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HomeMy WebLinkAboutCannan Fuel 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Snack Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. SAMEH KANAN BOARD OF HEALTH Whose place of business is: CANNAN FUEL 157 PRATT STREET License Number: S-77 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream ❑ MichaeCMCCCean, Chairman ----------- Permit for the Sale of Tobacco Products � Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: CANNAN FUEL 157 PRATT STREET BOARD OF HEALTH License Number: S-77 Permit Expires: December 31, 2016 Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY i Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION App icausf be -submitted aITeastdaysbefore the pTannedopenTng-da�e� 1) Establishment Name CANNAN FUEL 1 N- 2) Establishment Address 157 PRATT STREET 3) Establishment Mailing Address (if different) 157 PRATT STREET MANSFIELD, MA 02048 4) Establishment Telephone No (509) 339-3317 5 Applicant Name & Title: SAMEH KANAN - — -i 6) Applicant Address t 0, filth ye" 7) Applicant Telephone No.: (617) 407-9877 (508) 824-1300 24 Hour Emergency No.: (617) 372-5716 (617) 407-9977 i1�1 8) Owners Name & Title SAMEH KANAN 9) Owner Address (if different from applicant) Owner's telephone number 6174079977 10) Establishment Owned By: 1 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address ❑ An Individual ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ISAMMY KANAN, MANAGER Address: 177 POND STREET, #907, BROOKLINE, MA 02445 - - 1(- - -- - -- - Emergency No: (617) 372-5716 (617)07 9977 Telephone No: 508) X3`3-3317 24 Hour FAX: (508) 339-3392 1 E-mail KANAN.FIRSTCAPITALGROUP.SAMEH(a-)GMAIL.COM - AAlt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: j E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 3 j 17) DAYS/HOURS: M -F 6-9 SAT 7-9 SUN 8-9 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑d Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: Retail ( 700 Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 ❑ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 Retail Snack Food $12.50 0 Tobacco Products $12.50 23) Food Operations Definitions: PHF Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) - --I -- -- - - --- - - - - Sale of Commercial) Pre -Packaged Non-PHFs 1❑ PHFCooked To Order ?❑ Hot PHF Cooked and Cooled or Hot Held for ❑ Sale of Commercially Pre -Packaged PHFs 1 ❑Preparation of PHFs For Hot And -- -p - anrd RTE Foods Prepared For HighlyI g ❑ g - ---- + ❑ Sale of Raw Animal Foods Intended ❑ p Reheating of Commercial) Cold Holden For Single Meal Service Susceptible Population Facility Deliveryof Packaged PHFs _ ❑ g y to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _ _ -_. - ---- - ---- --- -- ---- -- - -- ❑ Use of Process Requiring A Variance ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only -_ - - — - ---.- contact alternative, time as a public health __ -__ _ --_-__ --___ ❑ Ice Manufactured and Packaged for F-1 Preoaration of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Retail Sale Animal -Origin I 0_1 Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date - - - - or Reconditioned Food T be completed by the Board of Health Total Permit Fee: $12.50 Payment is due with application ❑ waived 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 anted ll-otherrp''p if able law. ave been instructed by the board of health on how to obtain copies of 105C 9©:ate e federal o e.- 24) Signature of Applicant: Pursuant to MGL Ch.62C, s c. 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. 25) Social Security Number or Federal ID: 263-89-8693 iA c- 26) Signature of Individual or Corporate Name: Ca/ri newt ro �- Y Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S-77 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CANNAN FUEL LOCATION OF SALE OF TOBACCO PRODUCTS: 157 PRATT STREET TELEPHONE AT LOCATION: (508) 339-3317 OWNER OF BUSINESS: SAMEH KANAN ADDRESS OF OWNER: 77 POND AVENUE, #907, BROOKLINE, MA 02445 TELEPHONE OF OWNER: (617) 407-9977 FAX NUMBER: (508) 339-3392 If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 263898693 SIGNATURE: Ipo DATE: ro in c 0 c_ ED 'tv E m e CU w 0 CAG C ULL Q) < z a Z a w C (D Q C d � G) � 8 ;O l® d� i N N > C CD C E O® C y C �Q �CfA C LO v J) Q a� o W uNilL�® tN d O a. U Ccu a E Z r Z v 00 CM i e CD ® p Co 1 ®. m V d .a m �m o 2 50 M ®r 2f c In C1 `A U M 'V V W V CL 00 :0 4.) tm u V N 0000 G a � O E d Z � C U lII N C4 0 pREV 8 O C a� E E o 9 !E Z C 9 p � 'o c_opp h .Y a S H a h Q ro in c 0 c_ ED 'tv E m e CU w 0 CAG C ULL Q) < z a Z a w C (D Q C d � G) � 8 ;O l® d� i N N > C CD C E O® C y C �Q �CfA C LO v J) Q a� o W uNilL�® tN d O a. U Ccu a E Z r Z v 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. C. -""Y\ C"ra"I Ty-�(, * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) P,4 - �1- X03 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 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: cowwwVA G V,0 t,1 P , 1,Y, ( Address: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor 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 employees. [No workers'.comp. insurance req.] Phone #: 10 1&®33 CV71713 V - ype (required): it 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing I l.❑ Health Care 12.❑ Other *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: pI C1 C_ (� Insurer's Address: r . 0 e ?-,� C4 1456 City/State/Zip: Policy # or Self -ins. Lic. # 5 421 V 0 Yo p fi O 9, 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 na f perjury that the information provided above is true and correct -t�C:rmafitrr.' Date: "- Phone #: 6 11— k® -: 1 0 lv'cA' `4-9 - 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 11 Contact Person:Phone #: www.mass.gov/ala 1� SCI The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ACE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY ^ (GS62UB-4477P99-A-16) 02-14-16 TO 02-14-17 POLICY NUMBER EFFECTIVE DATES �o LEWIS R GAMMONS INS AGCY PO BOX 1235 LAKEVILLE MA 02347 NAME OF INSURANCE AGENT ADDRESS PHONE # m CANNAN GROUP INC DBA 157 PRATT ST o� CANNAN FUEL MANSFIELD MA 02050 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the OM provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services a_ provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably `— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 013182 W20P1G15 TO BE POSTED BY EMPLOYER Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer," MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit, The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below, Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year, Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (l,e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit; The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number., The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.govldia Farm Reviscd 5-26-05