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HomeMy WebLinkAboutFamily Food Mart - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health to Operate a Food Service 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:. PRANAN PATEL Whose place of business is: FAMILY FOOD MART 660 EAST STREET License Number: FS-25 Permit Expires: December 31, 2019 Food Fee: $175.00 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: FAMILY FOOD MART 660 EAST STREET License Number FS-25 Permit Expires: December 31, 2019 BOARD OF HEALTH Mchae[HeaCey, Chairman x f 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: Yt�M'I 7_ tJ Fo 6 Establishment Address: W Establishment Mailing Address(if different): Establishment Telephone No.: �Tj 3 3� - -2 6 e Applicant Name &Title: pt6)-NftV P19-Iql- IDhJJ494L Applicant Address: 17) 1-1.M6(in, f'I API .4. 1n(lndA '�'( Applicant Telephone No.: ] t� -Sk . 64 Ci 24 Hour Emergency No.: Applicant E-mail: YCIn4vki &1 'M I. Ga't Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: f a corporation or partnership, give name, title, and home address of officers or ITO An Association partner. H A Corporation Name Title Address Ell An Individual 110 A Partnership H Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: � �zlrla� v Qw/d 'Py Address: I -),I - H - M� 0-A,J . 9 e F Telephone No: . S (� - 6 2 It 24 Hour Emergency No: FAX: r I cuvQcrl�( E-mail: (��cii Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) :.. '-...,..,� -r. No. of Food Employees: DAYS/HOURS: (( I.') 1 If U r a ( "') i 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): l Location: [2 Permanent Location Establishment Type 0 Caterer $35.00 ifl Moblie Mobile Start Date: Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Q 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 l3 Manufacture Frozen Desserts/Ice Cream $25.001freezer Length of Permit: Annual Q Food Service up to 201 + $300.00 0] Pushcart $50.00 # of Pushcarts: Seasonal Seasonal Dates: ' Supermarkets $400 FJ Residential Kitchen $100.00 Q Retail Food $125.00 Q Retail Snack Food $50.00 E0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non-inmen6'ally hazardous food(no IimeRemperatum controls required) (Check all that apply): RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which needno 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 Q Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Delivery of Packaged PHFs r; Q Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Perishable Foods Only Vacuum Packaging I Cook Chill Q Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale Q Preparation of Non-PHFs Other Food Operations E] Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin E] Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities 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 i] 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 CfAR 5P0.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certify and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns �(GI-314-LASI 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. By signing this application, I declare that I have read the regulation and am responsible for tobacco product sales regarding federal, state and local laws. 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: Farn o-y LOCATION OF SALE OF TOBACCO PRODUCTS: TELEPHONE AT LOCATION: �5$) '6' 33el OWNER OF BUSINESS: Q V A N/i-,/ _ tl P l q,L ADDRESS OF OWNER: 1-7.2 ' 1--I 0CiJ'n _ f � TELEPHONE OF OWNER: 'Ii � - S 0 C 11 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Briefly describe your tobacco and nicotine delivery product sales training. Attach employee training documentation * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $150.