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Home My WebLink AboutJuice on Main - 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 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.. LORI A. DELANG Whose place of business is: JUICE ON MAIN, LTD 240 NORTH MAIN STREET PERSON(S) IN CHARGE: LORI A. DELANG Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-38 BOARD OF HEALTH MichaeCHeatey, 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) Establishment Name: Jvl « o✓rry, Lj0 Establishment Address: . 99f 0H?, —5�- i 2 p �(/ „� 5 ��. (/i J✓j�C1� Establishment Mailing Address(if different): Establishment Telephone No.: y- 2rf Y- 1/ yA-� Applicant Name & Title: LDa r A )�e l4NJ Applicant Address: '3 % ✓o fr 144i4'4'; 4,L4 Applicant Telephone No.: y - Z - U V L 24 Hour Emergency No.: Applicant E-mail: L02r0 UiceoA,.tAA,,7, co 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 19 An Association partner. Corporation Name Title ddress An Individual m V A 7 ✓U Si, /fv/ liialg / r t -7 Ad S- ffi A Partnership Id Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: lh4, %/"/', V /,Ur Address: 3 -) �,4✓i) j'f;, NJl6lLto Telephone No: 24 Hour Emergency No: 7 ? y >�l 0 Z FAX: E-mail: �2' l%/�uH�d✓A,w.(-off 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) No. of Food Employees: p DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. �/2/ �L/r♦N� Person Trained in Anti -Choking Procedures (If 25 Seats or more): [ Location: Permanent Location Establishment Type Q Caterer $35.00 M Moblie Mobile Start Date: Mobile End Date: r.-a Retail ( Z/(/ 0 Sq. Ft), Food Service up to 100 INCLUDING r' Milk & Cream $10.00 Q Mobile Food Consession Mobile Comments: ODD 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: Annual Food Service up to 201 + $300.00 r1 Supermarkets $400 ®Pushcart $50,00 # of Pushcarts; I� Residential Kitchen $100.00 tail Food $125.00 != Retail Snack Food $50.00 Seasonal Seasonal Dates: ® Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): De(nitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) E:t Sale of Commercially Pre -Packaged Non-PHFs ❑�' PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs i] Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility i] Delivery of Packaged PHFs Id Sale of Raw Animal Foods Intended to be Prepared by Consumer Fv,l Reheating of Commercially Processed Foods for Service Within 4 Hours Q Vacuum Packaging / Cook Chill _ 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 Q Customer Self -Service 6"7 Ice Manufactured and Packaged for Retail Sale rs Preparation of Non-PHFs Other Food Operations I] Juice Manufactured and Packaged for Retail Sale - i] Offers Raw Or Undercooked Food Of Animal Origin `❑'J Prepares Food/Single Meals for Catered Events or Institutional Food Service f-i 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 0 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 MR 590.000 and all r er applicable law. I have been instructed by the board of health on how to obtain copies of 1Qt'i GMR 590.OQb'jand tF( fe04 Fgod,C9de. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to m best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: �(/I <C O'L/ 'M /}, ri Social Security Number or Federal ID: 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. 111VICP a / 104-1ilI LiO L Signature of Individual or Corporate Name By: Corporate Oicd (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:\Usem\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 Business/Organization Name: J(11(e 6"1104,n/, I,T/) Address: ?-V o Sf City/State/Zip: 4W✓jl)1; o A* o 20 Y y Phone #: Argon 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 (me]. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp, insurance required] $• ❑ 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. ❑ 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.] 12.0 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 is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: me S I P7 S Insurer's Address: — _I/ 20 del"_ City/State/Zip: yuk6 )l i3 0 / p Policy 4 or Self -ins. Lie, 4 VV G 3 3 2 4 620 Expiration Date: 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 tfe pains and penalties ofperjury that the information provided above is true and correct. 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 1 JUICE-5 OP ID: IDS ACORO CERTIFICATE OF LIABILITY INSURANCE Dn06101112018 `—/ 06rotrzot8 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(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 thecerli0cate holder in lieu of such endorsements . PRODUCER 888-467.3330 NRjj�!GTDaneMeisler Kapaloes insurance 6ervlces LL PHONE 888.467.3330- - FAX 888-453-5755 725 Pruner, Blvd Suite 115 AAIC, No, Exl:_ (AIC, Net:__ _ _ _ Lake Mary, FL 32746 � ��^o^� , tlane�ia kTsIIG CDhI Dane Meister I --- --- -- - .. _ INSUf_tEj1LLFFORDING COVERAGE_- lNSURERA,WESCO INSURANCE_ CO _ _ 125011 INSURED Juice on Main LTD NSURER B Jon GoPPpolino — __. —___ .. __ __4 _. _ .. 479 Mal, St I INSURER C_ Medfield, MA 02052 t INSURER INSURER Ey____._.__..__ INSURER F r.nVPPAn PS rcoTmlr nTc nu lsnoco. 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 TERNS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY H_A_V_E_8_EEN REDUCED BY PAID CLAIMS. INSR- TYPE DF INSURANCE ABDL SUBR pCUCY NUMBER PDIM EFF POLICY E%P LIMITS COMMERCIAL GENERAL LIABILITY - EACNOCCURRENCE iCLAIMSMADE I OCCUR I _ DAMAGE TO RENTED I Rome) ',PERSONAL b AOVINNRY -I5_. GEN'L AGGREGATE LIMIT "PLIES PER: f I GENERAL AGGRSGi�T[ $ ._ _ POLICY jEGVi LOG ,-PRODUCTS _COMPYOP AGG_.1 AUTOMOBILE LIABILITY —� I C aMdIN toSINGLE LIIAII (EnncdanU___. 15 ANY AUTO BODILY INJURY [Pa pss ni S — OWNED SCHEDULED — _--" AUTOS ONLY ',.AUTOS pO 1�l Y1NJUNY LPor ACCtlonlyl3 AN��qq�� oo ppWW EEp S ONLY .. _j /NiR ONLY _ ALP OPERlo ITAMAGE $ IRRENCIE .i - UMBRELLA LIAR OCCUR i - I EAC OCC i$ EXCESS LIA CLMMS-MADE- A AGGREGATE ' BED I RETENTIONS ' A D EMPLO PER 'AWORKERS ERS' LIABILIIT! _ STATUTE ..r_X ERIi_ ANY PROPRIIETOILPARTNEPoEXECUTIVE EXCLUDED? NIA VVWC3326620 02r2712018 07J2712019 '..EL 500,00o FACHACCIUENr ,I j_.__._.. _ _ IN..SEory toBER �S. DISEASE -EA [hIFlOYgE 500,000 drmVlundor F1 DISEASE- POILI.Qy QuAll500,000 RIPPONOF 011MATIONR balm I � I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLEG (ALORD f et, Additional Remarks Schedule, may he attached If Moro space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE w 1a00-ZUIO Aq Ur%U GURHUHAI ION. All rights reserved. The ACORD name and logo are registered marks of ACORD � �w u z W-4 cw� � � � � \ ( ) J 0� \ \ \ t !rj \ \ \}\\ r » °5 c • � � • � der'✓ �+'tfy��S �y'� bJ �° Jane Doucette From: Lori DeLang <lori@juiceonmain.com> Sent: Thursday, December 6, 2018 3:39 PM To: Jane Doucette Subject: RE: Mansfield Food Permit Here you go Jane. 47-4436085 From: Jane Doucette <Jdoucette@mansfieldma.com> Sent: Thursday, December 6, 2018 3:01 PM To: Lori DeLang <lori@luiceonmain.com> Subject: Mansfield Food Permit Hi Lori, I will need your Federal ID number. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 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