HomeMy WebLinkAboutSimple Amenities - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Retail 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:.
MOHAMMAD ARIF KHAN
Whose place of business is: SHAHMIR, INC DBA SIMPLE AMENITIES
214 RUMFORD AVENUE, UNIT 103
Permit Expires December 31, 2019
License Number: RF-10
Food Fee: $125.00 Milk & Cream
BOARD OF HEALTH
Michae[HeaCey, 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: SHAHMIR, INC DBA SIMPLE AMENITIES
214 RUMFORD AVENUE, UNIT 103
License Number RF-10
Permit Expires December 31, 2019
BOARD OF HEALTH
MichaeCHeaCey, Chairman
FOR BOARD OF HEALTH USE ONLY Permit# Issued
FOOD ESTABLISHMENT PERMIT APPLICATI
C .
(Application must be submitted at least 30 days before the planned opg 03 it
Establishment Name: �um�2P2 Amo u rua
Establishment Address:ai Rom&d Ave STtr*1 /0-3
Establishment Mailing Address(if different):
Establishment Telephone No.: �50 Q 3'5 Oo03
Applicant Name & Title: {0_6vnma.d Ai� x7AO
_,1
Applicant Address: ,aly A'a Sit; Sk low �(c 4�'�%i .moo Ua'oefv
Applicant Telephone No.: 5L7? 6V VALt0 24 Hour Emergency No.: iv? 61, 8 94
Applicant E-mail: rY0m;r "01ayrn `AC-"
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
An Association
partner.
WA Corporation
Name Title Address
13 An Individual
9 A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ),4km*,a A 1?c"
Address: j� G{ cfid
Telephone No: )0� 6 tt� �a�/SOgo'ys)LyJ,4 Hour Emergency No:
FAX:
6�
E-mail: 40M'hn k_�416V Gry
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:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
NO of Food Employees:
DAYS/HOURS:
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):
__ l
Location:❑i Permanent Location
Establishment Type
i:7 Caterer $35.00
DMoblie Mobile Start Date:
[Retail (A' Lt6 Sq. Ft)
[5Milk & Cream $10.00
Moblie End Date:
Food Service up to 100 INCLUDING
0 Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Food Service up to 101 -200 $250.00
] Food Service up to 201 + $300.00
® Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
E] Pushcart $50.00 # of Pushcarts:
Length of Permit:
[Annual
------ -----
Q Seasonal
Seasonal Dates:
0 Supermarkets $400
Residential Kitchen $100.00
etail Food $125.00
I Retail Snack Food $50.00
Tobacco Products $150.00
Q Temporary
Temporary Start Date:
Temporary End Date:
TemporaryTime:
Rain Date:
-_--" "-- —
Food Operations
(Check all that apply):
Dentitions:PHF - Potentially hazardous food (timeltemperature controls required)
Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
0 Sale of Commercially Pre Packaged Non-PHFs
PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
-- -----
Q Sale of Commercially Pre -Packaged PHFs
--------
Q Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
i3 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
--------
Q Delivery of Packaged PHFs
------
------
Q Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially------""-"""-"
Processed Foods for Service Within 4 Hours
Q Vacuum Packaging /Cook Chill
Q Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control )
Q Customer Self -Service of Non PHF and Non-
Perishable Foods Only
-❑-�. Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
r❑:1 Preparation of Non-PHFs
Other Food Operations
® Juice Manufactured and Packaged for
Retail Sale
® Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
----------- _ _
To be completed by the Board of Health
❑.-,� Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
Total Permit Fee:
----"-"" -
Payment is due with application 0 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
and paid state taxes required under law.
of perjury that I, to my best knowledge and belief, have filed all slate tax returns
Signature of Individual or Corporate Name:
Social Security Number or Federal ID:
Town of Mansfield
Town of Mansfield, Board of Health 5 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:
LOCATION OF SALE
PRODUCTS:
Ltd'
TELEPHONE AT LOCATION:
'250- Q 3 cfvv3
OWNER OF
ADDRESS OF OWNER:
TELEPHONE OF OWNER:
_ �08 6��A���
FAX NUMBER:
If a corporation or partnership, give name, title, and home address of officers or
* Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00
CT-3T NUMBER:
FEDERAL ID/SS NUMBER: 9,6
SIGNATURE:
DATE: �/
i
c,5ae�;-'tRvF
�w
Commonwealth of Massachusetts Letter ID: L0775218816
o
"
Or
-'--
Department of Revenue Notice Date: December 14, 2018
Christopher C. Harding, Commissioner Account ID: CRL-10719457-010
�4rtNt
oF"
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
I�III"II'ICI'll���l��lll�l�"IIIIIII"��'I�I'i�lll��ll��ll�l�l��
SHAHMIR INC
SIMPLE AMENITIES
4250 E RENNER RD APT 1915
RICHARDSON TX 75082-2853
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
PsSac"t'rF�T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
y y Retailer License for Sale of Cigars and Smoking Tobacco`'
9��1 <svr o+� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
SHAHMIR INC Account ID: CRL-10719457-010
SIMPLE AMENITIES License Number: 1747562496
214 RUMFORD AVE STE 103
MANSFIELD MA 02048-2176
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: December 14, 2018 Expiration Date: September 30, 2020
CommomvealthofMassachusetts
Department of Revenue
Christopher C. Harding, Commissioner
masagov/dor
oho
Letter ID: L0369299072
Notice Date: December 17, 2018
Account ID: CGL-10719457-007
RETAILER LICENSE FOR SALE OF CIGARETTES
Jill IIIpIIIIIIII 1uh11d1,1I11,11111111111d11P'llJill III III I
SHAHMIR INC
SIMPLE AMENITIES
4250 E RENNER RD APT 1915
iiiiiiinit RICHARDSON TX 75082-2853
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 MassTaxComiect 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
�y sh°"t'Sa MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
T
� �,q, w Retailer License for Sale of Cigarettes
�?'1j�Nt or��S� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
SHAHMIR INC Account ID: CGL-10719457-007
SIMPLE AMENITIES License Number: 355215360`
214 RUMFORD AVE STE 103
MANSFIELD MA 02048-2176
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: December 17, 2018 Expiration Date: September 30, 2020
061, A�
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.
0
Signature of Individual or Corporate Name By: Corpo ate 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
The Coinnionwealth oj'Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
U1V wo,mmass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address:
City/State/Zip: (�Rpk-t 3 Phone #: S coy, ' 31 oaa3
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. []-Retail
pr part-time).* 6. ❑ Restaurant/Bar/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.
[No workers' comp. insurance required] 8• ❑ Non-profit
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. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care
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 #1.
I am an employer that is providing worirers' compensation irtstiance for my employees. Beloit, is the policy information.
Insurance Company
Insurer's
City/State/Zip:
P1
Policy # or Self -ins. Lie. # Expiration Date:
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
Investieations of the DIA for insurance coveraee verification.
I do hereby certifyslunder the pains and penalties ofperjury that the information provided above is trite and correct.
Phone #: ��O p Li B
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.gov/dia