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Home My WebLink AboutTown News - 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:. DINESH PATEL Whose place of business is: TOWN NEWS 165 NORTH MAIN STREET Permit Expires December 31, 2019 License Number: RF-13 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH MichaecifeaCey, Chairman ......_.... .._...... Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: TOWN NEWS 165 NORTH MAIN STREET License Number RF-13 Permit Expires December 31, 2019 BOARD OF HEALTH NichaeCHeaCey, Chairman 1A FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) \ c)wn Establishment Name: Establishment Address 1(� � ✓V�Vn `M ` M S } 1 M M s /� ' �j$ Establishment Mailing Address(if different): By: Establishment Telephone No.: U� 33 —6 1 C Applicant Name & Title: e5h \ cl U n rJ� Applicant Address: U CG« PP p 0C-<I&'Z —'6 S Applicant Telephone No.: S \� � 24 Hour Emergency No.: Applicant E-mail: �' Ylf. S\, 6 ��/�U • C-"" 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 El ��AA Association partner. Name Title Address LriACorporation Pr^-�� `R'� to C/ k 51N bte ❑ An Individual (O�^�\" ❑APartnershiP\�U�� ie� Y�e�� /�AvnS�l�r ✓v l� , Other legal Entity -- _ _ Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name& Title:iir-\es�v Address: es\rJl �Sh\� fir. ^na s2 ��c\ ,,MI'r`vLB Telephone No: CIA-qa-?_ 24 Hour Emergency No: FAX: E-mail: 6 C-(3) Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: SpGMtp S F Commonwealth of Massachusetts Letter ID: L0309285504 rt - Department of Revenue Notice Date: October 2, 2018 Orr1 . Christopher C. Harding, Commissioner Account ID: CRL-10806008-010 yF.'vroFf mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO P 111111111111111111111111111111191111111661111111111111111111 VASUDEV CORPORATION TOWN NEWS 165 N MAIN ST MANSFIELD MA 02048-2211 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 g°SSS"TT MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ma Retailer License for Sale of Cigars and Smoking Tobacco: This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. VASUDEV CORPORATION Account ID: CRL-10806008-010 TOWN NEWS License Number: 1396049920'" 165 N MAIN ST MANSFIELD MA 02048-2211 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 2, 2018 Expiration Date: September 30, 2020 SgpCHtteF Commomvealth of Massachusetts ort� Department of Revenue P Christopher C. Harding, Commissioner �p„yr pQ� massgov/dor Letter In L0989524864 R1. Notice Date: October 2, 2018 Account ID: CGL-10806008-007 RETAILER LICENSE FOR SALE OF CIGARETTES III I I I I I I I I I I I I I'I IIIIII'PI'I III IIIII I IuIIII II II101111111111111 VASUDEV CORPORATION TOWN NEWS 165 N MAIN ST MANSFIELD MA 02048-2211 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 PSSa�'Ss;T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T " Retailer License for Sale of Cigarettes- _ r�Nay This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. VASUDEV CORPORATION Account ID: CGL-10806008-007 TOWN NEWS License Number: 1286215680 165 N MAIN ST MANSFIELD MA 02048-2211 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 2, 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. y6\SU rev ck-"u. ,VSk--- Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 01_� S 3 3 5 7L3-- "Social Security No. (Voluntartt) 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\Scou's Documents\Food Establishments- Temp\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 Applicant Information Please Print Legibly Business/Organization Name:y(^S U t\ c\,/ Lc q Address: \ G S A10 rA4N Ma v\ `>k City/State/Zip:✓` r� 5kj 1- Phone #: SU<K' '�', 4 LA�_k Are you an employer? Check the appropriate box: Busines ype (required): 1, gd�I am a employer with <� employees (full and/ 5• etail 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. g. ❑ 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 requiredl* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121:1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers compensation poucy uuorurauvu. "+lf 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. lain an employer that is providing workerscompensation insurance for my employees. Below is the policy information. Insurance Company Name: S, 1� �/ /, `ly I er I Insurer's Address: �LA 5� City/State/Zip: Nv' & a� (L�� m t'r Q% 1`3 �. 6 Policy # or Self -ins. Lic. # 17 ` Expiration Date: \ \/30/ w 0 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 pains and penalties of perjury that the information provided above is true and correct. Signature: Pal upralrjDate: \ � / ` / t 6, Phoneft&c S-- — �SV77 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. It r Contact Person: Phone #: www.mass.govima /--N VASUC01 '4� RLDI, CERTIFICATE OF LIABILITY INSURANCE lo✓2"steno "1B 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(fes) must have ADDITIONAL INSURED provisions or be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endomement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemen s . PRODUCER 508 947-1818 J.K. Olivier! Iris. Agency 64 East Grove SL Middleboro, MA 02346 Kenneth W. Olivied .MACTKenneth W. OBViari n°HONc. E 508-947-1818 FAX ; s AFFGRdxacovERalrE INSURER A: NGM Insurance Co. NAx:s 14788 INSURED VasudsvCo ration dba To�,M. n' INs RIEn o jechnology Insurance Co. News & Tick �y.... 165 North Main Mansfield, MA 02048 INSURER C: INSURER D : INSURER E: INSURER F COVERAGES kIII rr -AI rum cn: • --•-• ---- ----- LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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 POLICY EFF POLICY EXP TYPE OF INBURANCE �" BR POLICY LIMITS 110001000 COMMERCULL GENERAL LUIBILffY EACH OCCURRENCE S DAMAGETO RENTED JBD,ODIi CLAIM SAIADE O OCCUR` - A X Business Owners BPF1371Y 1113N2018 11/30/2019 MEOEXP Au oRe ersoR 10,000 PERSONALaADV INJURY 4 1,000,000 GENERAL AGGREGATE E 2,OOo,000 GENLAGGREGATE ��LIMIT APPLIES PER X POLICY ,IEC LOG PRODUCTS-COMP/OP AGG 2,000,000 OTHER: COMBINED SINGLE LIMIT 4 AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY Per OVMED SCHEDULED BODILYINJURY PeracGdwl PRO aEwRl AMAOE Per $ WOO AVTEOS ONLY AUTOS ONLY MUON UMBRELLA LIAR OCCUR EACH OCCURRENCE E EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTIONS �( PER OTH- B WORKERS COMPENSATION ANDEMPLOYERs'LIABILITY YIN C3532727 0311=018 03%i3/20i"9' EL EACH ACCIDENT E 5001000 ANY PROPRIETORIPARTNERIEXECUTIVE a N/A 500,000 OFMFlCmFinBEREXCLUDED? � ! ELOISEASE-EA EMPLOY E 500'� llaMlyes NOU FOrPFRATIONS below E. DISEASE -PO ICYLI IT A DES'IRIP�fl Business Owners BPF1371Y 11/30/2018 11l3=019 see below for limit Liquor Liability DESCPoP oilaFOPERATR)NSILOCATIONS/VEHICLES (ACORD101, AddUoaal Remnks Scbadul% may b0l`IW a UMM$Paceu eWred) Liquor Liability: $1,000,000 each common Cause lirl!"2,000,000 aggregate limit. Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. .--....—w^Mnnea'l^kl All A-h1 ,Ma.A.d ACORD 25 (201601) The ACORD name and logo are registered marks of ACORD Hi Dinesh, I received the check for $285.00 for Town News and I am returning check # 7580 for $335.00. VASUDEV CORPORATION DBA TOWN NEWS & TICKET AGENCY 165 N MAIN ST MANSFIELD MA 02048-2211 PAY T��1=� Uq ��'a1,' TO THE � ORDER AF g 7580 G 53-131110 MA DATE ��"" i �� O 26ee3 $ 335.,E �---- •� lhll DOLLARS ankofRmerica ACH R/T 011OM38 /1 ...,..-- -.�....�.�..e.a.._,.�._._.,...n................_,.,......_.....r...� u•D0758❑u• I:D1100013184 0094197490700