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HomeMy WebLinkAboutWest Mansfield Variety - 12/31/2019)� l Commonwealth 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.. HIRENKUMAR PATEL, OWNER Whose place of business is: WEST MANSFIELD VARIETY 428 ELM STREET Permit Expires December 31, 2019 License Number: RF-15 Food Fee: $175.00 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: WEST MANSFIELD VARIETY 428 ELM STREET License Number RF-15 Permit Expires December 31, 2019 BOARD OF HEALTH MlchaeCHeaCey, Chairman 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: ihn e Q, ECEIV Establishment Address: Li �� e S� t �rr.S��^e 1 c, OCT 2 4 Establishment Mailing Address(if different):�1 Y.__ Establishment Telephone No.: �I, 2�/ )i 3g 2 Applicant Name & Title: \-V� e nk_u/,-�ar vs 1 �cu'Ve_ Applicant Address: C C_m,,, J y C) � c-00­y rNro o n qc d2 6 Applicant Telephone No.: So - 9 f 24 Hour Emergency No.: So iR�- 1�,-A p -- Wit) 9 r Applicant Email: p Yl '�2 �QA4,V� ( ryr) Owner Name & Title (If different from applicant): 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 E; An Association partner. ] A corporation Name Title 1 Address El An Individual Ni y_0+Myc'Cw �4�el Irl tolu y E 1 A Partnership I C 1 Other legal Entity 1���?��' �A 02'} 66 Person Directly Responsible \ For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �� 7e-n't� oPs ``CA-p- \ ) rvy Address: � CO,U,-VTA C t" W"i , \\�� o-aJ" , ' f 02 } 6 6 I c:lephone No: !&o g 4 D-- C,\ \ t 24 I lour 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: WATER SOURCE: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Food Establishment Information SEWAGE DISPOSAL: No. of Food Employees: 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 []Moblie Moblie Start Dale: Moblie End Date: Moblie Comments: Length of Permit: ( Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date ['. Retail ( 2-LA 0 USq. Ft) ❑ Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 ❑ Food Service up to 101 -200 $250.00 ❑ Food Service up to 201 + $300.00 [ ] Supermarkets $400 ❑ 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 R of Pushcarts: ❑ Residential Kitchen $100.00 [1;4elail Food $125,00 [ o ["Tobacco Products $150.00 Food Operations Definitions: PHF - Potentially hazardous food (iree/temperature controls required) Non PHFs non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - medy-lo-eat foods (Ex. sandwiches, salads, muffins which need no higher processing) [(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 [] Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public. health f 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 Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food To be completed by the Board of Health Total Permit Fee. Payment is due with application ❑ waived I, the undersigned, altest 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 to obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: __Ii_ Pursuant to MGL Ch.62C, sec. 49A, t certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all slate tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: JA_�4=1_(L_ — Social Security Number or Federal ID: 3 �. 12- 2 S 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 31st of each year. NAME OF BUSINESS: W l /l uk'nS � {' e ) ci 1/ u �SA e" ADDRESS: I t 2-2� E� -"l 'VY) u. A �"? c(. k �n (�- ©20 L( �5— TELEPHONE AT LOCATION: 7 t-LP - 2SSjt - <13 9 -,)— I CAI 2 111 Jj 1-1 A OWNER OF BUSINESS: eIN-) t MG d V� TELEPHONE OF OWNER: Sd g- b a 91 FEDERAL ID/SS NUMBER: A 2 - S "j FEE: $10.00 PERMIT NUMBER: SIGNATURE: � \ A 1 DATE: _ 01 2Le 1 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: U00S't "LtY�Sj '-e d- V ' LOCATION OF SALE OF TOBACCO PRODUCTS: `-i 2.55 Cf-"\ Si t v\u-n-sR-f 1 d TELEPHONE AT LOCATION: ` -3-Z( - Lf ,- Iq 3 q 2— OWNER OF BUSINESS: _ i i i 6-P-n 6Aern (4Y ADDRESS OF OWNER: Con-Ok Yj C� TELEPHONE OF OWNER: !� E� — `25t-t C) '`A\ t FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 L12 q CT-3T NUMBER: r 22_'5-0Zt2S-�-S- --7-t 2 L FEDERAL IDISS NUMBER: /( �-3— "y 2 - 2S I c) SIGNATURE: DATE: b P 0. CUJ � M N Cf147� w CI o to 0 n Cl s r i.l 4J q •a ✓, a Fes-' Q c o N op W o ua u a o w p r ro ti i•J � CI. to ,_,. '^ L' .T Vt �� W .n LA �.. «• �u m . 0 `..{ ! % .!.` 1 '"' �L'• r`", t.., Cl ; ; ill `�`` ;` '✓'� W :r, •� .\."' ...� L a .