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Home My WebLink AboutHilliard's Chocolates - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION 1202, (Application must be submitted at least 30 days before the planned opening data) y Establishment Name Hilliards Chocolates LLC Establishment Address 333 School Street, Unit 13150 Establishment Mailing Address (if different) 316 Main Street, North Easton, MA 02356 Establishment Telephone No 508-339-5333 Applicant Name & Title: Gordon C. Scott, Member and Manager Applicant Address 316 Main Street, North Easton, MA 02356 Applicant Telephone No.: 508-238-6231 24 Hour Emergency No.: 508-479-4902 Applicant Email gordon@shakervalleyllc.com Owner Name & Title (if different from applicant) Jonathan S. Kasen, Member and. Manger Owner Address 316 Main Street, North Easton, MA 02356 Gordon C. Scott, Member and Manager Owner telephone number 508-238-6231 Owner email: jonathan@shakervalleyllaarm gordon@shakervaileyilc.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or • An Association partner. • A, Corporation Name Title Address 11 An Individual Jonathan S. Kasen Member and Manager 42 Dartmouth St., Boston, MA 02116 Gordon C. Scott Member and Manager 87 Forest Ave., West Newton, MA 0 A Partnership N Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Maegan Dec, Vice President Address: 316 Main Street, North Easton; MA 02356 Telephone No: 508-238-6231 24 Hour Emergency No: 508-479-4902 FAX: 508-238-2389 E-mail: maegan@hilliardscandy.com Alt E-Mail: NIA District Or Regional Supervisor (if applicable) NIA Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: M 465 Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town No. of Food Employees: 19 OEP Public Water Supply No: (if applicable) DAYSIHOURS: Mondays to Sundays Name of Person(s) In Charge Certified in Food Protection Management: Tamrah Comprone Name of Person(s) In Charge Certified in Allergen Awareness Training Tamrah Comprone Name of pest control company routinely inspecting the premises for evidence of pests Burgess Pet Mgmt. people or more, a person trained in manual choke saving procedureswili be onsite at all times food is being prepared. L-] Yes N/A Does this establishment require a FOG permit? N/A If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual [A Retail Food $125.00 Mobile Food Consesslon Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 El Manufacture frozen Desserts/ice Cream Temporary Stan Date: Food Service up to 161-204 $250.00 $25.00/freezer Temporary End Date: 0 Food Seance up to 201 + $300.00 LJ Pushcart-$50.00 # of Pushcarts: Temporary Time: Q Supermarkets $400 �. Residential Kitchen $100.00 Rain Date: n.Milk &Cream $10.00 Caterer $35.00 Food Operations: pefinurons:PHF - Potenitally hazardous food(dmutemperatma conines required) NomPHF's-non-pofenually hazardous foodfno dmaifemperafure wnhois required) (Check ail that apply): RTE -matly-toeei Nods fEx.sandwiches, salads, .muffins which need no Portherprocessing) Sale of Commercially Pre -Packaged Non-PHFs iE] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service of PHFs For Hot eatAnd Se Sale of Commercially Pre -Packaged PHFs ❑. Cold Holding Cold Holding For Single MeafService ❑ PHF and RTE Foods Prepared For Highly Q Delivery of Packaged PHFs Susceptible Population Facility ❑. Sale of Raw Animal Foods Intended 0 Reheating. of Commercially to be Prepared by Consumer ❑ Use of Process. Requiring A Variance Processed Foods for Service Within 4 Hours andfor HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- ® Customer Self-service contact alternative, time as a public health Perishable Foods Only 0 Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale [] Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Q Vacuum Packaging./ Cook Chill El Offers RTE PHF in Bulk quantities Q Prepares'Food/Single Meals for Retail Sale of -Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information establishment operation will comply with 105 CMR 590.000 board of health on how to obtain copjpwa 105. CMRAO.q id affirm that the food I have been Instructed by the Signature of Applicant: �' ✓ Pursuant to MGI. Ch:82C, sec. 40A, I certify u t 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: 85-3284711 Signature of Individual or Corporate Name; Hilliards Chocolates 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. Halliards Chocolates LLC Signature of Individual or Corporate Name 85-3284711 "*Social Security No. (Voluntant) or Federal Identification Number By: Corporate OfiVer (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. CAUsenWeitODeskwp�9cotrs Documeniffood Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wo,mmass.gov/dia Workers' Compensation