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HomeMy WebLinkAboutCamping Cat - 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:. STEPHEN J CERULLO Whose place of business is: CAMPING CAT 137 MILL STREET PERSON(S) IN CHARGE: STEPHEN J. CERULLO Permit Expires: December 31, 2019 Food Fee: $185.00 License Number: FS-87 BOARD OF HEALTH NichaeCHeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: a'" P t Ack Establishment Address: J_l V\f\,\\ AC a -A Establishment Mailing Address (if different): Establishment Telephone No: �_0 y 3�1 "0(a3l( Applicant Name&Title: y}tiatie '$ Lt'vblo Applicant Address: V" WCtftP0''V- Rollo �Jv V4au M A J7 © '?Wl Applicant Telephone No.: t (y(p34 24 Hour Emergency No.: c�0$ 13 I Applicant Email: Owner Name & Title (If different from applicant): Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or H An Association partner. H A Corporation Name Title Address H An Individual H A Partnership I VOther legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: �J'�epHen �evJl(p Address: C ks't Telephone No: 24 Hour Emergency No:� 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: `—Vo W In SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) No. of Food Employees: 5� DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. '34tAen Clev000 Person Trained in Anti -Choking Procedures (If 25 Seats or more): ll Location: Permanent Location Establishment Type: Caterer $35.00 E] Mobile Mobile Start Date: t❑s Retail -NO FOOD PREP ( Sq. Ft) $125 [Milk & Cream $10.00 Mobile End Date: Moblie Comments: Q Food Service to 100 seats INCLUDING FOOD TRUCKS $175.00 0 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Length of Permit: EJ Food Service for 101 -200 seats $250.00 iJ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Annual � — °' Seasonal p� I L Seasonal Dates: Ci 3 t Q Food Service for 201+ seats $300.00 Supermarkets $400 ❑> Pushcart $50.00 # of Pushcarts: E] Residential Kitchen $100.00 0 Tobacco Products $150.00 E] Temporary Temporary Start Date: Yon 4y 0 Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: " Food Operations: (Check all that apply): Definitions: PHF- Potentially hazardous food (timeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) E3 Sale of Commercially Pre -Packaged Non-PHFs Eg-151-11'Cooked To Order '"; Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑-i Sale of Commercially Pre -Packaged PHFs reparation of PHFs For Hot And Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs :" Reheating of Commercially Processed Foods for Service Within 4 Hours iJ Sale of Raw Animal Foods Intended to be Prepared by Consumer E3 Vacuum Packaging / Cook Chill TJ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) i� Customer Self -Service of Non PHF and Non- Perishable Foods Only 0 Customer Self -Service Ice Manufactured and Packaged for Retail Sale iI Preparation of Non-PHFs Other Food Operations EJ Juice Manufactured and Packaged for Retail Sale EJ Offers Raw Or Undercooked Food Of Animal Origin Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service I Retail Sale of Salvage, Out -Of -Date or Reconditioned Food completed by the Board of Health 7Tota,fl,PermftFee: ent is due with application t•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 Win 105 PMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 10 /CMR 590. 0 e federal Food Code. Signature of Applicant: ✓ tV f1� 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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: c CICA 1 Caul 0 a-�2 ADDRESS: ILR oLjD cokonL' ►A(f,Y 5LLD TELEPHONE AT LOCATION: 1 560 ? 33 ci - 00 5 FAX NUMBER: OWNER OF BUSINESS:��H2✓t TELEPHONE OF OWNER: L1 ou FEDERAL ID/SS NUMBER: �LA, 5 � 6 3" FEE: $10.00 J PERMIT NUMBER: SIGNATURE: DATE: cGV.o e R vQ zw cc,w,)IP 6 rr "0 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. L., n CX,& Signature of Individual or Corporate Name Oki3 t5t 634D "Social Security No. (Volunhuy) or Federal Identification Number By: Corporate Officer (Mandatory, 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\sleile\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �" " _ /� ppPlease Print Legibly Business/Organization Name: CnC;(AY1--etko vi A uA � �' 'D &A- (2cc; w, 01 Qt Address: U1 �-o o t owti City/State/Zip: Wa*;�it,E LO IM ASS Phone#: '-09 3,3q 0037 Are you an employer? Check the appropriate box: Business Type (required): 1`.'CJ I am a employer with employees (full and/ 5. ❑ Retail 6. [f�estaurant/Bar/Eating Establishment or part-time).* 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. 