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HomeMy WebLinkAboutThe Store - 12/31/2021CIO 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 e Arf, �pq C I ��� � � f ! e sro f2 Establishment Address Q / � c d 0 f yj� 1 / i f7 S )Qk) (� /t c lcis Ni.4 C1 r Establishment Mailing Address (if different) Establishment Telephone Applicant Name & Title: f f , (I tf i,Y7e$Y f De-W ) Applicant Address 110 /y)r-fI26f Applicant Telephone No.: 07 _ �� f c f .2 qi� 24 Hour Emergency No. Applicant Email l )`kt�St � � 1 /SV "I Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: i An Association ` , A Corporation !An Individual A Partnership Other legal Entity cl`7 6 If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address '4b fro%vfr � , ��c �Ic Y 110 �'� o'yol O Sr Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: eS /, /C C210 CT Address:tCy,/I dT) C%fGi� Telephone No: �f C� ,2 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: WATER SOURCE: �7'DW11 DEP Public Water Supply No: (If applicable) Food Establishment Information SEWAGE DISPOSAL: 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 Tito o C 5f- 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? N 0 If yes, please attach the FOG permit application. Length of Permit: Annual Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type: Retail Food $125.00 _ Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 Food Service up to 201 + $300.00 Supermarkets $400 `/f-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 # of Pushcarts: Residential Kitchen $100.00 -j Caterer$35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no timalemperature controls required) (Check all that a PP Y) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs -j. 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 PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations PHFCooked To Order is Preparation of PHFs For Hot And Cold Holding For Single Meal Service ''. Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service ;'. Ice Manufactured and Packaged for Retail Sale Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 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 i. Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw Or Undercooked Food Of Animal Origin -', Vacuum Packaging / Cook Chill Prepares Food/Single Meals for Catered Events or Institutional Food Service 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 and the federal Food Code. Signature of Applicant: T ._ 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 ID: Signature of Individual or Corporate Name: __. _ Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185-DD00 Workers Compensation and Employers Liability Insurance Policy Carrier Polic #: Policy Period 014005032484120 01/01/2020to 01/01/2021 Information Page FEIN: 043521128 Renewal Policy Carrier Prior Policy #: 014005032484119 Item 1: Named Insured and Address Agency Kanku, Inc. HUB NE Association Programs The Store 300 Ballardvale Street 213 South Main St. Wilmington, MA 01887 Mansfield, MA 02048 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation FederalID#: 043521128 Risk ID: 000000000 NCCI / Bureau #: 34355 Unemployment ID #: File #: 014005032484120 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Pan Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000.00 each accident Bodily Injury by Disease $ 500,000.00 policy limit Bodily Injury by Disease $ 100,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000414A(01/19), WC000422B(01/15), NOE(01/01), WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13), WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code # Premium Basis Rate Per $100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $ 220.00 $ 466.00 $ 466.00 $ 0.00 $ 0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: () Braintree MA 02185-0000 12-30-2019 Form # WC 00 00 01 C (Ed.) 0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Peas, 1 of 1 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: PGA/xllC_d Q\t c ; W l) / A- '% r— _�>'%U 12 F_ Address: 2 /3 C 6 U1- /i')G-ii1 ST City/State/Zip: Ir✓lrh- 02x11fV Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with employees (full and/ 5. [0 Retail or part-time).* 6. ❑ RestaurantBar/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 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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 Name: H()3NC I+SSS nC t /I2TOnl P/L 0 6-2 AM-5 Insurer's Address: 3dO f3ALi_#12-DVALE Sr City/State/Zip: Z MA} 6/ 7 Policy # or Self -ins. Lie. # ©//Vl.) o C2U3 2.14 Sr bt / 2--Q Expiration Date: 202 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. Signature: H ' /� ` en, PA Date:/ o / % -- 12 0 2 U Phone #• 156 2d — 3 3 <l �S~b Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact www.mass.gov/dia Phone 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. LZACCL t> Signature of Individual or Corporate Name By: Corporate Officer (Mmidatory, if Applicable) 024__?) , _S_2— I12�,— "Social Security No. (Voltmtary) 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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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. X 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. X 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. -1 1_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 ` % C 'i Date: /0 f / ? 2 f Applicant Name (please print clearly) / 1 om' S f'S /' U ftt 1` dpC ' "