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HomeMy WebLinkAboutCanoe River CG 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health mit to Operate a Food Service Establish 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:. GONSALVES FAMILY Whose place of business is: CANOE RIVER CAMPGROUND 137 MILL STREET License Number: FS -6 Permit Expires: December 31, 2016 BOARD OF HEALTH Food Fee: $80.00 Milk & Cream W -MichaeCvicCCean, 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: CANOE RIVER CAMPGROUND 137 MILL STREET License Number: FS -6 Permit Expires: December 31, 2016 BOARD OF HEALTH michaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. GONSALVES FAMILY having a place of business at: CANOE RIVER CAMPGROUND 137 MILL STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -6 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -6 FOOD ESTABLISHMENT PERMIT APPLICATION Wpplicaft—on-must-be subm[tted aTTas-t-J"ays nefore the planned opening date) 1) Establishment Name CANOE RIVER CAMPGROUND 2) Establishment Address 137 MILL STREET 3) Establishment Mailing Address (if different) 137 MILL STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-6462 _ 1 5) Applicant Name & Title: MARK BURMEISTER, MANAGER 6) Applicant Address 137 MILL STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-6462 24 Hour Emergency No.: (508) 339-8684 (508) 789-6405 8) Owners Name & Title GONSALVES FAMILY 9) Owner Address (If different from applicant) 137 MILL STREET, MANSFIELD, MA 02048 Owner's telephone number (508) 339-8684 10 Establishment Owned By: i 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association I or partner. 0 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 tc )Name &Title: MARK BURMEISTER, MANAGER Address: 137 MILL STREET, MANSFIELD, MA 02048 Telephone No: (508) 339-6462 24 Hour Emergency No: (sos) 339-6684 (508)789 6405 FAX: 1(508) 339-5237 E-mail �MARKO-CANOERIVER COM Alt E -Mail: ;,OFFICE@CANOERIVER.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN l 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6 -- -- 17) DAYS/HOURS: JUNE - SEPTEMBER 18) Name of Person In Charge Certified in Food Protection Management: MARK A. BURMEISTER 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 f 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 1 20) Location: Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual d❑ Seasonal Seasonal Dates: JUNE -SEPTEMBER ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 0 Food Service up to 100 or up to 10' PHF display $62.50 ❑ 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 0 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.E Tobacco Products $12.! 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) ❑ Sale of Commercially Pre -Packaged Non -PRFs ❑ 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 PHFCooked To Order �❑ Hot PHF Cooked and Cooled or Hot Held ❑ Preparation of PRFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ---- -- -- -- -- -� Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill ❑ Customer Self -Service Ice Manufactured and Packaged for Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations ❑ Juice Manufactured and Packaged for E] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin - -- - ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities ❑ Catered -Events orInstitutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed b the Board of Health - - - Total Permit Fee: $62.50 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 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105AMR 590.000 and the feo_ralyood Code. 24) 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. 25) Social Security Number or Federal ID: 04-2375571 26) Signature of Individual or Corporate Name: ST, Ie -L Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET TELEPHONE AT LOCATION: (508) 339-6462 FAX NUMBER: OWNER OF BUSINESS: (508) 339-5237 GONSALVES FAMILY TELEPHONE OF OWNER: (508) 339-8684 FEDERAL ID/SS NUMBER: 04-2375571 FEE: $5.00 PERMIT NUMBER: FS -6 SIGNATURE: DATE: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS -6 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 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CANOE RIVER CAMPGROUND LOCATION OF SALE OF TOBACCO PRODUCTS: 137 MILL STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 339-6462 OWNER OF BUSINESS: GONSALVES FAMILY ADDRESS OF OWNER: 137 MILL STREET, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 339-8684 FAX NUMBER: (508) 339-5237 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: d 1-7 0 FEDERAL ID/SS NUMBER: 04-2375571 SIGNATURE: DATE: �% (o OEPAR TMF Form CT -3T 01702 Massachusetts Department of Revenue 2014-2016 m Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco DOA This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by l Date Of ISSUe: Application Number: 34953 License Number: 01702 09/11/2014 Federal Identification or Social Security Number: 042-37-5571 - - — - Retail sale location cif different than mailing address viaiiing address for license. CANOE RIVER CAMPGROUND STARLIN INC 137 MILL ST 137 MILL ST MANSFIELD, MA 02048 MANSFIELD, MA 02048amed above has paid the required license _ --- - This certifies that the taxpayer n q e fee and is licensed to sell at retail at the address shown above until September 30, 2016. This license is not transferable, and is subject to suspension for failure to comply with the law. �I ,i i 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. 1 -J -A--2 L.1 Al l /U C—, * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 0 q® o)-:3%SS- ** 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: 5-rAkU-U CANEe t✓e2 C,grvt.�✓G2v�+�' Address: /'I / (_., 57-, City/State/Zip: /�j q.�SF-� �-L �� m14. ©a v ,l e Phone #: -S-0 E 3 3 /, 6 1%6 �_ Are an employer? Check the appropriate box: I . I am a employer with L. employees (full and/ or part-time).* 2. ❑ 1 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.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing IL . ❑ Health Care 12.M Other C'�l/' c /. v t� ✓L V P (� *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: CA 2 /+/14 0�e l G,4,4_) Insurer's Address: a ��� a L ���� U i If V E City/State/Zip: >2L14/0b0 /=L , 3Q8/ Policy # or Self -ins. Lie. # 6-,72! LA 13-0 Expiration Date: -r:,- /13 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. Ido hereby certify, unde�/ hep 'ns and penalties ofperjuty that the information provided above is true and correct .5`0e - 339 6 LA. Q_ 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: www.mass.gov/dia Phone v®a ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0495N75-0-1 5 ) RENEWAL OF (6ZZUB-0495N75-0-14) INSURER: AMERICAN ZURICH INSURANCE COMPANY mil i fl"I STARLIN,'INC.,DBA CANOE RIVER CAMPGROUNDS 137 MILL ST MANSFIELD MA 02048 NCCI CO CODE: 17965 PRODUCER: COLONIAL INS 'SERVICES IN 310 N MAIN ST #6 MANSFIELD MA 02048 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05-13-15 to 05-13-1`6 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part 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: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee m� C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 066 v" o® m® D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE os _ 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-20-15 WC OFFICE: ZURICH-ORLAN 809 PRODUCER: COLONIAL INS SERVICES IN 024581 75W2J ST ASSIGN: MA *: m Q_ O m m N w w w GLX ui w O O a. V� ffi mp u ' 4 Cyd y E�� W q d C O EG m p 3 i W 00 w CE LL U _ ta - %. c_— U - r=3`� W a.. z c i c E o m Ea I LL x U W v CC O_ ,0 u u a, �- O � a v 0 O i 41 O i i C � m � u c � o u o o N � o oQ W LL C 2 w/ Nom.. O V .0 � to C o W � " '" C Z L L m m _ .0 m u N N Q 5 v C c z in .0O V1 v Z ma a z W m m u a w Q � bo E E T E O 04, N W� i 5 j O N U- O m V) N m 3 W O W VI V �I �. i Q Q m mp u ' 4 Cyd y E�� W q d C E m Im Wo �1 r-1 d ♦+ y U N 0 •i y b t i�/i dQi N N N N o o � � a o 0 U � N � o O h 4I 4-4 ct 0 v � �n d ♦+ y U N 0 •i y b t i�/i dQi to d � �n 0 •i to o o b4 .I � I` h 4I 0 v � O O 1 1 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 n 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 I 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 permit/license 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 futuro 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 (i.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 I-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Reviscd 5-26-05