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HomeMy WebLinkAboutCat Man Cafe - 12/31/2019m Commonwealth 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:. STEPHEN J. CERULLO, PRESIDENT Whose place of business is: CAT MAN CAFE 16 OLD COLONY WAY PERSON(S) IN CHARGE: STEPHEN CERULLO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-6 BOARD OF HEALTH MichaeCHeatey, 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: O4kvy'u.A 06'�2 Establishment Address: kU Oro �QiOVs4 VV\QVt&fILFLO Establishment Mailing Address (if different): Establishment Telephone No: jt) ? 5' 9 -0U 3 �? Applicant Name & Title: cow010 P.30V+On/ AAA 011b6 Applicant Address: 1C( WCim(�uv Applicant Telephone No.: S(�4 �( S� 3 24 Hour Emergency No.: Applicant Email: hc2rv((a CA (AMCOAII,UE 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 ❑ F5n Association partner. A corporation ❑ An Individual20Va Name Title _ Address ❑ A Partnership ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title:��q� 2�v.�UiV Address: vi "" V 114 v��(u 3,' Telephone No: 24 Hour Emergency No: O`( 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: DEP Public Water Supply No: (if applicable) SEWAGE DISPOSAL: No. of Food Employees: DAYS/HOURS: 30_ t A 00 Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Ch n e 6 Uf\4t�.2 Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ Location: ® Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: Establishment Type: ❑ Retail -NO FOOD PREP ( Sq. Ft) $124 F Food Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 ❑ Food Service for 101 -2 seas ❑ Sup Service for 201+ seats $300.00 ❑Supermarkets $400 ❑ C erL $35_00 ❑ Milk & Cream $10.00 ❑ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $50.00 5 .0Pushcarts: ❑ Residential Kitchen $100.00 ❑ Tobacco Products $150.00 ❑ Retail Snack Food $50.00 Length of Permit: 9 [9 Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions: PHF- Potentially hazardous food(time/temperatme controls required) Non-PHFs - non -potentially hazardous food(no thoMemperature controls required) RTE-ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of. Commercially Pre -Packaged Non-PHFs gPHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs Mpreparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer UReheating of Commercially Processed Foods for Service Within 4 Hours ❑ 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) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self-service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Nan-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ 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 ❑ 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 590.000 aAd the federal Food Code. Signature of Applicant: ✓ Pursuant to MGL Ch.62C, sec. 49A, I certify un er the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid slate taxes required=deal Social Security Number r F:V i3 ,� /ry� �+�Signature of Individual orName: (_Q 1 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 0 k4 3 5T CQ 3 �-o **Social Security No. (Voluntary) 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. R:\Hm1thVane's DocumentsTERMIT APPLICATIONS\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 Legibly Business/Organization Name: eg} o ao QLLV--9_ Address: SU CI \p Q0Uw( City/State/Zip: 1 C-U)S& LO #: s-w 33c� — 0oW Are you an employer? Check the appropriate box: Business Type (required): employees 1. [r I am a employer with (full and/ 5. Retail part-time) 6. [i2 l�estaurant/Bar/Eating Establishment 2. ❑ a so a proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. S. 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]* ILL] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 121-1 Other with no employees. [No workers' comp. insurance req.] *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: k M tat•e Y -:rNS Insurer's Address: K0 `Jccvj b a A 5t li P . R J(%s es 4e 2 .N w City/State/Zip: Policy # or Self -ins. Lic. # V �" �p� �g �� 3 4Z-11' Expiration Date: -Z- 2s' Zulu' 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. - . R: Z'..,,I_ �__ n ( o, A rtatP- 1,) I -I ' ZJ I '? Phone #: �-OJ _77,f -dry 3if 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 11/20/10 14:30:11 505-305-6666 -> 500 339 9524 RF Connect Page 002 CERTIFICATE OF LIABILITY INSURANCE 11120120TE 18 YV 1 1 /zo/2o 18 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. It 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 endorsement(s). PRODUCER PAYCHEX INSURANCE AGENCY INC NOAMTAC7 