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Home My WebLink AboutThe Store - 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:. HITESHKUMAR PATEL, OWNER Whose place of business is: KANKU, INC, dba THE STORE 213 SOUTH MAIN STREET Permit Expires December 31, 2019 License Number: RF -7 Food Fee: $125.00 Milk & Cream BOARD OF HEALTH MichaeCHeaCey, 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: KAN KU, INC, dba THE STORE 213 SOUTH MAIN STREET License Number RF -7 Permit Expires December 31, 2019 BOARD OF HEALTH NichaeC3-CeaCey, Chairman r� FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: ft Permit # I FOOD ESTABLISHMENT PERMIT APPLICATION - --_- (Application must be submitted at least-3-0-i1ays-beTo—re- the planned opening date) 1) Establishment Name kRN�0 'SNG , DINR I-V\e SToRL- 2) Establishment Address 21(\ARS0 S'IREk✓ , Mf I0_5VSE\D, MR V20t{5�- 3) Establishment Mailing Address (if different) 4) Establishment Telephone No `)0 Cri 1563 5) Applicant Name &Title: Pam+�� I_ 1C�Lm.a 6) Applicant Address 110 r Mu'A(21rn S)L`Ce0\y) 7) Applicant Telephone No.:50g.hog-X22 24 Hour Emergency No.: 50W-tAog-C322. icj'<S i5 Cc Nnilpe�m Cc v� -- �- 8) Owners Name & Title Wk CSr\�\A mclil 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers O An Association or partner. ly, A Corporation 11 An Individual ❑ A Partnership O Other legal Entity Name Title Address 01 C G _W1ykeshyq('( MICA ra�A Ot:J eD Ito MaR�y� 1101 ICo!in-PoIrk cAp---Qr�4l �, 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) - Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: N I i - Address: Telephone No L 24 Hour Emergency No: FAX: I E-mail: I Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) "- N0. 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: ❑ Permanent Location Establishment Type ❑ Caterer $35.00 ❑Moblie Mobile Start Date: X Retail ( i !�OIVSq. Ft) Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 INCLUDING ❑ Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 * Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: I] Annual ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: - - 0 Seasonal Seasonal Dates: Supermarkets $400 E] Residential Kitchen $100.00 ARetail Food $125.00 -rte � Retail Snack Food $50.00 0 Tobacco Products $150.00 _ _ - Temporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: _.._._..._.... _-..__.. Food Operations Definitions:PHF - Potentially hazardous food(timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which need no hatherprocessing) El 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 E] Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Hlghly Susceptible Population Facility --- ----- Delivery of Packaged PHFsf Raw Anima - Sale ol Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours ❑Vacuum Packaging /Cook Chill -- E] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) - -- --- Customer Self -Service of Non PHF and Non- Perishable Foods Only ------- [] Customer Self Service - � Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ElPrepares Food/Single Meals for Catered Events or Institutional Food Service _ Offers RTE PHF in Bulk Quantitie""�--"- s - _.__.._.._._.._...__— 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 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 of 105 CMR 590.000 and the federal Food Code. '/� Signature of Applicant: , n , ' ? a-'N'9-� 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. ` 1 e p p .f Signature of Individual or Corporate Name: \,4nD \ IX ) , 1 �V IL uSocial Security Number or Federal ID: MA I`S�—\\aIg Town of Mansfield Town of Mansfield - 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: KANKU INC, D/B/A THE STORE LOCATION OF SALE OF TOBACCO PRODUCTS: 213 SOUTH MAIN STREET TELEPHONE AT LOCATION: 508-261-1369 OWNER OF BUSINESS: HITESHKUMAR PATEL _ ADDRESS OF OWNER: 110 MARGIN STREET, PEABODY, MA 01960 _ TELEPHONE OF OWNER: 508-409-9228 _ FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. HITESHKUMAR