-, � jcn 0 N ty tr � Ctw v O N 1} N V O C7 0 a a+ �C GO cq Ci .y ca W v e Z dcz i 4w 6. L Ctm o o c da CL w G N tl C N O U U ` Sl O 3 00 C I O J 10 LIJ i/% to 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. e- Np Pu` e Signature of Individual or Corporate Name GI '3-3- `-I z — Lit n **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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 tinder the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleiie\Desktop\Scott's DOCUmentsFood Establishments- Temp\TAX CERTIFICATION FORM_doc _.. N Department of brdustr, ial Accidents Office of InvesXigatibns 600 Washington Street Boston, MA 02111 19 rvn,millass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: to 10 e4 lv) tl�� City/State/Zip: /ti)unc,6,e 1.l __/ )a4 nG, gPhone #: 2�5�(� Lt �`� 2- Are you an employer? Check the appropriate box: Business Type (required): I. I am a employer Willi _ 2_ employees ( full and/ 5. [,�J Retail or part-time).* 6. ❑ Rcstaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl, real estate, auto, ete.) employees working for nae in any capacity. [No workers' comp. instu'anw required] R. ❑ Non-profil 3. ❑ We are a corporation and its offices have exercised 9. ❑ Entertainment their right of exemption per c. 152, C 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12❑ other .\ny applictmt that checks box #1 nnist also fill out the section below showing their workers' compensation policy inronnatioil . -It the corporate officers have exempted IhemseI%cs, but the cotpota t on has other employees, a workers' compensation policy is required and such an n'imnization should check box N1. urn on emphgver that is providing workers' con+pensation insurance for aq' employees. Below is the poticy infotnation. nsurance Company Name:— _ � y���,� - �3-�S__""7 — -- -- asurer's Address:_-'�zz'✓.�------ 'ity/State%Zip: ____ --V� c�4° -Y-i-Z--------------- 'oliey h or Self=ins. Lic. h_t A) C— �_Q � �_ Expiration Date: lttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MG1.. c. 152 can lead to the imposition of criminal penalties of a Me 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 tine d up to S250.00 a day against the violator, Be advised that It copy of this statement may be forwarded to the Office of nvcstigations of the DIA for insurance coverage verification, (it) hereiw certifj,, under the pains crud penailies gfperjury that the inf rination provided above is true and correct. ,i.gnaturc: - . A _0 _ _ Date: .—xL3fa Q%licial use only Do not write in this area, to be cocupteted hi, ch(y or town glficial. City or Town: Permit/License Issuing Authority (circle one): I. Board of Health 2, Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www, mass.nov/dia I IWESTMAI ACO/2� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4✓ 10/09/2018 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 pollcy(les) 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 PRODUCER J.K. Olivieri Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivierl INSURED West Mansfield Variety Adhya Corp, 42.8 Elm Street Mansfield, MA 02048 508-947.1818 8 Group I nXIM-DACCC (`CDTICIr`ATG MI IMDFD. DFV141nId MI IMnFR• 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, TFIE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE "TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _EXC__LUS__I_ONS INAI TYPE OF INSURANCE ADDL HSn SUD Wye POLICY NU POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL UADILITY EACH OCCURRENCE $ 1,000,000 _ j CLAIMS MADF [ X J OCCUR DAMAGE TO RENTED PREMISF2 En nscurcC=J_ 1 000,000 $ _ .. A X Business Owners BZS56927776 09/25/2018 09/25/2019 MED Exrr(Any one personl_.. s 15,000 PERSONAL a ADV INJURY 1,000,000 XGENL _ AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER: C POLIY , LOG C—I JECT _GENERAL PRODUCTS COMPIOPAGG- 200'000 '0 _ _- OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO _ BODILYINJURY(Perpersnn �___----- ,___ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY IMURYIPer accen nil PRL cRQrMAGE_. _.—_ L W p AUTOS ONLY AI/TOS ONIY $__ 5 UMBRELLA LIAR _.._ OCCUR EACH OCCURRENCE $ EXCESS LIA9 CLAIMS -MADE AGGREGATE $ _ DED Ll RETENTIONS T _ [i WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN N ANY PROPRIETORIPARTNERlEXECUTIVE OFICE IMEMBId)EXCLUDED9 ry NIA WE169098A 09/25/2018 09/25/2019. PER FORTH—, X TATUME 1. FR— EL. EACH ACCIDENT_-___ ; _ 1000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yyes, describe under DF.SCRIP" ION 0 OPERATIONS below F.L. DISEASE - POLICY LIMIT 1000000 , , A Business Owners BZS56927776 09/25/2018 09/25/2019 per perso 1,000,000 Liquor Liability aggregate 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Romarks 8chedua, may be attached if morn spaco Is ramdrod) I'FDTICIrATC Wnt 11PID I A1I1AI MANST02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD