HomeMy WebLinkAboutCafe on the Common - 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:.
DIANE BEATTY, PRESIDENT
Whose place of business is:
CAFE ON THE COMMON, INC.
12 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
BILL FISHER
Permit Expires: December31,2019
Food Fee: $250.00
License Number: FS -4
BOARD OF HEALTH
NichaeCifeatey, Chairman
ri
Milk & Cream
FOR BOARD OF HEALTH USE ONLY Permit -
FOOD ESTABLISHMENT PERMIT APPLICA
(Application must be submitted at least 30 days before the planned
OCT 2 3 2V m0
date)
Establishment Name: J /�
Establishment Address: !a �$�yfi i %Gil Y1�{Yz'e� %i7QrYld / 1'�?� {4fA ivy
Establishment Mailing Address(if different):
0/0 ,D1ane ad-41NV, /loAdu6n-
Establishment Telephone No.:5og•339.9i3ok+,&w%iAvnU0�0
wd-/
-
Applicant Name &Title:J>UnC Bea+ yl, Pre6tdeH,-
Applicant Address: I& ,4u t4,bP-v, Dr' Wa, k6L-
Applicant Telephone No.: Ce( 6,03.8'/7.10W 3 24 Hour Emergency No.: 5GC In ¢—
Applicant E-mail: „t ire bea4-4
Owner Name & Title (If different from applicant):
Owner Address:
j Owner Telephone No.:
i
Owner E-mail:
Establishment Owned By: ( If a corporation or partnership, give name, title, and home address of officers or
0 An Association partner.
corporation Name Title Address
D An Individual\(,S
O A Partnership����
0 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: E i p 4: S!;kalr
Address: :30 q)) Cr__0-ry p—&,
Telephone No: �%7H - Sa (p • 9as 3 24 Hour Emergency No:
FAX:
E-mail: bi/�'Y qq& a' yc,
Alt E -Mail: �`� . _ 1 P� ,'t[� �� ('C • ��y �. �
District Or Regional- Supervisor (if applicable)
Name & Title:
I
Address:
Telephone No: 24 Hour Emergency No:
FAX: --�
E-mail:
Food Establishment Information
WATER SOURCE:'1&9!, SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) N0. of Food Employees / . ,
DAYSIHOURS: cD 1 YY1— J Pm "G' f 5 `� 6""✓"+$
Name of Person In Charge bertified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
Person Trai d Anti -Choking Procedures (If 25 Seats or more):
Location: L4-10 nnanent Location
Establishment Type
Caterer $35.00
❑Mobile Mobile Start Date:
Lj Retail ( Sq. Ft)
P.Milk & Cream $10.00
Mobile End Date:
Mobile Comments:
Food Service up to 100 INCLUDING
FOOD TRUCKS $175.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00 '..
�od Service up to 101 -200 $250.00
i] Food Service up to 201 + $300.00
Ei Manufacture Frozen Dessertslice Cream
$25.00/freezer
❑ Pushcart $50.00 # of Pushcarts:
Length Of Permit:
on g
;wt<nnual
Seasonal
Seasonal Dates:
❑ Supermarkets $400
Q Residential Kitchen $100.00
Retail Food $125.00
i] Retail Snack Food $50.00
-a-Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations Definitions:PHF- Potentiallyhazardous food(timeRemperatum controls required)
Non-PHF's - non -potentially hazardous Pood(no time/temperetme controls required)
(Check all that apply): RTE -ready -to -eat foods (Ex. sandwiches, salads, mu/fins 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
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Other Food Operations
'PHFCooked To Order
Preparation of PHFs For of And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Q Customer Self -Service
El Ice Manufactured and Packaged for
Retail Sale
E] Juice Manufactured and Packaged t
Retail Sale
Lj Offers RTE PHF in Bulk Quantities
E] 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 n 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 CMR 590.ODD and the feder Food Code.
Signature of Applicant: �� /rYh.( % /–]X / T d ;1,01n
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of pe that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Signature of Individual or Corporate Name:
Social Security Number or Federal ID:
El 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
E] Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
E3 Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
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 porate Name By: Corporate Officer (Mandatoni, i Applicable)
15q — 355,;oy 31
"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:Ulsers\sleite\Desktop\ScoWs 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 Print Lezibly
Business/Organizatioonn,N•ame: l Ql L' ��1 �'►K �df�lL�mM G'
Address: IQ �( ylni%ga*o� �'�
T p
City/State/Zip: eX Dr % y Phoone #:
Are you an employer? Check the appropriate box:
Business Type (required):
�I am a employer with _/_� employees (full and/
5. E] Retail
or part-time).*
6. J�Mestaurant/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.
8. ❑Non-profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their tight of exemption per c. 152, §1(4), and we have
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
I1.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
1 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 N.
I am an employer that is providing workers' compensa#n insyfance for my employees. Below is the policy information.
Insurance Company Name:
/ Iko 7T76L.'r 7- ICE 1 dt
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. # UQ __14/ a L.
Attach a copy of the workers' compensation policy
Expiration Date: OH
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 pena]tles of perjury 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
www.mass.gov/dia
Phone
12 (Policy Provisions: WC 00 00 00 C)
62
NK INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: TWIN CITY FIRE INSURANCE COMPANY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 14974
Company Code: 7
tily
4�
4u
HE
ARTFORD
Suffix
LARS RENEWAL
POLICY NUMBER: OB WEC NK6212 13
Previous Policy Number: OB WEC NR6212
HOUSING CODE: DW
1. Named Insured and Mailing Address: CAFE ON THE COMMO C
(No., Street, Town, State, Zip Code)
16 AUDOBON RD
FEIN Number: 043552431 WALPOLE, MA 02081
State Identification Number(s):
UIN:
The Named Insured is: CORPORATION
Business of Named Insured: RESTAURANT FAMILY STYLE: FRANC
Other workplaces not shown above: 12-14 MAIN ST
MANSFIELD MA 02048
2. Policy Period: From 04/01/18 To 04/01/19'-
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: UNDERWRITERS INS BKGE INC/PHS
301 WOODS PARK DRIVE
CLINTON, NY 13323
Producer's Code: 088324
Issuing Office: THE HARTFORD
301 WOODS PARK DRIVE
CLINTON NY 13323
(866) 467-8730
Total Estimated Annual Premium: $7,148
Deposit Premium:
Policy Minimum Premium: $267 MA (INCLUDES INCREASED LIMIT MIN. PREM.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by �""") 02/01/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 02/01/18 Policy Expiration Date: 04/01/19
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for successfully completing the standards set forth for the Seo.Safea Food
which is accredited by the American National Standards InsliNle (ANS
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which is accredited by the American National
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DATE OF I
local lays apply.
m Manager CerAfication Examination,
rence for Food Protection (CFP).
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EXAM FORM NUMBER
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DATE OF EXPIRATION
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