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Home My WebLink AboutTown Food Mart/AMDA Conv. Corp. - 12/31/2021n FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned 06 �021 Establishment Name AMDA CONVENIENCE CORP Establishment Address 242 CHAUNCY STREET ,MANSFIELD, MA 02048 USA Establishment Mailing Address (if different) Establishment Telephone No 508-982-8177 Applicant Name & Title: Dlnesh Patel Applicant Address 4 old stable dr, mansfield, ma, 02048 Applicant Telephone No.: 508-982-8177 24 Hour Emergency No.: 774-266-4631 Applicant Email pdinesh68@yahoo.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 11 n Association partner. Name Title Address A Corporation Dinesh Patel Director 4 old stable dr, Mansfield, ma, 0204 -- 11 An Individual Ashok Patel PRESIDENT 6 country club way, Norton,MA, 0 A Partnership EJ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ashok Patel Address: 6 country club way, Norton,MA, 02766 Telephone No: 508-493-0805 24 Hour Emergency No: 774-266-4631 FAX: E-mail: pdhruv22@yahoo.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 766 Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: No. Of Food Employees: 3 DEP Public Water Supply No: (If applicable) DAYSMOURS: Mon -Sat 5-10, Sunday 630-10 Name of Person(s) In Charge Certified in Food Protection Management: Dhruv Patel Name of Person(s) In Charge Certified in Allergen Awareness Training Dhruv Patel Name of pest control company routinely inspecting the premises for evidence of pests Al Exterminators 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. 0 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Len th of Permit: Establishment Type: nnual VRetail Food $125.00, Mobile Food Concession ❑i Temporary Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Dessertslice 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 0 Pushcart $50.00 # of Pushcarts: Temporary Time: E] Supermarkets $400 Q Residential Kitchen $100.00 Rain Date: 114tilk & Cream $10.00 E Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(tlnredemperatum controls required) Non-PHFs-non-potentially hazardous food(not rneRemperetum controls required) (Check all that apply): RTE- ready -to -eat foods (Exsandwiches, salads, muffins which need no further processing) e of Commercially Pre -Packaged Non-PHFs PHFCooked To Order EJ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly 0 Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer 0 Use of Process Requiring A Variance P cessad Foods for Service Within 4 Hours andlor HACCP Plan (including bare hand Self -Service contact alternative, time as a public health %Customer ustomer Self -Service of Non PHF and Non - Perishable Foods Only a Manufactured and Packaged for control) EJ Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of EJ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale EJ Vacuum Packaging / Cook Chill E] Offers RTE PHF in Bulk Quantities E] 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 obtaip. qft of 105 CMR 590,000 and the federal Food Code. Signature of Applicant: y r '•'� "'— 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 lax returns and paid state taxes required under law. Social Security Number or Federal to: 86-2829571 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. AMDA CONVENIENCE CORP Dinesh Patel Signature of Individual or Corporate Name 86-2829571 **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:\Usem\sleite\Desktop\Scotrs 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. 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. TROO - Applicant Signature Applicant Name (please print clearly) Dinesh Patel 3/25/2021 xThe Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: AMDA CONVENIENCE CORP 242 CHAUNCY STREET City/State/Zip: MANSFIELD, MA, 02048 Phone #: 508-982-8177 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 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. 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]* 110 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: J•K Oliylerl Ills. Agency Insurer's Address: 64 East Grove St City/State/Zip: Middleboro.MA. 02346 Policy # or Self -ins. Lic. # TBD Expiration Date: 06/01 /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 of perjury that the information provided above is true and correct. Signature: Date: 03/25/2021 ,r\�.1.`C� 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 www.mass.gov/dia Phone TOWNF01 CERTIFICATE OF LIABILITY INSURANCE I DATE041161202116/2021 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(les) 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 Corp dba - REVISION NUM ER; COVERAGES CERTIFICATE NUMBER. 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 v DOL TYPE OF INSURANCE U@R POLICY NUMBER ROLICY EFP POLIQY EXP LIMITS 1,000,000 A COMMERCIAL GENERAL LIABILITY EAC OCCURRENCE —. CLAIMS-MADE occuR TOBE DETERMINED 0610112021 0610112022 DAMAGETORENTED 50,000 X Business Owners -ME y onto!) _ _ 5,000 D XP Ar &ADV INJURY $ Included -PERSONAL ^� GENL AGGREGATE LqIIMpIIT, APPLIES PER; GENERAL AGOREOATE -_ )f POLICY jEOT LOC PRODUCTS-COMP/OP AGO $ �2,000,000 E_. --- -- -- _.__ _._ COMBINED _. $ AUTOMOBILE LIABILITY E acciden) � _ _ ANYAUTO SCDILYINJURY IPoLpereon ,$u OWNED SGHEDULEO ONLY ANNUOoTOppSWW BODILY INJURY_ Peraq"Ilt _ _.,. _ IA{UgTOS � AUTOSONLY AUT090NNLV RRC`pEgqTY gMAGE Peraaldanl ___ _ - UMBRELLA LIAR-- OCCUR -- - - -- EACH OCCU RENCE _. AGGREGATE __ $ -__ _.. EXCESS LIAB CLAIMS -MADE DED RETENTIONS X PE OTH A WORKERS COMPENSATION AND EMPLOYERS'LIASIUTY YIN OBE DETERMINED 0610112021 0610112022 - E EL EACH ACCIDENT 1,000,000 ANY PROPRIETORIPARTNEREXECUTIVE ��ppFI EMW�.�EMg�R EXCLUDED? F - NIA i EL IP SE�9E EMPLQYY 1,000,000 £ (Myyan�alory in NNI It des oundRIPTION er . ,EA EL D SE. POLICY LIM11 _ 1,000,000 E ow -_... _. _-_ DESCRIPTION OF OPERATIONS I LOCATIONS IVEMCLES (ACORD 101, Addlllonel Remarks Schedule, maybe aaached U more apace is required) CERTIFICATE HUILUCK .........�� ..... _... TOWNMAO 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 AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 �f`p`.y_ ACORD 25 (2016103) Q 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD