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Home My WebLink AboutFamily Food Mart 12/31/2021P �$ I y� T FOR BOARD OF HEALTH USE ONLY Permit #Issued L',. EQOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name t V i o} AWgAH 0 T7 o I 'T C�P - GC h h (. F/) rrl 1 L f F0,,1� M 0-p % Establishment Address �Go � � .5�itnISG1 �L1� 110 o 2-i,' Establishment Mailing Address (if different) Establishment Telephone No S o d- 3 3 9 '2 G� 5 Applicant Name &Title: PIP F}lUAV f01-71C2 ot✓I`I/�_R Applicant Address I)-.? . �_(,Mc, (1,1 i) - PP) -L( 6 oig-iod. Applicant Telephone No.: S frj 6 it 2 yl 24 Hour Emergency No.: 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 LlVnAssociation partner. A Corporation Name Title Address 0, An Individual _ ID A Partnership F1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: J��`GnuV A 10UJnei✓- Address: 19 a . til Mcnf/ �/ j -� 4- s, i Telephone No: 91 I'1 SK ( ' G 2 24 Hour Emergency No: FAX: / E-mail: O)elvlgvl�' f� t iy 1-tiG (9 a I rr " Dcf It 0 n 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: T of 'O SEWAGE DISPOSAL: -[�'W DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests C,Lif} AI31A I-( U 3 H lPy1 If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. L] Yes Does this establishment require a FOG permit? ),I a If yes, please attach the FOG permit application. Length of Permit: Establishment Type: `* Annual [�!I] Retail Food $125.00 n Mobile Food Consession E] Temporary El Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: (] Supermarkets $400 [I Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF - Potentialy hazardous food(time/temperature controls required) (Check all that apply): Non-PHPs- non -potentially hazardous leonine time/femperalure controls required) RTE- ready-lo-eat-foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) r3] Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held U. Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service El Delivery of Packaged PHFs Cold Holding For Single Meal Service L] PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Reheating of Commercially Susceptible Population Facility to be Prepared by Consumer Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance El Customer Self -Service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only [] Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale P ❑z Otters Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging / Cook Chill Offers RTE PHF in Bulk Quantities I1 Prepares Food/Single Meals for El 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 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 cppigs of 105 CMR 590.000 and the federal Food Code. 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. Social Security Number or Federal to: Signature of Individual or Corporate Name: S TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, 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) 461-S14-45( *"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:\Users\sleite\Desktop\Scou's 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 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ,) i v y 61 /tr k H o Li n J yo 1 � C— P Utz rn> ti`/ O (1 e- ( Address: G 6 O Eg S r S� City/State/Zip:MQ Yl61•elr t M 6k 010 1 Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ff] Retail or part-time).* 6. ❑ Restaurant/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. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 101-1 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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' compensation insurance for my employees. Below is the policy information. Insurance Company Name: f nv f}Yz 0 h/ 15 q -d 4 t e-- Insurer's Address: P O 6- )( U " /-i City/State/Zip: wl (UdA 0c/Y-r`e PO ' 0-03 - 062 O Policy # or Self -ins, Lie, # Dior I a Y l-�9 Expiration Date: " 1 I Is I a 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 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 Zu 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 #: OP ID: TL FAMIF01 �CORo CERTIFICATE OF LIABILITY INSURANCE DArE,MN„oDYYYY, 10/29/2020 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 terns 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 endorsements . 508-947-1818 PRODUCER J.K.OlivieriIns. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivieri cONTACr Kenneth W. Olivier! NAM FA% PHONE 508-947-1818 ac,uo: IAIC, Na, EXI AE ASS: INSURER R AFFORDING COVERAGE NAM # INSURER A: Guard Insurance NSU ED FIam, Y Food Mart Divya Akhand Jyoit Corp 660 East Street Mansfield, MA 02048 INSURERS: INSURER C: INSURER D: INSURER E : INSURER F COVERAGES CERTIFICATE NUMULK: '•"'-'-" BELOW HAVE BEEN ISSUED TO THE INSURED "-'-'-- - NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS DL UBR POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER 1,000,000 NERAL LIABILITY COMMERCIAL GE000 EACH OCCURRENCE TO RENTED $ $5,000 CLAIMS -MADE ❑X OCCUR PREMISES fEa S 000 5,ded A X Business Owners DIBP183009 05/12/2020 05/12/2021 MED EXP An ana rson $ Included PERSONAL B ADV INJURY s 2,000,000 GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 X POLICY ❑ zcl LOC PRODUCTS-COMP/OP AGG $ T a OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE UABILRY E emiden BODILY INJURY Per rson S ANY AUTO SCHEDULED BODILY INJURY Per accident S PROPERTY AMAGE Per acmtlent $ AUTOSAUTOS pp NA ToOONLY UDEDRETENTIONI$ EACH_OCCURRENCE $ OCCUR CLAIMS -MADE AGGREGATE $ IONS PER OTH- X STATUTE R A WORKERS COMPENSATION AND EMPLOYERS'LWBILRY YIN DFWC128759 0411512020 04115/2021 E.L. EACH ACCIDENT $ 5001000 ANY PROPRIETORIPARTNER/EXECtITIVE NIA $D9,DDD OFFICER/MEMBER EXCLUDED? E.L DISEASE- EA EMPLOYE (Mantlatory in NH) 500,000 Ilyes,descdbeunder EL DISEASE - POLICY LIMIT DESCRIPTION OP OPERATIONS below DIBP783009 05/12/2020 05I12/2021 See Limits A Business Owners Below Liquor Liability DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addificnal Remarks Schedule, maybe attached If more space Is requlred) Liquor Liability Coverage: 11,000,000 Each Common Cause Limit 2,000,000 Liquor Liability Aggregate Limit 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. REPRESENTATIVE 0 on.rc Ar non cnRPnRATIf1N_ All riahts reserved. ACORD 25 (2016/03) - The ACORD name and logo are registered marks of 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. 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 and Materials) Standards for compostability. LI have received a copy of the Polystyrene Container Reduction bylaw. I understand my esponsibility 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. I have received a copy of the 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: Applicant Name (please print clearly) �}� CA V rCi let