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Home My WebLink AboutTown News (Vasudev Corp.)- 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening _ Establishment Name Town News Vasudev Corp. 4AY?& Establishment Address 165 North Main Street, Mansfield,MA, 02048 Establishment Mailing Address (if different) 503-339-6744 Establishment Telephone No Applicant Name & Title: Dinesh Patel 4 old stable drive mansfield,ma,02048 Applicant Address 7742664631 Applicant Telephone No.: 5089828177 24 Hour Emergency No.: Applicant Email pdinesh68@yaho.com 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 ❑ A Association partner. corporation binesh Patel Owner dd 4 old stable dr,mansfield,m ❑ An Individual ❑ A Partnership Anjana Patel Shareholder 4 old stable dr, ❑ Other legal Entity I man s#teld; Ma D2048-- Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Dinesh Patel ,owner Address: 4 old stable dr, , Mansfield,MA,02048 Telephone No: 5089828177 24 Hour Emergency No: 7742664631 FAX: E-mail: pdinesh68@yahoo.com Alt E-Mail: pdhruv22@gmail.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) NO. of FOOdEmplOyeeS: 2 DAYS/HOURS: mon-sat 5:30 am to 9:00 pm , Sunday 6:30 to 8:30 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 601111 PC S7 &A 41, 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: nnual lwll etail Food $125.00 ❑ Mobile Food Consession ❑ Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑ 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 ❑Residential Kitchen $100.00 Rain Date: ilk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHPs-non-potentially hazardous food(no time/lemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) a e of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held E+�of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand ❑Customer Self -Service ❑ 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-PHFRetail Sales ❑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 ❑ 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 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 ID: Signature of Individual or Corporate Name: Vasudev The Commonwealth of Massachusetts _ Department of Industrial Accidents l l� Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lev_ibly Business/Organization Name: Town News /Vasudev Corp Address 165 North Main St, City/State/Zip: Mansfield/MA/02048 Phone #: 508-339-6744 Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail 1.❑ I am a employer with employees (full and/ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment I ❑ 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. g ❑ 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.] I *Any applicant that checks box #1 must also fill out the section below shaving 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: J.K. Olivieri ins. Agency Insurer's Address: 64 East Grove St City/State/Zip: Miridlehoro. MA.02346 Policy # or Self -ins. Lic. # BPF1371 Y Expiration Date: 11-30-2021 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 ofpenjury that the information provided above is true and correct. Signature TP' _41 Date: 10/27/2020 508-982-8177 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 VASUC01 OP ID DATD 10129/129I202020 CERTIFICATE OF LIABILITY INSURANCE 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 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 endorsements . PRODUCER 508-947-181B J.K. Olivieri Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivied c TACT Kenneth W. Olivieri PHONE 508-947-1818 APITO, No, Eat eli�R1E -- INSURER(SI AFFORQING COVERAGE NAIC# INSURERA: NGM Insurance CO. 14768 SUR 0 asuSev Corporation dba Town News & Ticket Aggency INSURER BI Technology Insurance Co. INSURER C: 165 North Main St Mansfield, MA 02046 INSURER D: - INSURER E. _.._ NSURERF: COVERAGES CtKlltlt;Alc rvumocrt:------------------- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. INSR TYPE OF DDL USR POLICY NUMBER POLICY EFF 11/30/2020 POLIDY"I' 11/30/2021 LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Business Owners BPF1371Y EACH OCCURRENCE 11000,000 ED PAEtAGE SO RENTus MEDEXP tAu oV ne cerson - P 500,000 $ 10,000 X PERSONAL&ADV INJURY 1,000,000 GENERAL AGGREGATE 2/0001000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICYu JPCOT TOO PRODUCTS-COMP/OP AGO 2,000,000 OTHER: COMBINED SINGLE LIMIT a AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY Per ,son BODILYINJURY IPer accident OWNED SCHEDULED AUTTOS ONLY AUTNNO-SWW p AUTOS ONLY ARVA%Na F20PERTY AMAGE ,accident $ UMBRELLA LWB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION ANDEMPLOYERS'LIABIUTY YIN ANY PROPRIETORIPARTNERIEXECUTIVE %FICaER/MEMBEREXCLUDED7 I an story In NH) It yes, describe under DESCRIPTION OF OPERATIONS beb Business Owners B A NIA TVVC3776493 BPF7371Y 03/1312020 1113012020 03113/2021 11130/2021 X PER OTH- E _ _STATUTE EL E1�C�H ACCIDENT 500,000 $ - EL,DISEASE-EAEMPLOYE EL DISEASE -POLICY LIMIT SOO,000 500,000 See Limits Below Liquor Liability DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Liquor Liability Coverage: 4000,000 Each Common Cause Limit 000,000 Aggregate Limit MANST02 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 Mansfield, MA 02048. AUTHORIZED REPRESENTATIVE rr ..... nTt(YLI A11 ni�h{c �ncn,�,nrl ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. Vasudev Corp Signature of Individual or Corporate Name 04 2628&" ot1- 3�,ij-911 Z **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (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. C:\Users\sleae\Desktop\Scott's Docnments\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. D.P. 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. D.P. 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. D.P. 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 T. RA - Applicant Name (please print clearly) Dhruv Patel 10/28/2020