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HomeMy WebLinkAboutFresh Catch, Inc. - 12/31/2019Commonwealth 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:. WILLIAM F. SARRO Whose place of business is: THE FRESH CATCH, INC. 30 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM F. SARRO, MANAGER Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS-78 BOARD OF HEALTH 7vlichaeCHeatey, Chairman Milk & Cream 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; CATERER 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.. WILLIAM F. SARRO Whose place of business is: THE FRESH CATCH, INC. 30 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM F. SARRO Permit Expires: December 31, 2019 Food Fee: $35.00 License Number: C-2 BOARD OF HEALTH NichaeCHeaCey, Chairman G� Date received: i -- FOR BOARD OF HEALTH USE ONL f A UtilIU11 Date Inspected: Approved _ Permit # FOOD ESTABLISHMENT PERMIT APPLICATION pp ica ron mus e su6mt e a eas 3 ays a ore e p anne -opening cTarJ 1) Establishment Name 2) Establishment Address 4rtd� a 3) Establishment Mailing Address (if different)�� ff 4) Establishment Telephone No SC&-33J-6d31 5) Applicant Name & Title; 6) Applicant Address 4,5,3 %"urrL p;kAa JV UA;D Z SW 4� 7) Applicant Telephone No.: �j 24 Hour Emergency No.: 8) Owners Name & Title Iw((eAl r- A-4 n ,,- 9) Owner Address (If different from applicant) Owner's telephone number ,roFE -qo (0(0 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El F i Association or partner. A Corporation O An Individual Name Title A Address �ti Pf�3t �$5 �ufRP% _b� 4J�tr� Z- Q.JSk. ❑ A Partnership I U Other legal Entity 12) Person Directly Responsible For uaiiy uperations (owner, person in cnarge supeivievi, niauayai C-tuI Name & Title uj t wi a iA Sam Address: a 5� Etlr '. Cc� b�. `�' Z. u�ca$ 1, I�LtSF, MA 0X3q5 _ { Telephor so � - CJ-(� (� 24 Hour Emergency No: ` FAX:._-. E-mail: ——ljF`�1 r4 f . ,-04 LAltE-Mail: _ 13) District Or Regional Supervisor (if applicable) Name & Title: `eat& Address: q 4 - . crKS41 Telephone No: 24Hour Emergency No: ,fJ ," FAX: 5079-331-391jr E-mail: byeen tiat'd FltSA_ t k_�/ie. (mid Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: _ra DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 1 17) DAYS/HOURS: UVot of ,,q ?4A - 9,l0A. 18) Name of Person In Charge Certified in Food Protection Management: See4k 'If e'it4c 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 Seats or more): 20) Location: VPermanent Location 22) Establishment Type (gyp Caterer $35.00 Mobile Mobile Start Date: [J Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Food Service up to 100 or [I Mobile Food Consession Mobile Comments: NCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 -- _---- — _ 21) Length of Permit: [Food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 0 Annual I] Pushcart $50.00 # of Pushcarts: Seasonal Food Service up to 201 + $300 Ll Residential Kitchen $100.00 Seasonal Dates n Retail Food $125.00 Retail 7] Temporary ❑ Food Service - Institution n Snack Food $50.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $150.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions:PHF - Potentially hazardous food(timeRemperatura controls required) Nan-PHFs -non-potentially hazardous food(no timeAemperature controls required) (,CCheeck all that apply): RTE- ready -two -eat foods (Ex. sandwiches, salads, mums which need no further processing) Lb Sale of Commercially Pre -Packaged Non-PHFs b rHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And i] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Delivery of Packaged PHFs 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer -- eheating of Commercially _ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours --.----- - — -.