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HomeMy WebLinkAboutCanoe River Campground - 12/31/2019r Commonwealth of Massachusetts Town of Mansfield Town of Mansfield a Park Raw 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:. STARLIN INC. Whose place of business is: CANOE RIVER CAMPGROUND 137 MILL STREET Permit Expires December 31, 2019 License Number: RF-11 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH NichaeCHeaCey, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: CANOE RIVER CAMPGROUND 137 MILL STREET License Number RF-11 Permit Expires December 31, 2019 BOARD OF HEALTH MichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) j Establishment Name: C, A A) uC-:- Al V� 2 G. 9 G2 ter- ✓ Establishment Address: 137 /,T ILL S'7 ., /w/q � )SF/ E cOJoy,p j Establishment Mailing Address(if different): I Establishment Telephone No.: 4--O y - Applicant Name & Title: S i-C- ✓ E:'� G S,4 L V Applicant Address: I '3S tit I LL S 7 - i�j Q.v$�I6 Z f�> A1A. O l(Dy.p Applicant Telephone No.: S 4? - 9 c/ V- -7 S 7 6 24 Hour Emergency No.: 5 c g •- 3 S- S 7 3 `� Applicant E-mail: p Fi- i c r= 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 rr An. Association partner. �ACorporation Name Title Address An Individual S fE�E C v 5k c Uc S 13 S_ ,UI I I L. <� i rigAPartnership ST Sr__ Other legal Entity L iN D it p ct EMS 7 s z / L/ i 411 L L- > 7. Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) 1 Name &Title: S'7�Vc GoNS¢LVE7S Address: 13S MILL 5 T. ��1 4 alSv�i ( L IWA . O ace Telephone No: S09, ' ?91 - � `/6 � 24 Hour Emergency No: _3 :3 c% - e6 ,P V FAX: Sv8- -�35-5-37 E-mail: 6v' c'K: C`' C ip.vo�,e I VE=e . CON! Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: Food Establishment Information WATER SOURCE: MU1/ic(F,+C_ SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: 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: EPI Permanent Location Establishment Type Caterer$35.00 FolMoblie Mobile Start Date: ,ri1 Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: 0 Food Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream ❑ --- --- Length of Permit: €d Food Service up to 101 -200 $250.00 $25.00/1reezer Annual - } Food Service up to 201 + $300.00 Pushcart $50.00 fE of Pushcarts: ❑Residential Kitchen $100.00 ---------- Seasonal Seasonal Dates: [] Supermarkets $400 :, Retail Food $125.00 � Retail Snack Food $50.00 ❑N Temporary Temporary Start Date: 0 Tobacco Products $150.00 Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF-Potentially hazardous food(timefiemperatun; controls required) Non-PHFs - nor potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- wady -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) 6E Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order Ft Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And for More Thar. a Single Meal Service Cold Holding For Single Meal Service P❑+', PHF and RTE Foods Prepared For Highly fie Delivery of Packaged PHFs ❑ ry 9 Susceptible Population Facility 01 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 � Use of Process Requiring A Variance N Customer Self -Service of Non PHF and Non- ❑ ..T Customer Self -Service ❑ and/or HACCP Plan (including bare hand Perishable Foods Only e� Ice Manufactured and Packaged far contact alternative, time as a public health ❑N Preparation of Non-PHFs Retail Sale control) Other Food Operations Juice Manufactured and Packaged for its Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑Offers RTE PHF in Bulk Quantities r Prepares Food/Single Meals for 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 gr�.-,, waived 1, 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 Alf 105 CMR 590.000 and he federal Fon/d!f�ode. Signature of Applicant: lPwl.-�r"-e"-� 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. Signature of Individual or Corporate Name: S'T-/l yc L Social Security Number or Federal ID: cc/ - d 3 7 JC`JC" 7 / 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. s';,42L_,.ti Signature of Individual or Corporate Name OY - a37s'S7/ "*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. C:\Users\sleite\Desktop\ScoWs Documents\Food Establishments- Temp\TAR 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 Le6bly Business/Organization Name: 57,4-to.✓ �L�N CA-NnE 1/ 10C'e C t v1PG2o t= L cav yP Phone #: saS' 3`)-C`%G� Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with employees (full and/ 5. El Retail 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 required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12 Other c tM 20 ao 1 V f''`/� t� with no employees. [No workers' comp. insurance req.] *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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Z L'(/�! I C /� - 14 MCt2 I G41t) Insurer's City/State/Zip: as L,4KE/t-(0nU-i AVL: Policy # or Self -ins. Lic. # 6 Z Z ` O Y 9SA) S — Expiration 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 pai!!X#nd penalties ofpeoury that the information provided above is true and correct. Y / / 9 s©a'- 3 ? g - 6 -16 )— 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.Other Contact Person: Phone #: www.mass.gov/dia VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0495N75-0-18) RENEWAL OF (6ZZUB-0495N75-0-17) INSURER: AMERICAN ZURICH INSURANCE COMPANY t NCCI CO CODE: 17965 INSURED: PRODUCER: STARLIN, INC. DBA CANOE RIVER C & S INSURANCE AGENCY CAMPGROUNDS 310 N MAIN ST #6 137 MILL ST MANSFIELD MA 02048 MANSFIELD MA 02048 Insured IS A CORPORATION Other work places and Identification numbers are shown In the schedule(s) attached. 2. The pblicy period is from 05-13-18 to 05-13-19 12 01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA d= B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy Includes these endorsements and schedules: �= SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-20-18 WC ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: C & S INSURANCE AGENCY 75W20 019744 Town of Mansfield Town of Mamfield - 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: r' __- LOCATION OF SALE OF TOBACCO PRODUCTS: > ✓,E' C :.a o y }� TELEPHONE AT LOCATION: OWNER OF BUSINESS: ADDRESS OF OWNER: TELEPHONE OF OWNER: FAX NUMBER: f 7 If a corporation or partnership, give name, title, and home address of officers or partner. t >L_G'G f Z,4 11"1,r4h.,..">'�tj— * Provide a copy_ of current D�attment of Revenue Retail Excise Unit License. -------------- FEE: O SIGNATURE: DATE: \& j} cq \ rq eo m\ \ \ \ }} )j ƒ \\ ) / �\ / \ § ,a, ) \ 0M / ) 2 CL \ CD j { )tj k \ « 2 ] a w //#S ( =�, J \»=m maE ggg \)2 ƒ 2�� • STARLIN INC OPERATING ACCOUNT 6646 137MILL ST 53-13/110MA MANSFIELD MA 0204E-3268 Date Pay to the Order of /f /J it $ I: Dollars BankofAmerica ��j AOH Rfi011000138 .4 For 1:01 I00❑ 138l: 00000 195 28380•6645 r