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Home My WebLink AboutD'Angelo's Grilled Sandwiches - 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:. BRIAN J. MCLAUGHLIN, PRESIDENT Whose place of business is: D'ANGELO GRILLED SANDWICHES 260 CHAUNCY STREET PERSON(S) IN CHARGE: BETH MASTROIANNI Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-16 BOARD OF HEALTH 34tchaeCHeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned open t)e) NOV 2,7 20% Establishment Name: Establishment Address: C' Establishment Mailing Address(if different): Establishment Telephone No.: Applicant Name& Title: �kanvck Applicant Address: � (' I vy "-A-LC) W P-A-1 t cko (" t ooc f f- Applicant Telephone N&;5,:, :A-u '10(4 6 �_e� 24 Four Emergency No.: \ I Applicant E-mail: Owner Name & Title (If different from applicant): ct A�[N" Lcud) I Owner Address:�A'ck_k' A i , Owner Telephone No.:(G (4' Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 4 A Association partner. VEN A Corporation Name Title Address H An Individual 0 A Partnership H Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: Address: �& Telephone No: a 24 Hour Emergency No: 29 i- 11 L! FAX: E-mail: 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: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: ., r V- � — � 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: €_ ermanent Location Establishment Type 0 Caterer $35.00 OMoblie Mobile Start Date: 0 R `all ( Sq. Ft) '�; Mlik & Cream $10.00 Mobile End Date: rod 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: 0 Annual Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: 0 Seasonal Seasonal Dates: I Supermarkets $400 E3 R idential Kitchen $100.00 Retail Food $125.00 Q Retail Snack Food $50.00 E; Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF- Potentiallyhazardous food(fimefiempereture controls required) Non-PHFs - non -potentially hazardous rood(no fimmemperature controls required) RTE-ready-to-eat foods (Ex. sandwiches, salads, mums which need no lurtherpmcessin9) Sale of Commercially Pre -Packaged Non-PHFs P•, PHFCooked To Order E" Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service G3 Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility 0 Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer �E1 Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) i:7 Customer Self -Service of Non PHF and Non- Perishable Foods Only i=.:' Customer Self -Service Ice Manufactured and Packa ed7tar Retail Sale 0 Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Retail Sale 0 Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities 0 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 10of5 th establishment operation will c ply board of health on how to ob ain rttcoplewith s of 10 Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify u and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: provided in this application and affirm that the food and all other applicable law. I have been instructed by the 0 and the federal Food Code. the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row 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: t'\�L c i . j`4 �� _° C't Adt "r C kk2 ADDRESS: TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: ! '( � DOE_ i Lx �t-c it t 0'- TELEPHONE OF OWNER:( �� Lj FEDERAL ID/SS NUMBER:y�y FEE: $10.00 4 PERMIT NUMBER: h SIGNATURE: DATE: 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. Signature of Individual or Corporate Name By: Corporate fficer (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:0seo\s1eite\Desktop\8cotPs Docoments\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts Department gf lnd'us'trial Accidents 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: % r1 1 }c , Address: t}& City/State/Zip:' M Jq-6,C01,k C Mft i ,47' 1 f' Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with � v '� 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] $• ❑ 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 rep.] 12.❑ Other *Any applicant that checks box #1 most 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 Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. 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. Ida hereby,eertify, under to ains and penalties ofperjury that the information provided bove i true and correct. (/ Cionafi�re•l%.fie .r. ./'" Pate• # �� /"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 Contact www.mass.gov/dia Phone DANGINC-01 AFRO CERTIFICATE OF LIABILITY INSURANCE C TAPLETO OATE(MMtODNYYY) 02/2012019 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 License#1780862 HUB International New England 300 Baliardvale Street Wilmington, MA 01887 co OT PpONE Pax AIC, NI�o, Eaq: (978) 8b7-5100 A/c, Nei:(978) 988.0038 EDOAIES INSURERS AFFORDING COVERAGE NAIC4 INSURER A: HanoverinsDr nce Company 22292 INSURED D'Angelo,Inc. 323 Manley Street West Bridgewater, MA 02379 INsumens:AilmericaFinancial Benefit Insurance 41840 -Company INSURERC: INSURERD; INSURER E: INSURER F: - COVERAGES CERTIFICATE Nl1MRFRn RPI9AInN MIIMRF:P- 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 CONTRACTOROTHER DOCUMENTWTH RESPECTTOWHICH 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 1111 TYPE OF INSURANCE ADOL SUaft POLICY NUMBER PtlLICY EFF 0110112018 POLoIMM)pY EXP 01/01/2019 LIMITS A TXcopMMERCfAL GENERAL LIABILITY CLAIM&MADE � OCCUR LBND46116900 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED P E ISE Ee occu re ce 100,000 MEDEXP �yone person e10,000 PERSONAL& ADV INJURY a 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑wi LOG OTHER: GENERAL AGGREGATE 21000,000 PRODUCTS - COMP/OP AGG $ $000,000 S B AUTOMOBILE LIABILITY ANY AUTO OWNEDAUTOS ONLY AUUpTT,NOpSSVVU..gqL..1IEDpp AUTOS ONLY AIITO&O�LY AWND461185 01/01J2018 01101/2019 COMBINED SINGLE LIMIT $ 1,000,000 X BODILY INJURY Per ersoo $ BODILY INJURY Per areldenl S RoraeeR�i AMAGE $ A X UMBRELLA LIAR EXCESS LIA6 I X IOCCUR CLAIMS -MADE UHMD46117400 01/01/2018 01101/2019 EACH OCCURRENCE S 20,000,000 AGGREGATE a_ 20,000,000 DED I X I RETENTIONS 0 A WORKERS COMPEpSATION AND EMPLOYERS' CIASILITY YIN AA�1p4Y PROPRIETgO�qRRpIPARTNER/EXECUTIVE I� (MenUatolry In NH) EXCL OED1 L....._I "'es' describe antler DESC PTION OF OPERATIONS below N /A WHND442216 12/3112017 42131f2918' PER OTH- E E.L. EACH ACCIDENT $ $00,000 E.L. DISEASE - EA EMPLOYE 500,000 E.L. DISEASE. POLICY LIMIT 600,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schadule, may he aaachad if more space is required) Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered (narks of ACORD 4� c 0 c � � u W G o O N U_ N O C a` V O U LL 6G A n V z G� O W W O O U a a N N N a VV a �O w76 N o N i+ a m T m Z a C S y N U A W N � Q da a E ro N aw r J W v@ V N j L N U t a O 03 3 i f O ch 0 I N