Insurance. Affidavits General Businesses Applicant Information Please Print Legibly Business/Organization Name: Hilliards Chocolates LLG Address: -9 l (tv M A rii,n $ it - Are you an employer? Check the appropriate box: i.0 I am a employer with 80 employees (full and/ or part-time),* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees, [No workers' comp. insurance required]' 4.n We are anon -profit organization, staffed by volunteers, with no employees. rNo workers' comp. insurance seq.] Phone #: 5 Ud� — Business Type (required): 5. ✓0 Retail 6. Q Restaurant/Bar/Eating Establishment 7, Q Office and/or Sales (me]. real estate, auto, etc.) & QNon-profit 9. ❑Entertainment 10.0 Manufacturing 11.0 Health Care 12.Q Other 'Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. **lf 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 91. I am an employer that Is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Name: Hanover Insurance Group Insurer's Address: 440 Lincoln St City/Staterzip: Worcester, MA 01653-0002 Policy # or Self -ins. Lic. # W HN H499632 Expiration Date: 2/1 /22 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 MOL 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 penahies ofperjury that the information provided above is true and correct 2/4/21 Official ase only. Do not write in tit is area, to be eampfeted by city or town offichil City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Contact 3. Cityfrown Clerk 4. Licensing Board 5. Selectmen's Office www.mass.govlcra Phone 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 onthe 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 (Le, 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 A+CORV CERTIFICATE OF LIABILITY INSURANCE DATEtMMro0 02/04l202121 THIS CERTIFICATE IS ISSUED AS 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 13 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 Morse Insurance: Agency, Inc. 285 Washington Street North Easton MA 02366 NAME: Karen Forrest 00 Ne 1508) 238-0058 ac Nu: (508) 230-8367 gooeEss: karenforrest,9morseins.com INSURER(S) AFFORDING COVERAGE NA1Ca INSURERA:. Citizens Insurance Co. of America 31534 INSURED Hilllards Chocolates LLC, USA: Hilllards House of Candy 316 Main Street ' Nonh.Easton MA 02356 INSURER B: Allmerica Financial Benefit Insurance Co. 41840 INSURER C: Hanover Insurance Company 22292 INSURER D : INSURER E: INSURER F: COVrRAGE9 CFRTIFICATFMIIMRFR! 21-22 REVISION NUMBER: THIS IS TO CERTIFY THATTHF:POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED, NOTWrrHSTANDING 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. LTR TYPE OF INSURANCE' N POLICY NUMBER MMNOAY' MWDFF OP/FYY LIMITS [AR COMMERCIAL GUNERALUASILITY CLAIMS -MADE Q OCCUR OBNH499638 02/01/2021 02/01/2022 EACH OCCURRENCE S 2.000,000 PREMISES Ea.Comence $ 300,000 MEDEXP(An .mi,muan) S 5,000. PERSONAL&ADVINJURY S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: X POLICY ❑, JJECI' LOC OTHER: GENERALAGGREGATE S 4,000,000. PRODUCTS-COMPIOPAGG S- 4,000,000 S g AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED. NON -OWNED AUTOS ONLY AUTOS ONLY AWNH499024 02//0112021 (001/2022 COMBINED SINGLE LIMIT Eaacr.Id.r0 S 1,000,000 BODILY INJURY (Per person) 5 BODILY INJURY War accident) S PROPEHTV DAMAGE Per Acddart S S A X UMBRELLA UAS EXCESS LIAB q-CUR CLAWSMADE OBNH499638 02/0112021 02/01/2022 EACH. OCCURRENCE $ 51000,000. 7 AGGREGATE $ 5,000,000 OED I X RETENTION S 0 S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN EXECUTIVE ANYPROPHIETORIPARTNEMW OFFICEREMDER EXCLUDED? (Mandatory in NHl Itym, describe under DESCRIPTION OF OPERATIONS below N/A WI-INH499632 02/Ot/2021 02/01/2022 X'STATUTE ER - E.L. EACH ACCIDENT g 500,000 E.L. DISEASE - EA EMPLOYEE. r S Er00.000 E.L. OISEASEPOUCV LIMIT S 50D,0DD DES(;MPTION OF OPERATIONS f LOCATIONS 7VEHICLES (ACORD 101,, Atlditummi Femmks Schedule, maybe attachedif more space Is required) LLC members, Gordon Scott and Jonathan Kasen, are not included for coverage under the workers' compensation policy. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6'Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 /j'ate4 ��`7�'�7' 01988.2016 ACORD. CORPORATION. All riehtS reSer ACORD 26 (2016103) The ACORD name and logo are registeredmarksof ACORD TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers, 41>I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1; 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing Testing and Materials) Standards for compostability, �'` J 1 have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. 61 S I have received a copyofthe Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Date:, z Applicant Name (please print clearly) [mot fXr�C?✓� J (A f �`