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: %i G 1 - 3 I'I Li� SIGNATURE: -✓(� DATE: ySs°H°SE� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m -Retailer License for Sale of Cigars and -Smoking Tobacco ➢ JJ�� �ti 'Fmoe�` This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DIVYA AKHAND JYOIT CORP FAMILY FOOD MART THE 660 EAST ST STE 5 MANSFIELD MA 02048-2951 Account ID: CRL-11286105-010 License Number: 606783488 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 MASSACHUSETTS DEPARTMENT OF REVENUE _ _ Form CT-3T Retailer License for Sale of Cigarettes :y t„ a This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. DIVYA AKHAND JYOIT CORP Account ID: CGL-11286105-007 FAMILY FOOD MART THE License Number: 1441044480 660 EAST ST STE 5 MANSFIELD MA 02048-2951 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. CJ- Signa of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) �b/- 31�-4fI **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\ScotPs Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents 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: r(}rn1t fa6D 117ARl Imyyfr AifhAHI).lyeIT C'aR ' Address: C( o EAST S'T Phone #: � D K - 3 31 - -t 4 K ci Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ 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. [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 10.0 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 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 isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: a V ({ r j n Sg1i(_q %L e_- Insurer's Address: Q U (SON City/State/Zip: Wl iV4� - Rcl>rYt, iA i mot Policy # or Self -ins. Lic. #J) 10 L e6 � �I I( Expiration Date:z ti Ii I I' 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 thepaIns andpenalties ofperjury that the information provided above is true and correct. -. 1,41 1yy_ Aare• I / / 11 1 / V Phone #: -7 -' / CO - r, p1 A Z'1 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 ContactPerson: Phone #• www.mass.gowma FAMIF01 OP ID: TL A` (7RI7 CERTIFICATE OF LIABILITY INSURANCE DATE/0912018 1 vos/zg18 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 endorsements . PRODUCER -" -' I.K.OIIvlarlIns. Agency '-'- nAMx - - PHONE 508-947-1818 FAX pvc, No, Extj: (PIG. Noj: 14 East Grove St. _ Nlddleboro, MA 02346ss; Sennoth W. Olivier] _ ,.INSURER{&)AFFORDING COYERAOE, ___. RAIC P. . .._ INSURER A: Guard_ Insurance INSURED Family Food Mart INSURER e.- DIvya Akhand Jyolt Corp INSURER C: _- 660 East Street - Mansfield, MA 02048 INSURER o: o CVICIf1M MIIMRCR• COVERAGES cen nr cA C umoC - --- - - - 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 SFIOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ . T INSR TYPE OF INSURANCE OLSUOR POLICYNUMOER POLICY EFF- POLICY E%P UNIT it MMIDD 1,000,000 COMMERCIAL GENERAL LIAOILITV EACN QGQURFiENCE§.. DAMAGE TO RENTED II 50000 CLAIMSMAOE (.X OCCUR PREMISES(Eaoccurraoco) $. 5000 A X Business Owners DIBP825533 0511212018I 05/1212019 MEDEXR(Myeea parson) �s. PERSONAL SAOV INJURY }g_ 1,000,00O - GENT AGGREGATE LIMIT APPLIES PEp GENERAL _AGGREGATE 000 2,000,000 X POLICY �R� LOC �___ _... PRODUCTSGOMPIGP AGG ;3_ 1 t ' IS 11 � COMBINED SINGLE LIMIT j AUTOMOBILE LIABILITY (Ea dadonll .... }...$.. -._. _.... I ANY AUTO 1 BODILY INJURY IF., Porson) i $. ..... _ .i OWNED j-- 'SCHEDULED IAUTO$ONLY L,,,- AUTOS BODILY INJURY {For ocudanl),$ - p CToni)AMAGE -- - _IIqq��pp ppNNpp EEOO AUTOS ONLY �� At/109V�NNLY , ,Lt�e�aci iS j I I ...__.. UMBRELLALIAU iOCCUR EACHQCCURRENCE $ ... EXCESS LIAe - CLAIMS -MADE AGGREGATE_. 5.. _—.. RETENTIONS DEO X COMPENSATION A WORKERS COMP AND EMPLOYERS'LIIABILITY YIN DIWC875175 ;eETAT T ERH 04/15/2018 0411512019 EL EACH ACCIDENT Si 500,000 ANY PRRO�PRpIETnO�RnIE%CTUEEIE ECUTIVE I NI �a�enaafvMryln NHi -. NIA, FI OLKASP., rA EMPLOyrii" 4. 500,000 If yyes, tloscnbe umlar DASft, &TIOUShelve !DIBP825533 ;.. E.L. DIS E . POLICY LIMIT 0511212018g0511212019 per perso 500,000 1,000,000 A '.Business Owners aggrega 2,000,000 !Liquor Liability DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 10L Additional Rammke Schodulo, m0y IR affachod If more space is raqueed) .... ..._ . —_ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfleld, MA 02048 AUTHORIZED REPRESENTATIVE -- 12a18103j ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are regUaTereu mat na . ' ......,... Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: �F} (YI 12\/ �6 a 0 M OIL ADDRESS: (� b I -c • 6 9m1-I r L 1 fx)p O 2 j� t TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: FEE: $10.00 PERMIT NUMBER: fin- 339 --26" fPAN4v 0A TAIL 7`7W' SIGNATURE: DATE: Io �zd�t