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HomeMy WebLinkAboutPrimrose School - 12/31/2019f P Commonwealth 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:. NEHA PATEL Whose place of business is: PRIMROSE SCHOOL OF MANSFIELD 201 COPELAND DRIVE PERSON(S) IN CHARGE: NEHA PATEL Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS-86 BOARD OF HEALTH MichaeCHealey, Chairman X Milk & Cream 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: pe)MkOSc SCtIML Of MAaS1FIEr-15 Establishment Address: ZO1 WCLA,1D •pR, NANSFIELO,MA 02-048 Establishment Mailing Address (if different): I g W ILa0 j, P A CZ JU 201 WVL,t ESLE4, HA 02481 Establishment Telephone No: SOS - 369 - 61 6 9j Applicant Name &Title: N@kA PAT91, ' (0 Wr'9IL Applicant Address: 113 WILLOW PAf-K, (,JELLESLEY, 14A OZ481 Applicant Telephone No.: 61-?. $18- 4589 24 Hour Emergency No.: 60-919,4S88 Applicant Email: APa '21 6A `ir1raf05ema4w . Gom Owner Name & Title (If different from applicant): Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. E ttd A Corporation Name Title Address EJ An Individual NENA ktft,�PAtA4 PAV owNEC (._$ tatLww PARK weL�Esl _SArtlt'_iA�EL k- fRALI Kft- O-WJe �t311ASYIN6) S1� FCAWaGI+A ElAPartnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: NFNA PA1EL, ©WO160 Address: I $ WkLtoW QAUcr WeLL6S Ley, MA 0z48 Telephone No: 611- 618 - tt f 91 24 Hour Emergency No: 6! i - g 1 LySB Y FAX: E-mail: OFOkLA PriMroxJn011frLOM Alt E-Mail: 0e ,5 Paw cL l • LoM District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: , MA Food Establishment Information WATERSOURCE: I DW P DF MANsateL D SEWAGE DISPOSAL: TOWtj of MA0F) el-b No. of Food Employees: 1- DEP Public Water Supply No: (If applicable) DAYS/HOURS: MOAAAA Name of Person In Charge Certified in Food Protection Management: NA N c N 60 -fc c2 If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or mare): Location: Permanent Location Establishment Type: I] Caterer $35.00 0 Mobile Mobile Start Date: lJ Retail -NO FOOD PREP ( Sq. Ft) $125 ". ilk & Cream $10.00 Mobile End Date: "' EJ Mobile Food Mobile Comments: Food Service up to 100 seats INCLUDING FOOD TRUCKS $175,00 EJ Food Service for 101 -200 seats $250.00 ON NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream O $25.00/freezer Le th of Permit: Annual E] Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: EJ Residential Kitchen $100.00 -- 0 Seasonal Seasonal Dates: Supermarkets $400 Tobacco Products $150.00 =a❑i Retail Snack Food $50.00 EJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions: PHF Potentially hazardous food(tlmaAemperatme controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE-wady-to-eat foods (Ex. sanolviches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order d Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑i Sale of Commercially Pre -Packaged PHFs 9-preparation of PHFs For Hot And lJ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service ill Delivery of Packaged PHFs Susceptible Population Facility lJ Sale of Raw Animal Foods Intended to be Prepared by Consumer eheating of Commercially Q Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance i Customer Self -Service of Non PHF and Non- 0 Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health control) E Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations I Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for 0 Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 1 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. 1 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: e Pursuant to MGL Ch.62C, sec. 49A, I certify and paid stale taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: . penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns 0 2219 16152,5 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31 st of each year. NAME OF BUSINESS: f �j" -%t S Uioa'— OF ►CANS FrE6 P ADDRESS: Zip CoftalPb -D(-� HPN5f ftQ, HA 02648 TELEPHONE AT LOCATION: 508 - 2)6 R • 61 6 3 1J:4IPlJi1EI4:41 OWNER OF BUSINESS: 06hA QR1E1 TELEPHONE OF OWNER: G tj , S � FEDERAL ID/SS NUMBER: FEE: $10.00 44:161k&k'Mi41:147i SIGNATURE:° - DATE: .f5/3i ! 