HomeMy WebLinkAboutWines & More - 12/31/2021W I5_9k5 — r.zs,-
FOR BOARD OF HEALTH USE ONLY Permit # Iss'd
FOOD ESTABLISHMENT PERMIT APPLICATION/",
(Application must be submitted at least 30 days before the planned o , nin-date)
Establishment Name Wines & More - Mansfield
Establishment Address 280 School Street, Suite 140, Mansfield, MA 02048
Establishment Mailing Address (if different) 1405 Douglas Ave.
North Providence, R102904
Establishment Telephone No 508-339-6900
Applicant Name & Title: Kathleen Haronian, President
Applicant Address 98 A Nipmuc Trail, North Providence, R102904
Applicant Telephone No,: 401.353-4400 24 Hour Emergency No.: 401-465-2527
Applicant Email license@wsretailers.com
Owner Name & Title (If different from applicant) Same as above
Owner Address
Owner telephone number
Owner email:
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
9AnIndividual
Kathleen Haronian President 98ANipmucTrail
North Providence, R102904
NO A Partnership
10 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Kathleen Haronian, President
Address: 98 A Nipmuc Trail, North Providence, RI 02904
Telephone No: 401-353-4400 24 Hour Emergency No: 401-465-2527
FAX: 401-353-4469
E-mail: srao@wsretailers.conr
Alt E-Mall: license@wsrewilers.com
District Or Regional Supervisor (if applicable)
Name & Title: Craig Power, Vice President of Operations
Address: 40 Whitelock Street, New Bedford, MA 02745
Telephone No: 401-465-2527 24 Hour Emergency No: 401-465-2527
FAX: 401-465-4469
E-mail' license@wsretailers.com
r
Food Establishment Information
WATER SOURCE: Town
SEWAGE DISPOSAL:
Town
DEP Public Water Supply No: (If applicable)
No, of Food Employees: 21
DAYS/HOURS: Mon: Sat. 9am - 9:00pin Sunday- 10a n- 6:00pm
Name of Person(s) In Charge Certified in Food Protection Management:
N/A
Name of Person(s) In Charge Certified in Allergen Awareness Training
N/A
Name of pest control company routinely inspecting the premises for evidence of pests Big Blue Bug
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. O Yes N/A
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
IN Annual
Zg Retail Food $125.00
Fa Moblle Food Consession
r7 Temporary
51 Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Dale:
FOOD TRUCKS $175.00
❑ Manufacture Frozen Desserts/Ice Cream
I
U2 Food Service up to 101 -200 $260.00
$25.00/freezer
Temporary End Date:
'ra Food Service upto 201 + $ 300.00
o-`❑=.i Pushcart $50.00 # of Pushcarts:
Temporary Time:
Ell Supermarkets $400
EU Residential Kitchen $100.00
Rain Date:
Ell Milk &Cream $10.00
za Caterer $35.00
Food Operations: Definition:PHF - Potentially hazardous food (dme4empereture controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(nolime/temperature controls required)
RTE- ready -to -eat roods (Ex. sandwiches, salads, muffins which need no /urtharprocessing)
IX Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order
W Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs iJ Preparation of PHFs For Hot And
for More Than a Single Meal Service
0 Delivery of Packaged PHFs Cold Holding For Single Meal Service
r9 PHF and RTE Foods Prepared For Highly
ra Reheating of Commercially 0 Sale of Raw Animal Foods Intended
Susceptible Population Facility
Processed Foods for Service Within 4 Hours to be Prepared by Consumer
Use of Process Requiring A Variance
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 li Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
Q Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
fj Offers RTE PHF In Bulk Quantities
IN Prepares Food/Single Meals for
F1Retail Sale of Salvage, Out-OFDate
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 wit 105 CMR 590.000 and all other applicable law. I have been Instructed by the
board of health on how to obtain op of 105 CMR 690.0()0 and the federal Food Code.
`1t /
Signature of Applicant: IL-�—�. TJ LLLiy,_�,
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: 27-276426
Signature of Individual or Corporate Name: GT Retail Inc. d/b/a Wines & More - Mansfield
77te Commonwealth ofMassachusells
Department offndustrialAecidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
wwwanass.gov/dla
Workers' Compensationlnsurance Affidavih General Businesses,
TO BIC FILED WITH TM PFRMTTTING AUTHORITY.
lieant Inr"olmation Pleaseprin2 Legibly
Misiness/Organization Name: GT Retail Inc, d/b/a Wines & More Mansfield
Address: 280 School Street Suite 140
City/State/Zip; Mansfield MA 02048 Phone #: 508-339-6900
Are you an employer? Check the appropriate box:
1, ® I am a employer with_21 employees (full and/
orpart-time).*
2, ® I am a sole proptletor or partnership and have no
employees working for me In any capacity,
[No Workers' comp, Insurance required]
3, ® 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, ❑ We are a non-profit organization, staffed by volunteers;
with no emulovees. Moworkers' coon, InsurancereoJ
Business Type (required);
5, [@Retail
6, QRestamant/Bar/EatingEstablishment
7, [] Office and/or Sales (lncl, real estate, auto, etc,)
8. [] Non-profit
9. ❑ Entertainment
1011 Manufacturing
11,0 Health Care
12,(] Other
Any applioautthd Checks boxdl must also fill out the section oaloW showing (heir workers' eompensallon palloy infonmtion.
tWtho corporals ottioem haya exempted themselves, but the ompomdonhas othoremploycea, aworkers' compensation polloy is required and seah on
organization should oheok box #1,
lain an employer that isprovldingworkers' compensation tnsaranceformyemployees. Below istltepolleylnformaflon.
Insurance Company Name: MA RETAIL MERCHANTS WC GROUP, INC.
Insurer's Address: P.O: BOX 859222-922
City/Stato/zip: BRAINTREE, MA 02185
Policy# orSelfits,Lie. # 014005032982120 _Expiration Date: 1/1/2021
Attache copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required nndor Section 25A ofM(sL c,152 can lead to the Imposition of criminal penalties of a
fine np to $1,500.00 and/or one year irnprisonment, as well as civil penalties in the form of a STOP -WORK ORDER and a -fine
of up to W0,00 a day agaWt the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verlficatlon,
f do hereby eerlW),
Official rise only. Do not write in lots area, to be completed by city or town ti flcial.
is true drtd cor'r'e04
10/30/2020
City or Town: PevotluLicenso #
Issuing Authority (circle one):
1. Board of Healtk 2. Building Department 3. CIty/Town Clerk 4, Licensing Board 5, Selectmen's Office
6, Other_
Contact Person: - 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.
Siba ue of Individual or Corporate Name
27-2176426
**Social Security No. (Voluntary) or Federal
Identification Number
Kathy Haronian
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\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORKdoc
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.
akI 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.
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
Applicant Name (please print
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