HomeMy WebLinkAboutPushkart Cafe - 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 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:.
Whose place of business is:
PUSHKART CAFE
219 NORTH MAIN STREET
PERSON(S) W CHARGE:
KATEENA N ALMEIDA
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS -85
BOARD OF HEALTH
MichaeCHeaCey, Chairman
YJ
FOR BOARD OF HEALTH USE ONLY Permit # Issued N.26 g
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name PUSHKART CAFE
Establishment Address 219 NORTH MAIN STREET
Establishment Mailing Address (if different) 171 WARE STREET, #2
MANSFIELD, MA 02048
Establishment Telephone No
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JAN ® Z 60
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Applicant Name & Title: KATEENA ALMEIDA
Applicant Address 171 WARE STREET, #2, MANSFIELD, MA 02048
Applicant Telephone No.: 24 Hour Emergency No.: (508) 272-9445
Applicant Email
Owner Name & Title (If different from applicant) KATEENA ALMEIDA
Owner Address (508) 272-9445
Owner telephone number (508) 272-9445
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
An Association partner.
A Corporation Name Title Address
An Individual - -
A Partnership -
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: KATEENA ALMEIDA
Address: 171 WARE STREET, #2, MANSFIELD, MA 02048
Telephone No: (508) 272-9445 24 Hour Emergency No: (508) 272-9445
FAX:
E-mail: JKIALMEIDA@COMCAST.NET
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: TOWN SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) No of Food Employees: 5
DAYS/HOURS MONDAY -SUNDAY 6AM-2PM -
Name of Person In Charge Certified in Food Protection Management: KATEENA N. ALMEIDA
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 LocationEstablishment Type:
Moblie Mobile Start Date
Retail ( Sq. Fp
Mobile End Date
Food Service up to 100 INCLUDING
Mobile Comments:
FOOD TRUCKS $175.00
Length of Permit:
j Food Service up to 101 -200 $250.00
Annual
1— - --- -- --
-
Food Service up to 201 + $300.00
Seasonal
Seasonal Dates: Supermarkets $400
Temporary
Temporary Start Date:
'
Temporary End Date:
Temporary Time:
Rain Date:
Caterer $35.00
Milk & Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $50.00 # of Pushcarts: 0
Residential Kitchen $100.00
Retail Food $125.00
Retail Snack Food $50.00
Tobacco Products $150.00
Food Operations: Definitions PHF- Potentially hazardous food (timeRemperatum controls required)
Non-PHFs - non -potentially hazardous food(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
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged for
Retail Sale
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
Offers Raw Or Undercooked Food Of
Animal Origin
Offers RTE PHF Prepares Food/Single Meals for
in Bulk Quantities
Selvage,_Out-Of-Date
Catered Events or Institutional Food Service
eRecondit Reconditioned Food orTo be completed by the Board of Health
Total Permit Fee: $175.00
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 tgoptain copies of 105 CMR 90.000_V0111h, federal Food Code.
Signature of Applicant:, 't1,tVTa'6h�°
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.
Social Security Number or Federal ID: 001-34-387944 �/ f f
Signature of Individual or Corporate Name: 4k 11111j -(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.
Signature of Individual or Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
t
I
✓!k y t tr�f Ik."
By: Corporate Officer (Mandator, 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.
R:\Health\Jane's Documents\PERMIT APPLICATIONS\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:
City/State/Zip:
Phone #:}( '
A�you an employer? Check the appropriate box:
Business Type (required):
U
I am a employer with employees (full and/
5. []Retail
or part-time),*6
Restaurant/Bar/Fating Establishment
2. ❑
I am a sole proprietor or partnership and have no
7, E] Office and/or Sales (inch real estate, auto, etc.)
employees working for me in any capacity,
6. ❑ 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.❑ Manufacturing
no employees, [No workers' comp. insurance required] *
11. ❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. iNo workers'.comp. insurance req.7
12.0 Other
*Any applicant that checks box #I must also fill out the scetion 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 provilling warners' compensation insurance far my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip;
�(',1 NOD1,
Policy 4 or Self -ins. Lie. # C � t �� Expiration Date: [ D it per_
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 parf s/and penalties ofperjury that the information provided above is true and correct.
Phone N:
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
3, City/Town Clerk 4, Licensing Board 5. Selectmen's Office
Contact Person: Phone
www.mass.gov/ma
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express'or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such -employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required,"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line. _
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple perrniUlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call,
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext406 or 1-877-MASSAFE
Fax # 617-727-7749
www.rnass.gov/dia
Foran Revised 5.26-05
AC4ORa CERTIFICATE OF LIABILITY INSURANCE
DATE112/20/8 Y)
10/12/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, 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, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCERONTACT
NAME: IlySsa Riley
pHCNNo Ex (800)675-6695 n/C, No: (800)754-1602
Encharter-MA
E-MAIL iriley@encharteccom
ADDRESS:
Encharter Insurance LLC
INSURER(S) AFFORDING COVERAGE _ NAICM
25 University Drive
INSURER A: The Hartford 00914
Amherst MA 01002
INSURED
INSURER B:
INSURER C:
Pushkart Cafe
_
D: _
171 Ware St Apt 2INSOBER
INSURER E : _
1 INSURER F:
Mansfield MA 02046
CAVERAGEC CFRTIFICATF NIIMRFR- 2018-2019 COIs REVISION NUMBER:
THIS 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 CONTRACTOR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I�jR
TYPEOFINSURANCE
ADDLbUUR
SD
WVD
POLICY NUMBER
MM/D�YEFF
MMIDDmYY
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE Fx_] OCCUR
1,000,000
PREMISES (E. occummce) S
MEDEXP(Anyonepmson) $ 5,000
A
OBSBAAB9745
10/10/2018
10/10/2019
PERSONAL&ADV INJURY 5 1,000,000
GEN'LAGGREGATELIMITAPPLIES PER:
GENERALAGGREGATE $ 2.000,000
PRODUCTS - COMP/OPAGG S 2,000,000
X POLICY jET F—] LOC
5
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident $
BODILY INJURY (Per person) $
ANYAUTO
BODILY I NJURY(Per accident) S
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTYDntAMAGE $
Peracclde
S
UMBRELLALIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAR
CLAIMS -MADE
DED I I RETENTION s
$
I
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PXCLUD /EXEDUTNE ❑
in NH) EXCLUDED'! Y
(Mantlatory in NH)
(Mandatory
NIA
OSWECACIYOK
10/10/2018
10/1072019
10
STATUTE ERH
EL. EACH ACCIDENT $ 500,000
E.L. DISEASE -EA EMPLOYEE $ 500,000
E.L. DISEASE -POLICY LIMIT $ 500,000
Ifyes,tlescdbeender
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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