9 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. MM405E SC41tV1- of kANSfIG��—�� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 8zti 91652-5 **Social Security No. (Voluntan/) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desklop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U'r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Q Qi M WC S (H wa- of µ A N sf )ell) Address: 22n1 wletAND Dg.MAIJ5fieiD, NR 02_1S1 City/State/Zip: Phone#: 61-7_$IS- 458-9 Are ygu an employer? Check the appropriate box: Business Type (required): 1. I am a employer with a- 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. [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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.U✓ Other 4cu j G{ U lw.,J C itrl:on NAW *Any applicant that checks box #1 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ma(ktt IASVJAw)(e Insurer's Address: 1 P n. Pocgwaj NI or44^- City/State/Zip: 1) e" f W I C 600 15 Policy # or Self -ins. Lie. # M W C D 14 b 25 -7 - 0 1 Expiration Date: it �r Ir W 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, end��th eppr the pains and penalties ofperjury that the information provided above is true and correct. Signature: �✓1 Date: `✓� �'�' iQ --W- 45g8 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY III INFORMATION PAGE MAR (EL°' Original Printing Issued March 29, 2019 Standard NCCI Carrier Code:22616 Type: Stock Markel Insurance Company Ten Parkway North Deerfield, IL 60015 1. The Insured's Name and Mailing address: Inspirational Minds, LLC 18 Willow Park Wellesley, MA 02481-5609 6178184111 Policy Number IMWC0146257-01 J Renewal of Policy: Rewrite of Policy: Fein # I Risk ID #: 822916525/ DBA Name: Primrose School of Mansfield SIC CODE: 8351 Other work place not shown above: See Attached Location Schedule Type of Limited Liability Company entity: 2. The policy period is from 04/01/2019 to 04/01/2020 112.01 AM Standard Time] at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: MASSACHUSETTS B. Employers liability Insurance: Part Two of this policy applies to work in each stale listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident: $1,000,000 each accident Bodily Injury by Disease: $1,000,000 policy limit Bodily Injury by Disease: $1,000,000 each employee C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here All states except those listed in Item 3A of the Information Page and the following states or territories: District of Columbia, ID, MT, NY, ND, OH, OR, WA, WY, Puerto Rico and US Virgin islands. D. California Endorsements and Schedules Other State Endorsements and Schedules: MDWC 1001, MWC 1201, WCOOOOOOC, WC000308, WC000406A, WC000414A, WC000422B, WC000425, WC 20 03 01, WC 20 03 02 A, WC 20 03 03 D, WC 20 04 01, WC 20 04 05, WC 20 06 Ol A, WC 20 06 04, MJ WC1000, MIL 1214, MPIL 1083, MPIL 1007 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject to verification and change by audit. Minimum Premium: 258.00 Deposit Premium:$437.00 Producer: DMS Insurance Agency Of Texas LLC Countersigned By: 12400 Colt Road, Suite 1100 972-419-7568 Dallas, TX 75251 Date: 03/29/2019 Servicing office: Markel Service, Inc., (888) 500-3344 Central Park Plaza, 222 South 15th Street, Suite 150ON Omaha, NE 68102-1680 (See extension of information page for class code, rate and premium detail) Total Estimated Annual Premium: $2,803.00 Pay plan: 10-Pay- 15004 THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY MDWC 100105 10 1 of 28 008012-01339644722540-03292019 MWO0146257-01 Ak W u c C `o •O V L W O d Z V O o m W C Q W Z 2 V d c v � X ` � , m 1 � N w v O�• Q _ O X Q c � � N w � � •o ry'Ar' y S � V) ° W O `Q F— .o -� Z W P o rn � � S a o � v XU uCo w_ z 000 \�` N ? u � Q v C O 0 N W ct C) T W 1 �J ct Q) Al m a 'O U L N O C W y L m C 4, 0 n 0 O N + L a x 3 O b4 o y s �0 3 •o C O L N > O Y O ••- V1 L ul �Y. � b O L C � U C U vY C L O C L O N by .0 C U ldto N y y Y 0 to L a T .� Cd O d a > CQ .y L fd a� m � C L U Z7 y > x N O N U L m N O bo A C � C ro a L o y y A y bU O � b w, �w 0 r-i ,00 e�� x o� O k� 0157 American Red Cross Certificate of Completion Nancy Butler has successfully completed requirements for Adult and PediatrictUR/AED - valid 2 Years conducted by American Red Cross Date Completed: 07/07/2018 Instructors: Kelly Ortendahl Certificate ID: GWFACV To verify, scan code or visit: redcross,or /confirm