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.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance rep.] 121-1 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 Insurance Company Nam Insurer's City/State/Zip: N�\ workers' a mpensation insurance for my employees. Below is the policy information. vi ift o R b `T VU, , Policy # or Self -ins. Lie. # I lL W L- 6 /� () 1 N 6' (� Expiration Date: —1 e ^ 20 �O 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: SVY 71,% y1 O(R, 3 Y Official use only. Do not ivrite in this area, to be completed by city or town official. City or Town: Permit/License -Z 7- a)01el Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone #: www.mass.gov/dia May 22 2019 10:59:59 EDT FROM: F2M/57092559150 MSG# 1630053105-006-1 PAGE 004 OF 004 CERTIFICATE OF LIABILITY INSURANCE OATe (MMIOOIVYYY) 1 05/22/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(ios) must be endorsed, If SUBROOATIONIS WAIVED, subject to the terms and Conditions Of the policy, Certain pollcles may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu Of Such a dorsament(s), PROMOOP. OVNTRGY Ngm0.t PAYCHCX INSURANCE AGENCY INC 76210705 150 SAWORASS DRIVE ROCHESTER NY 14620 PHONe 877 287-181P ( ) ^ (AIC, NO, CXq: P^X (flee) 448-6112 (NC, NO): E•Mgll AD"^')ORUAES$: E INSURER(6) AFFORDING CDVERAOE NAICF INSURER A: Tile I'iorlford ACCident and Indelnnity Insurance Company 22567 INSURBo .w INOUReR a; CHAMBERLINE AVENUE ENTERPRISES DBA INSURER C; CATMAN CAFE 16 OLD COLONY RD INSURSRO; INSURER E: MANSFIE40 MA 02048-2118 (NSUR0 F ; CCAMRAr9FR CFGTIFIC ATE. NIIMRFR• RFVIRIr1M MIIMRFRI THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURES NAMED ABOVE FOR THE POLICY PERIOD I1,10I0ATEO,NOTWITHOTANDINC ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOOUMENT W TH AaOPEOT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OBSCRIBEO HEREIN 1`i SV8JEOT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCES BY PAID CLAIMS. IN k TYPQ OFINSURANCQ DDL Us WVD NOUCY NVMneI{ POLICY I IV POLICYa M I O W LIMITS GOMMERCiPI GENrE�RA'yL LIABILITY EACH OCCOPRENCE CLAIWwAW 0000E � Nam'' — P' 45 t' r I nnn. MED EXP (Any oAS rRlgm) kt Z' tSV �NJ-UP.7""' C.GN'1. AOORCr ATC LIMIT APPLI Ve PCP: CCN6OAL A&'W _*A'YE POt.IGY ❑ 0- Q LOC PRODUCTS • COMPIOP AGG OTI4ER: AUTOMODILC LIAOILITY (%OMBINEO SINGLE LIMIT RY (I", ANY AUTO ALL OWNED SoH6OULED AUTOS AUTOS RY (P<r OxlUaat) DAMAGE HIRED NON -OWNED AtfrOS AUT05 FEACH M9Ar"A LIAO OCCUR RRRNCreXOQA3 E UAo C.LAIMF. MADE ED RETENTION $ WORKERS COMPENSATION AND 6MPLOYER6' LIABILITY P4SE X OTH" ' A v' " EL EA01I'1 ACCIDENT $1,000,000 ANY YIN A PROPRiemOW AFTNfMIBXEVUTIVE UFNIGEWMEMnER eA LUODOT NIA 76 WEG AD1 N56 04/02/2019 04/02/2020 C. L. DIGLf1:•C CA QMPLOYC19 $1,DDQ,DBD IManaatory In NHl --------— Ifypf,opTanppondnr E L DISEASE..- POLICY I.IMIT y110001000 OEEUJUPTION OF OPERATIONS bM:'loN bEH0A1PTIPN OP OA5NAVONS1LOCATIONA/VF.HICLEB(ACOAO Of. Additional Remnrku st.0111e, miry be"R Aad IY metre •Pees Ic rogvlwdl Tnose U$V81 to tile In$Ured'S Operell0ne. Board Of Health - BEFORE THE 144XPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED MAIN ST IN ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD MA 02048 AOT`NORIZED RVP+ReSRR+NTATIVP (E) 1000-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and lope are registered marks of ACORD NATIONAL, REGISTRY OF FOOD SAFETY" PROFESSIONALS® CERTIFIES'-: STEPHEN .J CERUL LO ' HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE , CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: E LAw RENCE J. 1...YNCt-i, CAE Notification of Test Results ID#: xxx-xx- Scaled Test Score: 78 Candidate Status: Pass Test Date: April 15, 2019 Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. Preventing Contamination and Cross Contamination (Competent) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product'rime and Temperature (Needs review) Conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Needs review) ISSUE DATE:,APRIL I5, 201 9 EXPIRATION DATE APRIL.15, 2024. CERTIFICATE No:21572438 TEST FORM: EZS44 This certificate k not vgid for'more than five year fin. date of iuue: National Registry of Food Safety Professionals CERTIFIED FOOD SAFETY MANAGER. STEVREN , J CERULLO, STEPHEN J CERULLO 19 WAMPUM RD NORTON, MA 02766 C.tifieate No 2157208 14sne'Date: Apti1 15, 2010 Expiration Date: April 15, 2024 National Registry of Food Safety Professionals® 1 6751 Forum Drive Ste 220 i Orlando, FL 32321 1 Phone: 407.352.3830 1 Fax: 407.352.3603 2 I \� \ \ \ ( / � , o ) \ ƒ a & \ )\)(\ / m \\tl )\}�( )` \ t&s3 « � /