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HomeMy WebLinkAboutMansfield Adult Day Health Center - 12/31/2019pu 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:. HEALTHCARE OPTIONS Whose place of business is: MANSFIELD ADULT DAY HEALTH CENTER 300 BRANCH STREET PERSON(S) IN CHARGE: KAREN AMADO, PROGRAM DIRECTOR Permit Expires: December 31, 2019 Food Fee: License Number: FS-43 WAIVED HARD OF HEALTH Milk & Cream -'aeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued f FOOD ESTABLISHMENT PERMIT APPLICATION rNrtg� (Application must be submitted at least 30 days before the plane17 1) Establishment Name Mansfield Adult Day Health Center M 2) Establishment Address 300 Branch Street, Mansfield, MA 02048 3) Establishment Mailing Address (if different) ` 4) Establishment Telephone No (508) 339-2119 5) Applicant Name & Title: Dawn Sullivan, Director of Clinical Services/COO 6) Applicant Address 10 Emory Street, Attleboro, MA 02703 7) Applicant Telephone No.: (508) 222-0118 24 Hour Emergency No.: (508) 695-0359 8) Owners Name & Title HealthCare Options 9) Owner Address (If different from applicant) 10 Emory Street, Attleboro, MA 02703 Owner's telephone number (508)222-0118 10) Establishment Owned By: Ed An Association EZ A Corporation H An Individual l A Partnership El Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Karen Amado Program Director Address: 300 Branch Street, Mansfield, MA 02048 I Telephone No: (508) 339-2119 24 Hour Emergency No: (508) 695-0359 (508) 339-3820 FAX: E-mail: kamado@mansfieldadhc.com Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name &Title: Dawn Sullivan, Director of Clinical Services/COO Address: 10 Emory Street, Attleboro, MA 02703 Telephone No: (508) 222-0118 24 Hour Emergency No: FAX: (508) 226-3573 E-mail: dsullivan@communityvna.com Food Establishment Information 14) WATER SOURCE: Town 15) SEWAGE DISPOSAL: Town 16) No. of Food Employees: 1 DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: Mon - Fri 7:30 AM to 4:30 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Richard Keefe Required as of 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ra 20) Location:®< Permanent Location 22) Establishment Type rJ Caterer $35.00 !'?1 Moblie Mobile Start Date: IU Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING Ei Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 wJ Food Service up to 101 -200 $250.00 hM Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21) Length of Permit: ig Annual ----------- rl Food Service up to 201 + $300.00 r=r.! Pushcart $50.00 # of Pushcarts: O Seasonal Seasonal Dates: Supermarkets $400 !L{ Residential Kitchen $100.00 !'a Retail Food $125.00 Q Retail Snack Food $50.00 r? Tobacco Products $150.00 _ 9H Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: - 23) Food Operations Definitions:PHF- Potentially hazardous food(lime/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperatura controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, mufns which need no further processing) G9 Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service re Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Delivery of Packaged PHFs ❑W Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours Vacuum Packaging / Cook Chill iH Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) t Customer Self -Service of Non PHF and Nan- Perishable Foods Only E Customer Self -Service rt Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations F1 Juice Manufactured and Packaged for Retail Sale R Offers Raw Or Undercooked Food Of Animal Origin F2 Prepares Food/Single Meals for Catered Events or Institutional Food Service r=:1 Offers RTE PHF in Bulk Quantities fa Retail Sale of Salvage, Out -Of -Date or Reconditioned Food — To be completed b the Board o Y of Health Total Permit Fee: Payment is due with application waived I, the undersigned, attest to thrn racy of the inf rmation provided in this application and affirm that the food establishment operation will cply h 105 CMR 90.000 and all other applicable law. I have been instructed by the board of health on how tc obip es of 105 C /590.000 and the federal Food Co e. 24) Signature of Applicant: (�t' / UO J C Pursuant to MGL Ch.62C, sec. 9A,.1 cerfi un er the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Q 25) Social Security Number or Federal ID: a a S'✓ 26) Signature of Individual or Corporate Name: 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. Healthcare Options, Inc Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 22-2543620 *"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\Scotts Documents\Food Estabhshmeirts- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwip.