Loading...
HomeMy WebLinkAboutWines & More - 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:. KATHLEEN HARONIAN Whose place of business is: WINES & MORE - MANSFIELD 280 SCHOOL STREET Permit Expires December 31, 2019 License Number: RF-16 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH MichaeCHeaCey, 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: WINES & MORE - MANSFIELD 280 SCHOOL STREET License Number RF-16 Permit Expires December31,2019 BOARD OF HEALTH MichaeCHeaCey, Chairman 'A 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:: Wines & More - Mansfield^T�mm�l ' Establishment Address: 280 School Street, Suite 140, Mansfield, MA 02048 Establishment Mailing Address(If different): 1405 Douglas Ave. FNOV 18 North Providence, R102904 Establishment Telephone No.: 508-339-6900 BY: Applicant Name & Title: Kathleen Haronian, President Applicant Address: 98 A Nipmuc Trail, North Providence, RI 02904 Applicant Telephone No,: 401-353-4400 24 HOW Urnergency No.: 401-465-2527 Applicant E-mail: license@wsretailers.com Owner Name & Title (If different from applicant): Same as above 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. IeA Corporation Name Title Address ® An Individual Kathleen Haronian President Same as above ® A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Kathleen Haronian, President Address: 98 A Nipmuc Trail, North Providence, RI 02904 Telephone No: 401-353-4400 24 Hour Emergency No: 401-465-2527 FAX: 401-353-4469 E-mail: srao@wsretailers.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name& Title: Craig Power, Vice President Operations Address: 40 Whitelock Street, New Bedford, MA 02745 Telephone No: 401-465-2527 24 Hour Emergency No: 401-465-2527 FAX: 401-353-4469 E-mail: srao@wsretailers.com Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No, of Food Employees: 18 DAYS/HOURS: Mon. -Sat. 9am-10pm Sun. 12 pm-6pm 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 26 Seats or more): ❑® ❑® Caterer $36.00 Milk & Cream $10.00 Location: Permanent Location ❑® Mobile Mobile Start Date: Establishment Type VRe(all ( Sq. FI) Mobile End Date: Mobile Comments: Q Food Service up to 100 INCLUDING FOOD TRUCKS $176.00 ® Food Service up to 101 •200 $260.00 Q Mobile Food Consesslon NO PHF PREPARED ON SITE $100.00 ® Manufacture Frozen Desserts/lea Cream $26.00/freezer Length of Permit: [Annual Food Service up to 201 + $300.00 H Pushcart $60.00 # of Pushcarts: Min Seasonal Seasonal Dates: p Supermarkets $400 Residential Kitchen $100.00 Retail Food $126.00 ® Retail Snack Food $60.00 (] Tobacco Products $150.00 © Temporary -- Temporary Stan Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Check all (hat I ( Pp Y) Definlflons:PHF - Potentially hazardous food(lfmaRemperalura controls required) Non-PHFs-non-potenitellyhazardous lood(nolimellemperefure controls required) RTE- ready-(o-eat lootls (Ex. sandwiches,salads, muffins which need no furtherprocessing) Sale of Commerclally Pre -Packaged Non-PHFs Q PHFCooked To Order T Q Hot PHF Cooked and Cooled or Hot Held for More Then a Single Meal Service ® Sale of Commercially Pre -Packaged PHFs p Preparation of PHFs For Hot And Cold Holding For Single Meal Service Dellvery of Packaged PHFs 0 PHF and RTE Foods Prepared For Highly Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours Sale of Raw Animal Foods Intended to be Prepared y Consumer b ®Vacuum Packaging /Cook Chill I] Customer Self -Service of Non PHF and Non• Perishable Foods Only Q Customer Self -Service W Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand contact alternative, (line as a public health control) Q Ice Manufactured and Packaged for Retail Sale ® Preparation of Non-PHFs Other Food Operations Q Juice Manufactured and Packaged for Retail Sale ® Offers Raw Or Undercooked Food Of Animal Origin © Offers RTE PHF In Bulk Quanlitles ® Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health ® Retail Sale of Salvage, but -Of -Date or Reconditioned Food Total Permit Fee: Payment Is due with application ® waived o,o,y,ma, wuosi ro the accuracy of the information provided In this application and affirm that the food establishment operation will comply with 1 CMR 690.000 and all other applicable law, I have been Instructed by the board of health on how to obtain copias 105 CMR 690.90P and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec, 49A, I