HomeMy WebLinkAboutOld Country Store & Emporium - 12/31/2021FOR BOARD OF HEALTH USE ONLY5-lermit 9 Issued,!' IN
FOOD ESTABLISHMENT PERMIT APPLICATION
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(Application must be submitted at least 30 days before the planned openinqd1e)
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Establishment Name 0 r r
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Establishment Address rV po,
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: ('h V
Applicant Address C,
Applicant Telephone No.: "g I'- 74r Z( 24 Hour Emergency No.: C
Applicant Email Y-Y L11 -,fwl f_ /11 (_J, 1 7 61
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
D An Association
partner.
10 A Corporation
Name Title Address
1:1 An Individual
P_
El A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: (1-r
Telephone No: 24 Hour Emergency No:
FAX:
E-mail: ,j 4C
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:
DISPOSAL
=No.
r
DEP Public Water Supply No: (If applicable) (,;'L t
Employees:
DAYS/HOURS: ('Ut c'�j- ,{".'i
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
F
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Name of pest control company routinely inspecting the premises for evidence of pests
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. Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
[`Retail Food $125.00
Mobile Food Consession
Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
El Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
0 Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
El Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
E] Caterer $35.00
Food Operations: Definitions: PHF - Potentially hazardous food (timeRemperature controls required)
Check all that a I Non-PHFs -non-potentially hazardous food(no tlme/temperature controls required)
( PP y) RTE - roady-to-eat foods (Ex. sandwiches, salads, mums which need no further processing)
d Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
0 Delivery of Packaged PHFs Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
0 Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer
Use of Process Requldng A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only 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
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
0 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 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 aqAthe federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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: 2
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)
-! ` / 2,-7 C r- i 2,
"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:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1ri 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information
Please Print Legibly
Business/Organization Name: NV rc'✓,. V` c`
SAC yr�,
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p:4 /`_1 ps
Ci /State/Zi � �- .� Phone #:
Are you
an employer? Check the appropriate box:
Business Type (required):
5. fvj Retail
1.
I am a employer with ° employees (full and/
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑
I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (met. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
3.❑
[No workers' comp. insurance required]
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]*
I LE] Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
12.❑ 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:
Insurer's Address: I zel,
City/State/Zip:1
Policy # or Self -ins. Lic. # f (y ! ; t.7 C= 3_5- , 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 penalties of perjury that the information provided above is true and correct.
_. 11-4 /'g t't
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
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: Hartford Insurance Company of the Midwest
ONE HARTFORD PLAZA HARTFORD CT 06155
NCCI Company Number: 20605
Company Code: G
POLICY NUMBER:
Previous Policy Number:
Suffix
LARS RENEWAL
76 WEG GG3568 F —F 6
76 WEG GG3568
1. Named Insured and Mailing Address: OLD COUNTRY STORE & EMPORIUM, INC.
(No., Street, Town, State, Zip Code) 26 OTIS STREET
MANSFIELD MA 02048
FEIN Number: 27-1270212
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: All Other General Merchandise Stores
Other workplaces not shown above:
2. Policy Period: From 01/29/20 To 01/29/21 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: HARTFORD FIRE INSURANCE COMPANY
55 FARMINGTON AVENUE
HARTFORD CT 06105
Producer's Code: 76250805
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877) 287-1316 _
Total Estimated Annual Premium: $1,639
Deposit Premium:
Policy Minimum Premium: $260 MA (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by C"� 12/19/19
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 12/19/19 Policy Expiration Date: 01/23/21
INFORMATION PAGE (Continued) Policy Number: 76 WEG GG3568
3. A. V forkers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states
li:;ted here: MA
B. E mpioyers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
T he limits of our liability under Part Two are:
Bodily injury by Accident $500,000 each accident
Bodily injury by Disease $500,000 policy limit
Bodily injury by Disease $500,000 each employee
C. ('4her States Insurance: Part Three of the policy applies to the states, if any , listed here:
/,LL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES
DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. 1 his policy includes these endorsements and schedule:
;EE ENDORSEMENT -WC 99 03 68
4. TIr a premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Pl 3ns. All information required below is subject to verification and change by audit.
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
Total Standard Premium
Expeise Constant
Terrc'rism Risk Insurance Program Reauthorization Act Disclosure Endorsement
Estinated Annual Premium (before Surcharges)
Total Estimated Surcharges
"See the attached Schedule(s) of Operations for Location and State Level Premium Information
Total Estimated Annual Premium: $1,639
Deposit Premium:
Policy Minimum Premium: $260 MA (includes Increased Limit Min Prem.)
Interstate/Intrastate Identification Number: Refer to Schedule of Operations
NAICS: 452990
Lab�)r Contractors Policy Number: SIC: 5399
$1,204
$338
$49
$1,591
$48
Fort-i WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 12/19/19 Policy Expiration Date: 01/29/21
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.
-LLLi 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.
[_� I 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.
t 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. 1 understand
violations of this bylaw will result in fines.
Applicant Signature' `%''�� � Date:
>?n'J nr—
Applicant Name (please print clearly) 6' �`.