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Home My WebLink AboutMansfield Deli - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health to Operate a Food Service 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:. THOMAS E. REILLY Whose place of business is: MANSFIELD DELI 72 PRATT STREET License Number: FS-46 Permit Expires: December 31, 2019 BOARD OF HEALTH Food Fee: $175.00 Milk & Cream MichaeCAeaCey, 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 DELI 72 PRATT STREET License Number FS-46 Permit Expires: December 31, 2019 BOARD OF HEALTH MichaeCHeaCey, Chairman X 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: KE ETTO Establishment Address: MANSFI D9 [VIA 02048 Establishment Mailing Address (if different):', t� s Establishment Telephone No: Applicant Name & Title: • 7 , Applicant Address: -� Grover I-410 I-is'xbo)� AV, DLo3 Applicant Telephone S11'0� (� pp p )7'� � 24 Hour Emergency No.: Applicant Email: `T•6_&J(lq lu��coa�tir� 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 ID An Association partner. 9,A corporation Name Title Address An Individual — _rtbw �' �e � LL L 11 s�e11 O A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: S�+tBSat 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: :FNo. WAGE DISPOSAL: DEP Public Water Supply No: (If bl applicae) 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): Location: [.Permanent Location Establishment Type: ❑ Caterer $35.00 Mobile Mobile Start Date: [ 2gaiI ( )00 Sq. Ft) $125 ilk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING ❑ Mobile Food Consession Moblie Comments: DOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length Of Permit: ❑ Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $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 obacco Products $150.00 ITITemporary ❑ Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food thrreRemperature controls required) Non-PHFs - non -potentially hazardous lood(no timellemperature controls required) (Check 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 ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Cold Holding For Single Meal Service -- Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Vacuum Packaging / Cook Chill Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours __ __.__._....._...._. ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service - Perishable Foods Only contact alternative, time as a public health ❑ Ice Manufactured and Packaged for Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑Prepares Food/Single Meals for 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 fhe 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 CM000 and all other applicable law. have been instructed by the board of health on how to obtain c((��jjppies of 105 CC R 90.000 and the federal Food Code. � /�-� Signature of Applicant: � A,/ Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. Social Security Number or Federal to: Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield - z d ooeaCti a PERMIT NUMBER: Town of Mansfield 6 Park Row Mansfield, MA 02048 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. As a provision of this permit, all employees who sell tobacco or nicotine delivery products have read the applicable BOH regulations and have signed a statement that the employee understands and upholds the regulation. 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: MANSiHELD D FUJ5 p L LOCATION OF SALE OF TOBACCO PRODUCTOAN��°�',t D, Ph"l 02043 TELEPHONE AT LOCATION: OWNER OF BUSINESS: ADDRESS OF OWNER: rr � L, c- I' r /aju A-,-k 3 I TELEPHONE OF OWNER EMAIL ADDRESS: Tt If a corporation or partnership, give name, title, and home address of officers or pa tner. " Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3TNUMBER: L (ALL Ioy 3Yi-v�-vib FEDERAL ID/SS NUMBER: Z 01 Nrq1 SIGNATURE: DATE: I L i y,�nrheF Commonwealth of Massachusetts ' Department of Rcvcnuc Christopher C. Harding, Commissioner mass.gov/dor MAE LetterlD: L0339133056 �fN� Notice Date: September 6, 2018 Account ID: CGL-10938204-006 RETAILER LICENSE FOR SALE OF CIGARETTES 1111111u11111111111111111111111' Jill III IIIIIIJ11111'll�'1'1'll�� MANSFIELD DELI LLC MANSFIELD DELI 72 PRATT ST 3"1210010:1911"T AX11111 BLII Ai -- ----- Attached-below-is-youtR-etailer 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/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 SPss� Seri MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o a Retailer License for Sale of Cigarettes r6FMoFS. 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 DELI LLC Account ID: CGL-10938204-006 MANSFIELD DELI License Number: 156420096 72 PRATT ST MANSFIELD MA 02048-1927 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, 20,20 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 oVorporate Name By: Corporate Officer (Mandatonj, if Applicable) ry UV 1-t6- iI'L— *"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:\UsersWeite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION F'ORM.doc The Common vealth 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 Applicant Information tlPaa� g ] Please Print Leeibly Business/Organization Name: 712 5FIRRIATT 1151TREEIT MAIN City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Ret il' or part-time).* 6. estaurant/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. 8• ❑ 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 4. ❑ no employees. [No workers' comp. insurance required]* We by 11. ❑ Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance teq.] 12.0 Other *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 # 1. I am an employer that h providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: blL �q r City/State/Zip: 1—tG))7�bti� Policy # or Self -ins. Lic. # 0V - W 1- If I I Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited 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, un�derr/g��e pains and penalties of perjury that the information provider! above is true and correct. Sianature: ��/ 1 •. Date: rL t Official use only. Do not write in this area, to be completer) 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.nrass.gov/dia O® A `V(J/]� CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDOIYYWI 12/06/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 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). PRODUCER C & S Insurance Agency, Inc. CONTACT Lisa Fonseca NAME: PHH,0No E,d : (508) 339-2951 ac No : (508) 339-4811 nDORIEss: lisa@candsins.wm 190 Chauncy Street/P.O Box 406 INSURERal AFFORDING COVERAGE NAIC If INSURERA: Employers Mutual Casualty Company 21415 Mansfield MA 02048 INSURED INSURER B: Commerce Insurance Co 34754 INSURER C: Hartford Casualty Insurance Cc 29424 MANSFIELD DELI LLC INSURER D: Hospitality Mutual Insurance Company 72 PRATT ST INSURER E: 1 INSURER F: MANSFIELD MA 02048-1927 COVERAGES CERT1EIPATM Ml IMRPP• 2018 Cert of Liab REVISION NUMBER: V 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. VTR TYPE OF INSURANCE NSD Me POLICY NUMBER MMIDDVIYYYY EXP MMIDDEFFY/VYYY LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEOCCUR PREMISES(Ea occurrence $ 500,000 MED EXP Anyone 2ersor $ 5,000 A 5W07628 02/10/2018 02/10/2019 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY ❑ JECT LOU S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidend.o t) $ 1,000,000 BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY (Per acdden0 $ B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED x AUTOS ONLY HAUTOS ONLY BBZQVVJ 02/20/2018 02/20/2019 PROPERTY DAMAGE Perecdtlenl $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIP B CLAIMS MADE DED I I RETENTION $ $ WORKERS COMPENSATION X1 STATUTE EORH C AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ (Mandatory In NH) NIA 08WECTJ7416 04/24/2018 04/24/2019 -..... -..' E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT S 600,000 II yes, describe under If DESCRIPTION OF OPERATIONS below $1,000,000 p Liquor Liability 00076810LL 02/10/2018 02/10/2019 $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town Of Mansfield 6 Park Row Mansfield MA 02048 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 n 40AA-91115 ACf1Rn CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD aw c w E mc a O l� u W Z O 6 N (U w 0 E O a N cn 0 o a� i O O N Cp C to 0 0N 00 F N w 1 10 O m K LL O Ln i _ w 6 C1 O u O zv�0� w O W M W Q Z N � N N N y O O Z U q Q tom'` B gu'',a~s o sad x� woo � M V1 M 0 � v yJ yl n � S N C � L w 42 y C/ W Z 0 IH v N N N c 0 S N