HomeMy WebLinkAboutSmoke & Squeal BBQ LLC - 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 Serviee Establishment
Type:
XFINITY FOOD PERMIT
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:.
Whose place of business is:
SMOKE AND SQUEAL BBQ, LLC
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ADAM BATCHELDER
Permit Expires: December 31, 2019
Food Fee: $125.00
License Number: XFS-30
BOARD OF HEALTH
MichaeCHeaCey, Chairman
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name SMOKE AND SQUEAL BBQ, LLC
2) Establishment Address 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 49 MAIN STREET
PAWTUCKET, RI 02860
4) Establishment Telephone No (617) 595-7646
5) Applicant Name & Title: ADAM BATCHELDER
6) Applicant Address 152 FISHER STREET, MILLVILLE, MA 01529
7) Applicant Telephone No.: (6»)596-7646 24 Hour Emergency No.: (617)595-7646
8) Owners Name & Title ADAM BATCHELDER
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By:
An Association
A Corporation
An Individual
A Partnership
6175957646
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title ADAM BATCHELDER
Address: 1152 FISHER STREET, MILLVILLE, MA 01529
Telephone Na (617) 595-7646
FAX:
E-mail: ADAM(cDSMOKEANDSQUEALBBQ
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
24 Hour Emergency No: (617) 595-7646
Telephone No: 24 Hour Emergency No:
1 FAX: 1E mail:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL TOWN
DEP Public Water Supply No (If applicable) 16) NO of Food Employees: 1
17)DAYS/HOURS: MAY-DECEMBER201
9-
18) Name of Person In Charge Certifie in Food Protection Management: ADAM F. BATCHELDER
If more than 3 individuals are certified, complete list is on file.
Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of ADAM BATCHELDER ALLERGEN 1-23-2
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: Permanent Location 22) Establishment Type Caterer $25.00
Moblie Moblie Start Date: 5/112018 Retail ( Sq. Ft) Milk & Cream $10.00
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
12/31/2018 Food Service up to 100 or
up to 10' PHF display $125.00
Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
Food Service - Institution
( Meals/Day)
Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
Retail Food $100.00
Retail Snack Food $25.00
Tobacco Products $25.00
23 Food O era
tions Definitions PHF- Potentially hazardous food (time/temperature controls required)
P Non-PHFs - non -potentially hazardous food(no ame/temperature controls required)
C1 Call that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
I 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 PHFand Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged for
Retail Sale
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
Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Offers Raw Or Undercooked Food Of
Animal Origin
PULLED PORK, BRISKET AND SAUSAGE _. ---_-- Catered Events or Institutional Food Service
SANDWICHES Offers RTE PHF in Bulk Quantities
1 Prepares Food/Single Meals for
Retail Select Salvage, Out -Of -Date _ _ ---
or Reconditioned Food i To be completed by the Board of Health
_- -__- Total Permit Fee: $125.00 -
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 ofj,0,5,QMR 590.ND-and the feOwal Food Code---.— -
24) Signature of Applicant:
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.
25) Social Security Number or Federal ID: 81-4959811
26) Signature of Individual or Corporate Name:
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 Officer (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.
RAHdthUane's Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
lop . 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
. Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LegibIy
Business/Organization Name: S2M,,L af—
Are you 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. ❑
1 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.
S. ❑ Non-profit
[No workers' comp. insurance required]
3. V1
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
11.0 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 #I 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 Nar
Insurer's Address:-
City/state/zip:
Policy # or Self -ins. Lie.
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 the pains and pens[ of perjury that the information provided above is true and correct
Offaial use only. Do not write In this area, to be completed by city or town official
City or Town:
PermitiLicense
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.mess,gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such' employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete, and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05
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Business Entity Name:
Smoke & Squeal BBQ Ile
Office, of the State Fire Marshal
560 Jefferson Blvd. Warwick, Rhode Island 02886
Telephone: (401) 889-5555 Fax: (401) 889-5533
MOBILE FOOD ESTABLISHMENT FIRE INSPECTION CERTIFICATE
BE IT KNOWN THAT
Mobile Food Establishment Owner:
Adam Batchelder
Millville, MA 01529
DBA (Doing Business As):
Smoke & Squeal BBQ
Name of Mobile Food
EstablishmentlTruck (If
different than Entity Name or
DBA:
DMV License Plate State an
Number of Truck/Cart/Traiit
or DEM Registration Numbe
71385
has met the requirements of the Fires Safety Code and has been granted this Certificate of Inspection as a
Truck which serves Prepared Foods
IN THE STATE OF RHODE ISLAND
Inspection Number: MFE-23 Issuance Date: April 15, 2019 Expiration Date: April 15, 2020
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S1 institute,"
We Make Protecting and Sav
Adam Batchelder
50 Constitution Blvd
Franklin, MA 02038
re: OSHA 10 Hour
Adam Batchelder
Congratulations on your
10 Hour General Indust]
which should be kept in
continued success in yc
Sincerely,
7
Scott Wallace
OSHA Program
Summit Training
ASHI, MEDIC First Aid', 24-7
Lives EasyTM
Industry Course
recent successful completion of SL mmit's OSHA
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3 safe Iocation.You have our best ishes for
jr safety efforts.
Inc.
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