HomeMy WebLinkAboutSubway - 12/31/2019ID
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: 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:.
CHARLES SMITH
Whose place of business is:
SUBWAY
84 COPELAND DRIVE
PERSON(S) IN CHARGE:
CHARLES SMITH, OWNER
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS-71
BOARD OF HEALTH
MichaeCHeaCey, Chairman
'
Milk & Cream
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: L) Y
Establishment Address: 7y eDPe��NC �✓ f �QitJS7 7C Ida, '�We"
Establishment Mailing Address(if different):
Establishment Telephone No.: '�Ed t? - 3 3 � , 06 46
Applicant Name & Title: CJA,,.v (CS S e I-L rI0 w xie✓'
Applicant Address: ) j" Dal,-, GIN oll 7� /C N-,>% / * D Z 9�6 U
Applicant Telephone No.: 77y- 2,S_' /-3V 60 24 Hour Emergency No.:
Applicant E-mail: Cv`US/ti✓���3�@y���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
An Association partner.
;VA Corporation /Name Title Address
® An Individual C.Gtar(CS S ��G __-_ow'Ver_ ( r1 OIL
® H
/ +�a//__✓1Ul". __ _---
A Partnership /U. T/�boe,a M
® Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: C�Ie,3 S/4/`�/l� ow✓�r
Address: 1 ✓- n� k 40(l Z> . 416AV0. W 4- 0 2 7-62)
Telephone No: -7a'y ^ 7i'jrrf' 3yei 24 Hour Emergency No:
FAX: PV- 33e- ®Tit!D
E-mail:dGIG�Ni�i� 3j@19�rCLi�Cv/�
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: "' er1✓Ia�/A�J�0! L 0A/4�
Address: 300 s„TrTyr flGl� JV
Telephone No: y01 - 3TO - 000?
FAX:
�.s Z� N• �rvv;4�laGl� �,1 BZPoy
24 Hour Emergency No: L(O / 3 90 — 006
E-mail: 0 j a b (ask /< eo yeti o0, -4-
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL: �Ovv SPwC�
DEP Public Water Supply No (If applicable) V,� [,/QNo. of Food Employees: g'
DAYS/HOURS: P7` �n _ ,,)ax4_? 5"o UA"_
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): 19
Location: Permanent Location
®Moblie Moblie Start Date:
Mobile End Date:
Mobile Comments:
Length of Hermit:
V Annual
fft Seasonal
Seasonal Dates:
® Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations
Check all that apply):
Establishment Type
® Retail ( 1,3190 Sq. Ft)
Food Service up to 100 INCLUDING
OOD TRUCKS $175.00
® Caterer$35.00
Milk & Cream $10.00
® Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
® Manufacture Frozen Desserts/Ice Cream
® Food Service up to 101 -200 $250.00 $25.00/freezer
----- - -- --I ® Food Service up to 201 + $300.00
® Supermarkets $400
® Pushcart $50.00 # of Pushcarts:
® Residential Kitchen $100.00
® Retail Food $125.00
Retail Snack Food $50.00
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Nan-PHFs -non-potentially hazardous food(no time/lemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order ® 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 -.
® Delivery of Packaged PHFs - - Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly
---- -- Susceptible Population Facility
----- ® Sale of Raw Animal Foods Intended
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 -
Perishable Foods Only
Other Food Operations
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
of Health
Total Permit Fee:
Payment is due with application H 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 conies of 105 CMR 590.000 and the federal Food Code.
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
® Juice Manufactured and Packaged for ® Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
-- -- __-1®
® Offers RTE PHF in Bulk Quantities Prepares rood/Single Meals for
Catered Events or Institutional Food Service
® Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be
Signature of Applicant: ( (/Lw 4__
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns
and paid state taxes required under law. II --
Signature of Individual or Corporate Name:y`
Social Security Number or Federal ID: 2, q
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.
l/ /La, L u l . L , fief', ', i ASignature of Individual 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:\Users\sleite\Desktop\Scott'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: (1 S S 5 Ao:s
Address: X ceme" �/r;yt
Phone #: Fb 81 5,3 2' - e0.9 iJ A —
Are you an employer? Check the appropriate box:
Business Type (required):
1.B
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. t. Restaurant/Bar/Eating Establishment
2. ❑
I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (met. real estate, auto, etc.)
employees working for me in any capacity.
S. ❑ 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 required]*
I I.❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. fNo workers' ccmp. insurance req.]
12.❑ Other
*Any applicant that checks box #1 must 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 check box 411.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: (,r
Insurer's Address: 360D IJ j,Q6041) �
City/State/Zip: Z.J
Policy # or Self -ins. Li c. # —7 b t tl Cy- eqC/ Expiration Date: 1 2
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 cert�, under the pains and penalties of perjury that the information provided above is true and correct.
�A M LiMiiiiiiii
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit7License
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
www.mass.gov/dia
Phone
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE `
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: The Hartford Insurance Co of the Midwest
ONE HARTFORD PLAZA HARTFORD CT 06155
NCCI Company Number: 20605
Company Code: G
tuy
Man
A
ffi'WORD
suffix
LARS RENEWAL
POLICY NUMBER: 76 WEG GC0709 5
Previous Policy Number: 176WEGGCO709
1. Named Insured and Mailing Address: CSS SUB INC
(No., Street, Town, State, Zip Code) 74 TAUNTON AVE
SEEKONK MA 02771
FEIN Number: 27-1418387
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: Full -Service Restaurants
Other workplaces not shown above:
2. Policy Period: From 12/09/18 To 12/09/19 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: COMPLETE BENEFIT SOLUTIONS/PAC
ONE CARANDO DRIVE SUITE 1
SPRINGFIELD MA 01104
Producer's Code: 76250837
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877)287-1316
Total Estimated Annual Premium: $2,070
Deposit Premium:
Policy Minimum Premium: $215 MA
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by I`1a"11f 10/30/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 10/30/18 Policy Expiration Date: 12/09/19
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HERMANN KONATE
for wccessfdly completing the standards set forth for 4- 5em5afe'' Foad Prelection Manager Getilimlion Examination,
which is accredited by the American National Stmsdards InsliMe IANSII-Conference for Food Prole,ion ICFPh
87 10440
N Urn B ER EXAM FORM NUMBER
9/20/2020
"w DATE OF EXPIRATION
DATE OF E3("*T#Q :sx' t n6<mo R is
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