PATEL, OWNER, 110 MARGIN ST, PEABODY, MA 01960 KAILASH. K. PATEL, DIRECTOR, 51 FOXWOOD LANE, RAYNHAM, MA 02767 * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $150.00 CT -3T NUMBER: FEDERAL ID/SS NUMBER: -0 SIGNATURE: P. A DATE: it) II L< l i �S�CNLSFT ' pLVirrt`Iq 9 FNr oP� �� tt'. MASSACHUSETTS DEPARTMENT OF REVENUE -Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. KANKU INC THE STORE 213 S MAIN ST MANSFIELD MA 02048-2519 Form CT -3T Account ID! CGL -10884290-006 License Number: 367302656 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 1, 2018 Expiration Date: September 30, 2020 °5s�sp�MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T - r — " Retailer License for Sale ofCi;ars 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. KANKU INC THESTORE 213 S MAIN ST MANSFIELD MA 02048-2519 Account ID: CRL -10884290-009 License Number: 42100736 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 1, 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. GSL AJ K 0 1,-J(2, Signature of Individual or Corporate Name 04-3 s't9 I/,- "Social Security No. (Voluntary) or Federal Identification Number �'l1`-ft4lil�anrV.r�1 /�� By: Corporate Officer (Mandator, 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\Scotts Documents\Food Establishments- Temp\TAX CERTWICATION FORM.doc The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: XAn/KL2 JIUG- Address: f}f3 f--2aIrrH f"IA) e;'i City/State/Zip: M,6FiUSF( L� f /yjA— D.Vt(f Phone #: 5js�,,ga / 4,!l Are you an employer? Check the appropriate box: Business Type (required): 5. n• Retail 1. fp I am a employer with employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, E] Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ 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]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.0 Other *My 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: MA- 01 .A,C A -i,4 Arr-S (06 611til / P 1A)6. Insurer's Address: n r). o e,y, _1 gA - q 9--L City/State/Zip: P312,0 i—t Utz Ate-- r� Policy # or Self -ins. Lie. # Expiration Datc:_,0j. 10 D 13 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 ofpetjury that the information provided above is true and correct. Signature: 13. Date: /G /I —411 II, 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 www.mass.gov/dia Phone iNORMATION PAGE Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: Kanku, Inc. The Store Mailing Address: 213 South Main St. Mansfield, MA 02048 Other workplaces not shown above: NO OTHER WORKPLACES FOR THIS POLICY RENEWAL AGREEMENT PRODUCER: Agent# 5960 HUB NE Association Programs 300 Ballardvale Street Wilmington, MA 01887 Carrier Policy #: 014005032484118 Carrier Prior Policy #: 014005032484117 Fein: 043521128 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1/01/2018 to 12:01 a.m. on 1/01/2019 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA 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 $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOC(01/15) WC000414(07/90) WC000422B(Ol/15) WC200102(01/14) WC200301(04/84) WC200302A(09/08) WC200303D(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis No. Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 600.00 Minimum Premium $ 229.00 Expense Constant $ Rate Per Estimated $100 of Annual Remuneration Premium 00 Deposit Premium $ .00 SCHEDULE OF OPERATIONS FOR: PAGE: 1 ***** PREMIUM INFORMATION FOR MA ***** The Store Carrier Policy #: 014005032484118 Kanku, Inc. Fein: 043521128 213 South Main St. Mansfield, MA 02048 DIV #: 00000 E/L Number: 0000000001 Code Classification Payroll Rate Premium 8006 Store:•. Grocery Retail Manual Premium 50,733.00 1.43 Rate Deviation 15.00% Merit Rating Standard Premium Normal Premium Expense Constant Domestic Terrorism C .030 Annual Premium DIA Assessment (00930) 1.6100% / 1.6100% Total Merit Rating .9500 1/01/2018 WC 00 00 01 B 725.00 725.00 109.00 585.00 585.00 585.00 15.00 600.00 11.00 611.00