HomeMy WebLinkAboutNRG Lab - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:.
LUTHER WHITE, PRESIDENT
Whose place of business is:
THE ENERGY LAB, INC. DBA NRG LAB
280 SCHOOL STREET
PERSON(S) IN CHARGE:
LUTHER WHITE, PRESIDENT
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS -77
BOARD OF HEALTH
MichaeCHeatey, Chairman
k
Milk & Cream
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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)
1) Establishment Name ruk (A
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No Jng - �tit 1y
-- --
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.: c _ 24 Hour Emergency No.:
8) Owners Name &Title L,
9) Owner Address (If different from applicant)
i
,�(z
I Owner's telephone number.
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
An Association
or partner.
1 A Corporation
Name Title Address
An individual
^r _
A Partnership
Other legal Entity _
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title
rrt
Address:
Telephone No:
i FAX.
K:0. C,,
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title Ate }may,
Address:
'Telephone No:
FAX:
lE mail:
24 Hour Emergency No:
24 Hour Emergency No: r11
Food Establishment Information
14) WATER SOURCE 15) SEWAGE DISPOSAL:
DEP Public Water Supply No (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS: ��lJl } 1`7 } r 1 " 1 ; Js"✓8:
18) Name of Person In Charge Certified in Food Protection Management: +
If more than 3 individuals are certified, complete list is on file.`}
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seals or more):
20) Location: Permanent Location 1 22) Establishment Type
Mobile Mobile Start Date: ❑ Retail ( S Fp
Mobile End Date:
Moblie Comments:
21) Length of Permit:
Annual
L..I Seasonal
Seasonal Dales:
i J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
!(Check all that apply):
L
q
F.] Food Service up to 100 or
up to 10' PHF display $125.00
L] Food Service up to 101 -200
or up to 25' PHF display $150.00
❑ Food Service up to 201 +
or 25'+ PHF display $275.00
rJ Food Service - Institution
( Meals/Day)
Caterer $25.00
Milk & Cream $10.00
Mobile Food & Consession $75,00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $25.00 S of Pushcarts:
Residential Kitchen $100.00
Retail Food $100.00
Retail Snack Food $25.00
Tobacco Products $25.00
DeBnillons: PHF- Potentially hazardous rood (tlme/temperature controls required)
Non-PHFs - non -potentially hazardous food(no timeltemperalure controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
j Delivery of Packaged PHFs
1 -Reheating of Commercially
Processed Foods for Service Within 4 Hours
i- Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
rJ PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging /Cook Chill
LJ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
I J Ice Manufactured and Packaged for
contact alternative, time as a public healtn
Retail Sale
control)_
J Juice Manufactured and Packaged for
[J Offers Raw Or Undercooked Food Of !
Retail Sale
Animal Origin.
r Offers RTE PHF In Bulk Quantities
Prepares Food/Single Meals for
_
Catered Events or Institutional Food Service
rJ Retail Sale of Salvage, Out -Of Data
-- ----- _ ---
or Reconditioned Food
_
To be completed by the Board of Health
I, the undersigned, attest to the accuracy of the information provided in this
establishment operation will comply with 105 CMR 590.000 and all other ap
board of health on how to obtain copies of 105 CMR -590:000 -and -the -Wen
24) Signature
Total Permit Fee:
Payment is due with application a waived
Ion and affirm that the food
law. I have been Instructed by the
Pursuant to MGL Ch.62C, sec. 49A, I certify under the -penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 4l-
26)
la26) Signature of Individual or Corporate Name: - k- ti� LAR {�"- ll"- -" z✓ ••'
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 or Corporate Name
W- -)Y] (-)I-7 k3
"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 under the authority of Massachusetts General Law
Chapter 62C, section 49A.
R.\i-IealthVane's Doc=eats\PrRMrr APPLICATIONSITAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of IndustrialAecidents
1 Congress Sheet, Suite 100
f Boston, MA 02114-2017
www• neass•gov/dia
Workers' Compensation Insurance Affldavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Business/Organization Name., '44 l lvy"3-
Address: < 6i7 C,4 j, 1 ,, .
City/Slate/Zip:' -A1s ,tU ilrv'(', '. 30S Phone#: '�Y--Y1=
Aree yn an employer? Check the appropriate box:
L I am a employer with I'a 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, ❑ 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.
Business Type (required):
5. ❑ Retail
6. Restaurant/Bar/Bating Establishment
7. Q Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9, ❑ Entertainment
10,0 Manufacturing
11. ❑ Health Care
12,MOther 6Ion
*Any applicant that checks box #1 most 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 cheek box #1.
I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy Information.
Insurance Company
Insurer's Address;4.3tisetdlt:Y1
City/StatelZip; Q L ^� �^ I a
r c L 7 (,
Policy # or Self -ins, Lie. #- fi 1,�'--� �i Expiration bate: it f )
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 maybe forwarded to the Office of
investigations of the DIA for insurance coverage verification,
I do hereby certify, s ndar thh ains and penaltles ofperjnry that tire Information provided above istrueand correct
J
Date: ° zl / V
Official use only, Do not write in this area, to be completed by city or town official.
City or Town:
Permft/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's.Offnce
6, Other
Contact Person
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: The Hartford Insurance Cc of the Midwest
ONE HARTFORD PLAZA HARTFORD CT 06155
THE
HARTFORD
NCCI Company Number: 20605
Company Code: G
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WEC CP0502 5
Previous Policy Number: 108 WEC CP0502
1. Named Insured and Mailing Address: THE ENERGY LAB, INC.
(No., Street, Town, State, Zip Code) 38 RUSSET HILL RD
FRANKLIN MA 02038
FEIN Number: 46-2870170
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: Fitness and Recreational Sports Centers
Other workplaces not shown above: 280 SCHOOL STREET, BUILDING F
MANSFIELD MA 02048
2. Policy Period: From 11/01/18 To 11/01/19 '' ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: DOWLING & O'NEIL INS AGENCY/PHS
PO BOX 1990
HYANNIS MA 02601
Producer's Code: 08088233
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTON 10 TX 78251
(866) 467-8730
Total Estimated Annual Premium: $3,020
Deposit Premium:
Policy Minimum Premium: $286 MA (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by g� C�� 09/22/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 09/22/18 Policy Expiration Date: 11/01/19
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