certify under (he penalties of perjury that I, to my best knowledge and belief, have flied all state lax returns and paid state taxes required under law. /�I/ Signature of Individual or Corporate Name: %A, Social Security Number or Federal to: 27.2176426 Town of Mansfield Town of Mansfield - .board of Health 6 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: Nines & More - Mansfield LOCATION OF SALE OF TOBACCO PRODUCTS: 280 School Street, Suite 140, Mansfield, RI 02048 TELEPHONE AT LOCATION: OWNER OF BUSINESS: ADDRESS OF OWNER: 508-339-6900 Kathleen Haronian MW TELEPHONE OF OWNER: Trail, No. Providence, R102904 401-353-4400 FAX NUMBER: 401-353-4469 If a corporation or partnership, give name, title, and home address of officers or partner. Kathleen Haronian, President 98 A Nipmuc Trail, No. Providence, RI 02904 * Provide a cop�r of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $160.00 CT-3T NUMBER: 489965568 FEDERAL ID/SS NUMBER: 27-2176426 SIGNATURE: DATE: 10/25/18 yssC,ttUc�, Commonwealth of Massachusetts Department of Revenue Christopher C. Harding, Commissioner �pNr oF�' mass.gov/dor o-o Letter ID: L0021889664 0 Notice Date: September 4, 2018 Account to: CGL-11451273-008 RETAILER LICENSE FOR SALE OF CIGARETTES Jill 111]11616dr[oil u"" 11111dlllt'L�r11iJt'ILn'h�ulli GT RETAIL INC WINES & MORE - MANSFIELD 1405 DOUGLAS AVE NORTH PROVIDENCE RI 02904-4052 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 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 Pes"` 5 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes" This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. GT RETAIL INC Account ID: CGL-11451273-008 WINES & MORE - MANSFIELD License Number: 489965568" 280 SCHOOL ST MANSFIELD MA 02048-1840 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 revolted for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 ,ShCn+.icy�.A Commonwealth of Massachusetts -�-I Department of Revenue Christopher C. Harding, Commissioner mass.gov/dor o-o Letter ID: L0021889664 0O Notice Date: September 4, 2018 Account ID: CGL-11451273-008 RETAILER LICENSE FOR SALE OF CIGARETTES �I�Illlll�hlluhln�""" ��II�dIII+�1+�iIInL��Ln�h�n�h GT RETAIL INC o WINES & MORE - MANSFIELD '^= 1405 DOUGLAS AVE MOWN NORTH PROVIDENCE RI 02904-4052 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 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 �PsS"c"use MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T h w Retailer License for Sale of Cigarettes y�1 F; �.*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. GT RETAIL INC Account ID: CGL-I 1451273-008 WINES & MORE - MANSFIELD License Number: 489965568 280 SCHOOL ST MANSFIELD MA 02048-1840 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 revolted for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 next IN ss icF CommonwealPo of Massachusetts Letter ID: L1245188736 � -{-� Department of Revenue ' Notice Date: September 4, 2018 Christopher C. Harding, Commissioner Account to: CRL-11451273-01 I rNToP�' mass.gov/dm' RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO II'llllllllll'llllllllllll'I'III'llll""I'llll'I"II"II'llPlll GT RETAIL INC WINES AND MORE N — 1405 DOUGLAS AVE m NORTH PROVIDENCE RI 02904-4052 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 ssncliUSF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T b Retailer License for Sale of Cigars and Smoking Tobacco Lt fvLCC.� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. GT RETAIL INC Account ID: CRL-11451273-011 WINES AND MORE License Number: 1540757504 280 SCHOOL ST MANSFIELD MA 02048-1840 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, 2020 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 o n ividual or Corporate Name By: Corporate fficer (Mandatory, if Applicable) z-g — zl ---mAQ .0 "Social Security No. (Voluntary) or Federal Identification Nmnber *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:\Usem\sleite\Desktop\Scott's Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Depai iment o, f Industrial Accidents Office of Investigations 600 Washington Street Voston, MA 02111 FFj mm.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly $usiness/Organization Name: GT Reta]lr Inc. D/$A Wines &More Mansfield Adcll'ess: 280 School Street, Suite 140 MA Are you an employer? Check the appropriate box: 1. [� I am a employer with 18 employees (full and/ or part-time).