PHONE FAX (A/C No Eft (fi➢7) 362-6795 (A/C No): (8]]) 677-0947 E- I ADDRESS: p.y.hex@tavelers.com INSURER(S) AFFORDING COVERAGE NAK:# 150 SAWGRASS OR ROCHESTER, NY 14620 (877) 362-6785 INSURER A: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT INSURED CHAMBERLAIN AVENUE ENTERPRISES INC DBA CATMAN CAFE INSURER B INsuRERc: INSURER 0: 16 OLD COLONY'RD INSURER E: MANSFIELD, MA 02048 INSURER F : COVERAGES CERTIFICATE NUMBER: 261468105590423 REVISION NUMBER: 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN _SR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUM13ER POLICY EFF MM/DD/YY POLICY EXP MWDD/YYV LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGETO FIENTEO PREMISES Ea oc. rmgge�,f_ $ MED EXP AnY onePerson) $ PERSONAL B ADV INJURY $ GEML AGGREGATE LIMN APPLIES PER: POLICY [::]JERC LOG OTHER: GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY NON -OWNED HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B (Eaaaacoid COMBINED SINGLE LIMIT ccident $ BODILY INJURY(Pe(person) $ BODILY INJURY (Per accidenQ $ PROPERTY DAMAGE (Per accklenQ $ UMBRELLA LAB EXCESS LAD OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE O OFFICEILMEMSER EXCLUDED? (Mandatory In NH) If yes, describe under DESCR IPTION OF OPERATIONS be. N/A UB-6G617342-18 02/08/2018 02/08/2019 -:-. x STATUTE ORTH- E.L EACH ACCIDENT $100,000 E.L DISEASE - EA EMPLOYEE $100,000 E.L. DISEASE -POLICY LIM IT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 CONGRESS ST. STE 100 BOSTON, MA 02141 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 cc119RR.9n15 ACC)RO CnRPCRATION. All riahfs reserved ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A c"R" n CERTIFICATE ©F LIABILITY INSURANCE DATE (MMIDDIYYYV) 11/06/18 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 endorsement(s). PRODUCER Barrows Insurance Agency, Inc. 216 North Main Street Mansfield, MA 02048 CONTACT NAME: Muriel Studley AHC HONE, Ezt: 606-339-7260 n/c, No: 508-339-9624 noDRless: info@barrowsins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hospitality Mutual Ins Co INSURED INSURER B: INSURER C: Chamberlain Avenue Enterprises Inc dba Catman Cafe 19 Wampum Road Norton, MA 02766 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSO MD POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE [X OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP (Any oneperson) $ 6,000 PERSONAL &ADV INJURY $ 1,000,000 A 00101170GL 04/16/18 04/16/19 GEH'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ PRO- ❑ JECT LOG PRODUCTS -COMPIOPAGG 8 2,000,000 $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODI LY I NJURY(Per person) $ ANY AUTO OVJPIED SCHEDULED AUTOSONLY AUTOS HIRED NON OWNED AUTOSONLY H AUTOS ONLY BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LAG OCCUR EACH OCCURRENCE $ 7fEXCESS AGGREGATE $ LIAB CLAIMS -MADE DED 177[RETENTION$ 8 _ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OH STATUTE ER AIJYPROPRIUOR/PARTNER/EXECUTIVE❑ E.L. EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE-EAEMPLOVEE $ It yes, describe under DESCRIPTION OF OPERATIONS below I I E.L. DISEASE- POLICY LIMIT $ Per Occurrence $600,000 A Liquor Liability 00101171LL 04/16/18 04/16/19 Aggregate $600,0001 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All rinhtc reeerved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD O N O N N N N N N N N O Z W F a V U. F W v C O O u � U C O •0 C V •a � 0 U a O d u. a o u u c c N B c w o U gz L2 Q o � ° W 9 � p� V o 0 0 c o N `a � Z -a° a c u g 'c die LLJ s Q � o C S N �T o m N xs wu u a a O 0 ° O p o u CK / ( / .\ \ ƒ \ \ / ƒ \ 14. \ \ \ \ \ ± .��k�\�) ©!}a&, / \/ \ ƒ « } J®!a & \ /\� S t3 \ � / FLYNN PEST CONTROL, INC. 32 ANAWAN ST., RT. 118 REHOBOTH, MA 02769 508-252-9661 1-800-237-BUGS PEST MANAGEMENT SERVICE REPORT Customer / - r ,'- TYPE OF SERVICE Address a ❑ FOG-ULV or SMOKE Bldg. ❑ INITIAL. ❑FOLLOW UP Time in t Time Out ❑ REGULAR Date � " ❑ OTHER SERVICES PROVIDED & FINDINGS 1 TARGET PESTS = CERT. l i i. i NO.OFTECHS ' TECH INIT i r z r SANITATION CONDITIONS/MAINTENANCE RECOMMENDATIONS: Product used % Active In rg edent T Quantity Equipment Replaced Quantity E.P.A. #s Yes No ❑ ❑ = Lot clean - free of harborage ❑ ❑ = Bldg. free of holes ❑ ❑ = Doors rodent proof/windows screened ❑ ❑ = Storage 1 ft or more from walls ❑ ❑ = Storage area clean, free of spillage ❑ ❑ = Storage off floor ❑ ❑ = Rodent bis insp. cleaned ❑ ❑ = Interior Insp. ❑ ❑ = Exterior Insp. ✓ Yes X No Tech Signature: Cert. Number: Cust. Signature: Total Fee NOTIFICATION = SIGNS POSTED