenue Notice Date: September 4, 2018 Christopher C. Hardin Commissioner P 6. Account ID: CGL-1 1477902-007 3 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES n1llhrhllldl�11�u1114�IP�n11l1�IhI�ul��hrPlllgllltl MANSFIELD SERVICE INC MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnectto view and re-print a copy of this license. - - - - -- --- If you have any questions about your license, call us at (617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m, to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 Form CT -3T Account ID: CGL -11477902-007 License Number: 1725306880 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 Commomvealth of Massachusetts Letter ID: L1924436608 Otis Department of Revenue Notice Date: September 4, 2018 lip Christopher C. Harding, Commissioner Account ID: CRL -I 1477902-010 str� 'Fvroee mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO IIIInIIIIr II16IIIII, III nupIIIIllll"�IIILJIIL611IIL�h MANSFIELD SERVICE INC S 1 MANSFIELD SERVICE INC 189 CHAUNCY ST MANSFIELD MA 02048-1355 I Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT -3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m, DETACH HERE SSPeHIISF,r MASSACHUSETTS DEPARTMENT OF REVENUE < Form Retailer License for Sale of Cfgars and Smoking Too fern, _ y 6� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. MANSFIELD SERVICE INC Account ID: CRL -11477902-010 189 CHAUNCY ST License Number: 1099065344 MANSFIELD MA 02048-1355 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 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. maw yi Signature of Individual or Corporate Name By: Corporate Officer ( ndatory, if Applicable) 7Y -3Z3 ZF_S�7 *"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 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 Business/Organization Address: Phone #: S00 SS 1-`10S Y A e I. A ou an employer? Check the appropriate box: I am a employer with employees (full and/ Busin ss Type (required): 5. Retail 2. ❑ or part-time).* I 6. ElRestaurant/Bar/Eating Establishment am a sole proprietor or partnership and have no employees working for me in any capacity. 7• El Office and/or Sales (incl. real estate, auto, etc.) 3. ❑ [No workers' comp. insurance required] We 8. ElNon-profit are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, 1 l.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0Other *Any applicant that checks box #I 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 boxfl. 1. I am an employer that is providing workers' omp isation insurmice for my employees. Below is the policy information. Insurance Company Name: fA( y ( cf tl a rl f/l rJP t n "A In„ 1,1 r Z Insurer's Address:_ P, 0 6 D x' I qS� V 1 City/State/Zip: / 1, `OU& 6 0,-19 , P-I(A, 02 3 q t/ Policy # or Self -ins. Lic. # �S 6' O u i — 1' O / L.,Y'7 — 6—/S Expiration Date: // Z I 9_ 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 pains and penalties of perjury that the information provided above is true and correct. Siynature: c _J � Date: Z' /O v // g Phone #S2'— 3 3S 1 ^ 9 l93 3S 1 ^ 919 fit% 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.muss.gowma TYPE AR WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GS60UB-9701 L87-6-18 ) RENEWAL OF (GS60UB-9701L87-6-17) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. INSURED: MANSFIELD SERVICE INC 189 CHAUNCY STREET MANSFIELD MA 02048-1355 NCCI CO CODE: 10456 PRODUCER: R D MURPHY INS AGENCY 75 HANCOCK ST BRAINTREE MA 02185 Insured is A CORPORATION Other work places and Identification numbers are shown in the schedule(s) attached. 2. The policy period is from 11 -25-18 to 11-25-19 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies 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 Item 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 Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: 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: 11-02-18 WC OFFICE: ORLANDO DA HTFD 05G PRODUCER: R D MURPHY INS AGENCY 007409 75TBC ST ASSIGN: MA z 0 LLM W V IIA • El-