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HomeMy WebLinkAboutHangar #12 - 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:. MICHAEL LEVINSON & WADE FEDERICI Whose place of business is: HANGER #12 RESTAURANT, LLC 265 FRUIT STREET PERSON(S) IN CHARGE: MICHAEL LEVINSON Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-33 BOARD OF HEALTH -%lichae(HeaCey, Chairman Milk & Cream ly, FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned ope 1) Establishment Name I,44. 2)Establishment Address `� 3) Establishment Mailing Address (if different) T 4) Establishment Telephone No ­79) - 3 L3 5) Applicant Name & Title 2 \jr,.xf- 6) Applicant Address - 7) Ap nt Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title M _c4.�� Lev n3on L, K e-- Fe )w- r C 9) Owner Address (If different from applicant) owner's telephone number 761- 3 63 -,k 10) Establishment Owned By: 11) if a corporation or partnership, give name, title, and home address of officers 1 An Association or partner. A Corporation Name Title Address individual Ac1vA 4v� 3��vuef S` uh�C St- itoPK+nkn H,, 01,714 APartnership 4�C Ftvr UUfy-f 4(.6 Ii6s 5-t AbnSEen rA - — -- -- Okher-Iega1_F4tity.__-- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title. Address: IS_ S } Rvfkr, Telephone No: 72 - 3 j a(� 24 Hour Emergency No: FAX:E-mail: �(��J503y ► r�l `Jh�wt� . Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No 1 24 Hour Emergency No: FAX: 1 E-mail: 0 `n- Food Establishment Information 14) WATER SOURCE 15) SEWAGE DISPOSAL: - DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: da -7A _) P 18) Name of Person In Charge Certified in Food Protection Management: j If more than 3 individuals are certified, complete list is on file. Required as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of j certificate -544 f t 'Tet ( � 19) Person Trained in Anti -Choking Procedures (If 25 Seals or more): LLT 20) Location: _7 Permanent Location i 22) Establishment Type Mobile Mobile Start Date: I -I R tail ( S Ft) Mobile End Dale: Mobile Comments: 21 ength of Permit: Annual ,._1 Seasonal 1 Seasonal Dates: -I Temporary Temporary Start Date Temporary End Date: Temporary Time: q• [_ end Service up to 100 or up to 10' PHF display $126.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 [J Food Service up to 201 + or 25'+ PHF display $276.00 Food Service - Institution ( Meals/Day) U Caterer $25.00 [;;. 4ilk & Cream $10.00 Mobile Food & Consession $75.00 IJ Manufacture Frozen Desserts)ice Cream $25.00/freezer Pushcart $25.00 M of Pushcarts: Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous roodflime/lemperalure controls required) Non-PHFs - non -potentially hazardous food(no time4amperature controls required) '(Check all that apply): RTE- wady -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 Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours i Customer Self -Service or Non PHF and Non Perishable Foods Only j Preparation of Non-PHFs Other Food Operations 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 I J Ice Manufactured and Packaged for Retail Sale JJ Juice Manufactured and Packaged I Retail Sale 1 Offers RYE PHF in Bulk Quantities 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 Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service )J Retail Sale of Salvage, Out -Of -Date __ or Reconditioned Food lr a completed by the Board of Health i Total Permit Fee: Payment is due with application L] 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 5 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain gpAe 105 CMR 690.000 and the federal Food Code. 24) Signature of Applicant: Jf r 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: 26) Signature of Individual or Corporate Name: 14 tya Ll IQ 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. Si ature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) ��- s`I6 y�Sl� "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. RAH=RhVme's DooumeutsTERMIT APPLICATIONMAX CERTIFICATION FORM.doc The Commonwealth ofMassuehusetts Department oflndushialAccidents 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Joe r 1), lUrz n •1— L L G Address: ut S'} City/State/Zip: '' n r` klcjxSei t ci IkA , Phone M k - 3 6 :? " L " 3 Are yqu an employer? Check the appropriate box: 1. CS I am a employer with,, _ employees (full and/ Business Type (required): 5. ❑ Re or part-time).* 6. estaurant/Bar/Bating Establishment 2: ❑ lam a sole proprietor or partnership and have no ?. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 6. El 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 with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information. a"li the corporate ohiccrs have exempted themselves, but We corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. fain an employer that is pro ing [porkers' compensation iinsurance for my employees. Below is the policy information. Insurance CompanyName:0e)�it� 1� '^� :r/ urcr Insurer's Address:j1ab' oo-1` City/State/Zip: 17'PSI,,; !AoNN 0a"6N? / Policy # or Self -ins. Lie. #- C P� yG 3 3 ?. cl Expiration Date: 3 / 7 // l 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby g der the pains and penatdes of perjury that the information provided above is true and correct Si tr�atnre•�/I��(Y\ Date; la! ur /1 Phone #• �721 "3 6.3 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Perodt/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: AC"I?H CERTIFICATE OF LIABILITY INSURANCE 1%� DATE(MMIODNYYY) 1 12/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACTNAME: Jeanne McPhail JOHN J LAMB INSURANCE AGENCY INC PNcoNE (781) 749-6960 ac Na: AM less; kariny@jlambinsurance.com INSURERS AFFORDING COVERAGE NAIC # 24 NORTH ST INSURER A: HARTFORD UNDERWRITERS INS CO 30104 HINGHAM MA 02043 INSURED INSURER B ; IN$URERC: HANGER 12 RESTAURANT LLC INSURER D : INSURER E : 265 FRUIT STREET INSURER F: MANSFIELD MA 02048 COVERAGES CERTIFICATE NUMBER: 344008 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TRINSD TYPE OF INSURANCE AODL SUER POLICY NUMBER MM/DDNYYY MMI�DIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE-DAMAUE—TO $ CLAIMS -MADE ❑ OCCUR RENTED PREMISES Ea occur ante $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ N/A GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- JECT ❑ LOG PRODUCTS - COMP/OPAGO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED TEDSAUTO$ N/A PROPERTY DAMAGE Per eccideM $ NON -OWNED H R AUTOS UMBRELLALIAS OCCUR EACH OCCURRENCE $ AGGREGATE $ E%CESS LIAB CLAIMS -MADE N/A DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICEWMEMBEREXCLU EXCLUDED? ANYPROPRIETOWPARTNEWEXECUTIVE NIA (Mandatory in NH) NIA N/A 6S6OUB1K22992018 03/08/2018 03/08/2019 X STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 If yas, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD/01,Additlenal Remarks Schedule,maybeattachedifmorospacelsrogalred) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. 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. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 Daniel M. Crowley, CPCU, Vice President —Residual Market— WCRIBMA V 1988-ZU14 ACUKU CUKPUKA I ILIN. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD A� Ra® CERTIFICATE OF LIABILITY INSURANCE DATE 12104116 rrl 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 pollcy(les) 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 CONIACT NAME: ac°NN E4 781.749.6960 Alc No: 781-749-8822 John J. Lamb Insurance Agency Inc. AODREss: kLiny Lidy@Jlambinsurance.com 24 North Street Hingham, MA 02043 INSURER(S) AFFORDING COVERAGE RAID# INSURER A: Scottsdale lnsuarnce INSURED INSURER B INSURER C: HANGER 12 RESTAURANT LLC INSURER D : 266 FRUIT STREET MANSFIELD, MA 02048 INSURER E: INSURER F: CnVERAr.EC CERTIFICATE NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 NSD WVD POLICY NUMBER MM/DDY� MWDD/FULIQYYYYY LIMITS A X COMMERCIALGENERAL LIABILITY CLAIMS -MADE � OCCUR CPS3032329 03/07/18 03/07/19 EACHOCCURRENCE $ 1,000,000 PREMISESOEaoNccurrence 8 50,000 MED EXP An one arson $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER POLICY ❑PHI JECT F—]LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 1,000,000 AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDOSULED AUTOS ONLY AUT HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINEDSINGLEINGLE LIMIT Ea awccidanttlenl $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PROPERTY DAMAGE Peraccid.rd $ UMBRELLA LIAR EXCESS LA9 OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe antler DESCRIPTION OF OPERATIONS be. NIA STA UTE OERH E,EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ EL.DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached If more space is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. jeanne McPhail © 1988-2015 ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD SCOTT TEFFT v\lho h i ai all the ,); Oil36 fGtt�7l requiranients f01 cerb a-,,iolI in, ANSI RCCXE iOVPOENPI. J nCCan110 enc i E oJP[ol[[l an i• ' Exam 1821 Recognized By Conference For Food Protection Certificate No: 1939250 ::: t Exam Date: 02/28/17 'Ryan McMiiiim, Chentservices Manager Test Code: 6203041821 Pmnidrk 7e1CorpomteWn ,No18h9ham,MD212:i61 800.624.273E Expires on: 02/28/22 I Fr � , ■