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: HealthCare Options Inc. Address: 10 Emory Street City/State/Zip: Attleboro MA 02703 Phone #: (508) 222-0118 Are you an employer? Check the appropriate box: Business Type (required): 1. r❑ I am a employer with 110 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. R 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]* 11.0Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 must also fill out the section below shoving 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 ant an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. C—� Insurance Company Name: 16A//ail /'?,t U l IA�S-72-0x�T CcrP ' v Liberty Mutual Insurance Insurer's Address: 'p0 66-IV ,20,,1_7 Attn: Payment Processing Con er,1449 J 100 Liberty Way City/State/Zip: /�'%/� ✓ -1- 6 ��� Dover, NH 03820 Policy # or Self -ins. Lic. 3/S- 3991195 -BJk- 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 Investigations of the DIA for insurance coverage verification. I rho hereby certify, raider the pains and penal#ens ofperjury that the information provided above is true and correct. Phone9: soi ',�d� - 0/1"k 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 Phone www.iums.gov/dia ACORO® CERTIFICATE OF LIABILITY INSURANCE �/ DATE (MMIDD YWY) 1/10/2018 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 MARSH & MCLENNAN AGENCY LLC DBA THE PROTECTOR GROUP INSU 100 FRONT ST STE 800 WORCESTER, MA 01608 CONTA T PHONE FAx A c No E-MAIL ADDRESS: mma rotector ro,upcort@mma-newengland.com INSURERS AFFORDING COVERAGE NAICH INSURERA: LM lnsurar Corporatkuri 33600 INSURED HEALTHCARE OPTIONS INC INSURER B: 10 EMORY STREET INSURERC: INSURER D: _ ATTLEBORO MA 02703 INSURER E : INSURER F: COVFRArFS CFRTIFICATF N1IMRFR- ADAsnA79 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 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. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICYNUMBER POLICY EFF IMWDD)YYYY1 POLICY EXP IMMIDDWWILIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea Accunence $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ AGGREGATE LIMIT APPLIES PER: AGGREGATE $ GEN'L POLICY ❑ jECT LOG S-COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITY D SINGLE LIMIT SnlANYAUTO JURY(Per person) ftn$ SOWNED SCHEDULED ONLY AUTSHIRED JURY(Per accitlenl) $AUTOS Y DAMAGE nt SAUTOS NON -OWNED ONLY AUTOS ONLY S UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIA9 CLAIMS -MADE DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑N NIA WC5-31S-388495-018 1/1/2018 1/1/2019 ,/ STATUTE ERH E.L. EACH ACCIDENT $1000000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE$ 000000 If es, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) WOKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates, only as they relate to workers' compensation coverage. CFRTIFI(:ATF HOI TTFR CANCFI 1 ATION MANSFIELD BOARD OF HEALTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, WILL BE DELIVERED IN 6 PARK ROW ACCORDANCE W THDATE THE POLICY PROVISIONS.E MANSFIELD MA 02048 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 39830875 1 1-388495 1 10-19 WC I n0254981 1 1/10/2018 1:01:11 PH (EST) I Page 1 of 1 0 W I W W v 'r)r' ry U_ ry F ua f _ Z f O w N Q O X L w O a N W* 0 W � � � � � � W u � z � z � � � VA, \ e § ] \ \ \ \ o ( 4 / » / ® ƒ(\J { \\\ \ ®® t \\\\ \ q Mansfield Board of Health Request for Fee Waiver for Food Permit Date /4/3/ /da We, /'Lload7Iovo ii P1,9Y bt-% ' ! 9M-restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department, Please list the department: cQ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature `L �oz� Title *Please provide proof of valid 501(c)(3) status BOH Use Only — Approved Denied Reason: Signature: Date: FA '�`11"3 CY Dcparlmont ol'tho Treasury yy�''11//�� RS lutorn: 1 Itovenue smwice P.Q. Box 2508 Cincinnati OH ti , 17712 In reply refer to: 0248162365 45201 July 31, 2009 LTR 4168C EO 22-2543620 000000 00 00018672 BODCi TE HEALTHCARE OPTIONS 'INC 10 EMORY ST ATTLEBORO MA 02703-3002 Employer Identification Number: 22-2543620 Person to Contacti Robert C Voss Toll Free Telephone Number: 1-877-829-5500 Dear Taxpayer: This is in response to your request of July 22, 2009, regarding your tax-exempt status. Our records indicate that a determination letter was issued in October 1986, that recognized you as exempt front Federal income tax, and discloses that you are currently exempt under section 501(c)(3) of the Internal Revenue Code. Our records also indicate you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a)(1) and 170(b)(1)(A)(vi). Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections,2055, 2106, and 2522 of the Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely yours, 'jt�sJle&''1� �u�awT� Michele M. Sullivan, Oper, Mgr. Accounts Management Operations I