* 2. ❑) 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required] 4. ❑ We are a non-profit organization, staffed by volunteers with no employees. [No workers' comp, insurance req. Phone #: 508-339-6900 Business Type (required): 5, Retail 6. Restaurant/Bar/Eating Establishment 7: ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. ❑ Entertainment IO.F� Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box MI must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation ties other employees, a workers' compensation policy is required and such an organization should check box III, _ I ant an employer that is providing workers' eonipeasation insurance for my employees. Below is lire potley information. Insurance Company Name: MA RETAL MERCHANTS WC GROUP INC. Insurer's Address: P.O. BOX 859222-9222 City/State/Zip: 1RT.11111011:7 01 fain 131 Policy # or Self -ins. Lie..11 014005032982118 Expiration Date: 1/1/19 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 MOL 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 hereb , certi under the ins aad enables o e 'a that the information provided above is true and correct. J %Y / V ,%V rJ rJ' f Sirmatr Date: 8/24/18 Official use only. Do not write in this area, to be connpleled by cite 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 AC Rbr CERTIFICATE OF LIABILITY INSURANCE o1o/3o/z01ATE1MMlo2018 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 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(si. PRODUCER Hays Companies 133 Federal Street, 4th Floor Boston MA 02110 INSURED GT Retail Inc., DBA; Wines & More 280 School St. Emmeline Kuo .".(617)723-7 Mansfield MA 02048 1INSURER F: I I COVFRArFA CFRTIFICATE NUMBER-18-19 Master/Liquor Liab 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 - - - ADDL SUER _- POLICY EFF-- POLICY EXP l LTR TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MNIDDrc LIMITS X COMMERCIALGENERALLIABILITY j EACH OCCURRENCE $ 1, 000, 000 DAMAGE TO RENTED r 1, 000, 000 A CLAIMS -MADE OCCUR PREMISES LEa occurrence) I $ BZW56917371 1/1/201B 1/1/2019 MED EXP(Any one pemom $. 15,000 PERSONAL a ADV INJURY $ 1 000,000 - _— GENL AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ 2,000,000 I X POLICY JECOT r LOG', PRODUCTS COMPIOP AGG $ 2,000,000 _ OTHER', 'i. LIQUOR LIABILTY �$ 2,000,000 AUTOMOBILE LIABILITY j COMBINED J SINGLE LIMIT I I $ 1,000,000 ANY AUTO BODILY INJURY (Per person) $ A - ALLOWNED SCHEDULED AUTOS AUTOS BZW56917371 1/1/2018 i/1/2019 BODILY INJURY (Per acuden)l$ NON OWNED X. HIRED AUTOS FX AUTOS PROPERTY DAMAGE (Peracchl.m)__.. $ $ UMBRELLA LIAB LXJ OCCUR EACH OCCURRENCE $ 5,000, _000 E �X EXCESS LIAB CLAIMS -MADE AGGREGATE �$ 51000,000 LED X RETENTION$ 10,000 US056917371 1/1/2018 1/1/2019 $ WORKERS COMPENSATION X (STATUTE EORH AND EMPLOYERS' LIABILITY ANY PROPRIETOMPARTNERIEXECUTIVE �YIN Et EACH ACCIDENT __$ 500, 000_ C OFFICERIMEMBER EXCLUDED? Lry IMry and.toin NH) _ - NIA 14005032982118 1/1/2019 1/1/2019 EL DISEASE -EA EMPLOYE_ $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE -POLICY LIMIT $ 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Evidence of Insurance rcorronATo unr nvo CAMCFf I ATHIM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE James Hays/CDOHER�2--��f (S) 198B-ZU14 ACUKU COKPUKA I IUN. All rignis reserveG. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) Jane Doucette From: Sal Rao <srao@wsretailers.com> Sent: Friday, November 09, 2018 9:33 AM To: Jane Doucette Cc: Diana Sabetta Subject: RE: Mansfield Food/Tobacco Application Attachments: #58 Cigarette Dealer's License Exp Sep '20.pdf; #58 Cigar & Tob Dealer's License Exp Sep '20.pdf; GT Retail Inc..pdf; #58 Food Permit Expires 12 31 18.pdf HiiJane, The items you requested are attached, Thanks for followmg up with us. Salvatore IL Rao„ Jr, Tri-State Group, Inc, srao@wsretailers.com 401353,4409 From: Jane Doucette[mailto:Jdoucette(amansfieldma.coml Sent: Thursday, November 08, 2018 12:57 PM To: Sal Rao <srao@wsretailers.com>; 'srao@wsretailer.com' <srao@wsretailer.com> Subject: Mansfield Food/Tobacco Application Have received your renewal paperwork but will not be able to process the application until I have a workers comp insurance certificate. Also, do you sell cigars; if so I will need the CT-3T form for that. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here.