---- I Use of Process Requiring di Variance and/or HACCP Plan (including bare hand 0 Customer Self -Service of Non PHF and Non- � Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale __ Preparation of Non-PHFs O Juice Manufactured and Packaged for VOffers Raw Or Undercooked Food Of Other Food Operations Retail Sale Origin ,�PAnimal IJ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service _ Retail Sale of Salvage, Out -Of -Date _.. or Reconditioned Food To be completed by the Board of Health Total Permit Fee: — Payment is due with application [J waived I, the undersigned, attest 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 CMM90.0QD-and the fedeeEaLEwd-Code. 24) Signature of Applicant: 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: 0 26) Signature of Individual or Corporate Name: ./l�— 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. sy tz Signature cf Indiv dual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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:\Usem\.sleite\Desktop\ScotVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of'IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.moss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: 3 f kf, Address: City/State/Zip: 441p 0200 Phone #: Ca 9'3 1-547 Are you an employer? Check the appropriate box: BuType (required): sme s 1. I am a employer with 40 employees (full and/ 5. Mail or part-time).* 6. Ea estaurant/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• 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fiIl out the section below showing their workers' compensation policy information. **If the corporate offices have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 0 d / 0 l� Expiration Date: OILD l 9 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. 7 do hereby certify, under the pn' s ananalties ofperjury that the information provided above is true and correct. Phone #: -60. 'S' 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 G. Other Contact Person: Phone #: www.mass.gowam ® ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/29/2078 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 C & S Insurance Agency, Inc. 190 Chauncy Street/P.O Box 406 Mansfield MA 02048 CONTACT Laura Wiesner NAME: a'ONrm Ext : (508) 339-2951 IaC Net: (508) 339-4811 E- AIL /aura cendsins.com ppORE55: 6ra@candsins.com - _ INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Merchants Preferred Insurance 12901 INSURED The Fresh Catch Inc. PO BOX 34 Mansfield MA 02048 INSURERS: MA Retail Merchants WC Group Inc MSURERC: INSURER D: _ INSURER E : _ 1 INSURER F: COVERAGES CERTIFIr:ATF NIIMRFR' MASTER 18-19 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. LTR TYPE OF INSURANCE INSD We POLICY NUMBER POLICY EFF MMIDD POLICY EXP MM/DDAYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 RENTED DAMAGE TO 50,000 CLAIMS -MADE ❑X OCCUR PREMISES Ea occurrence $ MED EXP(Anyone person) $ 10,000 A CMP9155886 02/28/2018 02/28/2019 PERSONAL&ADV INJURY $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 4,000,000 PRODUCTS - COMP/OPAGG $ 4,000,000 X POLICY ❑ PRO, LOC JECT OTHER: COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY t INJURY person) $ ANYAUTO INJURY accident) $ A OWNED x SCHEDULED MCA0000159 02/28/2018 02/28/2019 AUTOSONLV AUTOS v NON -OWNED XAUTOS DAMAGEHIRED l $ ONLY AUTOS ONLY$ RAGGREGATE UMBRELLA LIAR OCCURURRENCE $ E $ EXCESS LIAB LAIMS-MADE DED I I RETENTION $ $ WORKERS COMPENSATION X H STATUTE FR AND EMPLOYERS'LIASILITY YIN 500,000 B ANY PROPRIETORIPARTNERIEXECUTIVE NIA 014005031479118 O7/0112016 D1/01/2019=. E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE g 500,000 E.L. DISEASE POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability CMP9155886 02/28/2018 02/28/2019 Common Cause Limit $1,000,000 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 2 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988.2015 ACORD CORPORATION. All rights reserved. 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M OE COMPLETION IN RECOGNITION OF SUCCESSFUL COMPLETION IN: Standard - CPR / AED (Adult / Child / Infant) Automated External Defibrillator (AED) Emammizammummam Beth Stewart The above mentioned Student is now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the Terms & Conditions of National CPR Foundation - Valid for 2 years. Course administered in accordance with the 2015 ECC/ILCOR and AHA® guidelines. ID#: F2139E8 Completion: November 6, 2018 Instructor: Paul J. Scruton � COURSE PROVIDED ©Y: faftorsaIPREoundation Signature: