HomeMy WebLinkAboutCommunity Corner Store 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Snack Establishment
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:.
LAURETTA OKOYE, OWNER/PHARMACIST
BOARD OF HEALTH
Whose place of business is:
COMMUNITY CORNER STORE LLC
214 RUMFORD AVENUE
License Number: S-33
Permit Expires: December 31, 2016
Food Fee: $25.00
Milk & Cream W
NichaeCNcCCean, 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:
BOARD OF HEALTH
COMMUNITY CORNER STORE LLC
214 RUMFORD AVENUE
License Number: S-33
Permit Expires: December 31, 2016
MichaeCvlcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
RF -8
FOOD ESTABLISHMENT PERMIT APPLICA I IUN
— ---- 7App ica ion mus esu mi e a eas -3U-da—ys-berme f�p-Ua-ti-n—eopen�n—g-d�a-le 1
1) Establishment Name COMMUNITY CARE PHARMACY
2) Establishment Address 214 RUMFORD AVENUE
3) Establishment Mailing Address (if different) 214 RUMFORD AVENUE
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-9080
5) Applicant Name & Title: LAURETTA OKOYE, OWNER/PHARMACIST
----------
6) Applicant Address 214 RUMFORD AVENUE, MANSFIED, MA 02048
7) Applicant Telephone No.: (508) 339-9080 24 Hour Emergency No.: (781) 626-1955
8) Owners Name & Title LAURETTA OKOYE, OWNER/PHARMACIST —
9) Owner Address (If different from applicant) — _—_—-
Owner's telephone number (781)676 . -1956
- ---- -- — — —
10) Establishment Ow7By,.:1f
a corporation or partnership, give name, title, and home address of officers
❑ An Associationartner.
[Name & Title:
W A Corporationme
Title Address
❑ An Individual
- _-- -- — —
❑ A Partnership—
-
FAX:
�❑ Other legal Entity
_- - --- -
-
. hn . ci incrvicnr mnnnnpr Pta)
12) Person Directly Responsible For uaily Operations kownei, person _10P, -111
Name & Title:
LAURETTA OKOYE r5 S
Address:
214 RUMFORD AVENUE, MANSFIELD, MA 02048 —
Telephone No:
FAX:
(508) 339-9080 24 Hour Emergency No: (781) 626-1955
------------
(508) 339-9084
E-mail
CPHARMACY2140_YAHOO-COM _— --- —--
Alt E -Mail
- ---- -- — — —
----
13) District Or Regional
Supervisor (if applicable) — --
[Name & Title:
JONAS OKOYE
Address:
214 RUMFORD AVENUE, MANSFIELD, MA 02048 A
(508) 339-9080 24 Hour Emergency No: (781) 626-1604 -- — —
Telephone No:
CPHARMACY214@YAHOO.COM
FAX:
(508) 339-9084 JE -mail:
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: M -F 9AM - 9PM, SAT 9AM-9PM, SUN 12PM - 6PM
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 1
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: W Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
0 Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
❑ Retail ( Sq. Ft)
❑ 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
Milk & Cream $5.00 /J /)k
❑ 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
Tobacco Products $12.50
-----
23 Food Operations Definitions: PHF -Potentially hazardous food (time/temperature controls require
p 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)
1
Sale of Commercially Pre -Packaged Non-PHFs
❑ 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
Other Food Operations
❑ PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
-----------
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service llllll111111
❑ Retail Sale of Salvage, Out Of Date --- —�
or Reconditioned Food To be completed by the Board of Health
-- Total Permit Fee: $50.00
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 wit 5 MR 0.000nd all other applicable law. I have been instructed by the
board of health on how to obtain copiEq of 105 CTffl 590.04and the federal Food Code.
24) Signature of Applicant: -
Pursuant to MGL Ch.62C, sec. 49A, I certify unde the pe Ities of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. r q-06
f-
25) Social Security Number or Federal ID: 80-0929400 1-7 — 3 6 q-3 K 0 6 / _ ,r`' f �,� ST LLC
26) Signature of Individual or Corporate Name: 1 �7ro1 1 �-
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
PERMIT NUMBER:
7
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: b -w "kA-�J< <Y C6 zL'r&-P— 9(�W U G
LOCATION OF SALE OF TOBACCO PRODUCTS: 214 RUMFORD AVENUE, MANSFIELD, MA 02048
TELEPHONE AT LOCATION: (508) 339-9080
OWNER OF BUSINESS: LAURETTA OKOYE [ pP( S (9 k-60 `t
ADDRESS OF OWNER: 32 HILL STREET
TELEPHONE OF OWNER: (781) 626-1955
FAX NUMBER: (508) 339-9084
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:---8f}6929� 7 ` Sb L 3��
SIGNATURE:
DATE:
m
OE°"RrMFyr Form CT -3T 00640
a Massachusetts Department of Revenue
Cigarette Excise Unit 2014-2016
Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco
DOH
This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law.
Application Number: AK099 License Number: Date of Issue:
ederal Identification or Social Security Number: 800-92-9400 00640 09/04/2014
?ailing address for license:
;-OMMUNITY CARE PHARMACY INC
214 RUMFORD AVENUE 103•
MANSFIELD, MA 02048
Retail sale location (if different than mailing address)
COMMUNITY CARE PHARMACY INC
214 RUMFORD AVE
MANSFIELD, MA 02048
This certifies that the taxpayer named above has paid the required license 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 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.
* Signature of Indi, idua
Corporate Na (Ma
By: Corporate Officer
(Mandatory, if applicable)
rye ZO-3GLOL�1)G
** 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:
�n'L /U cll2 LC
Address:
City/State/Zip: p,- oZ4 e #: C, -Z S-�, C 9 y,;;-- 6
Are you an employer? Check the appropriate box:
1. I am a em toyer with "-7 employees (full and/
or art -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.]
Business Type (required):
5. 5V Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.0 Manufacturing
11. ❑ Health Care
12.❑ Other
*Any applicant that checks box it l must also fill out the section below showing their workers' compensation policy mrormation.
**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 {Il.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: ((_����C��(
Insurer's Address: 1->A_P_T nn_6_R_b
City/State/Zip:
12
Policy # or Self -ins. Lia # `1 " 1 Expiration Date:
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 t ins an enalties of perjury that the information provided above is true and correct;
�:,...,..,...o, e Date:
D
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
www.mass.goy/dia
3b
CB INFORMATION PAGE
wEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: HARTFORD FIRE INSURANCE COMP,4NY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 13269
Company Code: 1
Suffix
rLARS RENEWAL
POLICY NUMBER: 91 WEC CB3621 1 00
Previous Policy Number: NEW
]d
HOUSING CODE: SA
1. Named Insured and Mailing Address. COMMUNITY CORNER STORE LLC
(No., Street, Town, State, Zip Code)
FEIN Number: 473643406
State Identification Number(s):
UIN:
214 RUMFORD AVE
MANSFIELD, MA 02048
The Named Insured is: LIMITED LIABILITY COMPANY
Business of Named Insured: BEER, LIQUOR & WINE STORE
Other workplaces not shown above: 214 RUMFORD AVE
MANSFIELD MA 02048
2. Policy Period: From 09/23/15 To 09/23/16'
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: PMC ADVANTAGE INS SERVICES INC
PO BOX 370
ALGONA, IA 50511
Producer's Code: 828578
Issuing Office: THE HARTFORD
8711 UNIVERSITY EAST DRIVE
CHARLOTTE NC 28213
(877) 853-2582
Total Estimated Annual Premium: $732
Deposit Premium:
Policy Minimum Premium: $294 MA (INCLUDES INCREASED LIMIT MIN. PREM.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by r''If CQar' 09/23/15
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 09/23/15 Policy Expiration Date: 09/23/16
IRSINTERNAL
OF THE TREASURY
90IR INTERNAL REVENUE SERVICE
CINCINNATI OH 45999-0023
COMMUNITY CORNER STORE LLC
JONAS IKE OKOYE SOLE MBR
214 RUMFORD AVE
MANSFIELD, MA 02048
,rDate of this notice: 04-07-2015
Employer Identification Number:
47-3643406 \
Form: SS -4
Number of this notice: CP 575 A
Fbr assistance you may call us at:
1-800-829-4933
IF YOU WRITE, ATTACH THE
STUB AT THE END OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN). We assigned you
EIN 47-3643406. This EIN will identify you, your business accounts, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, payments, and related correspondence, it is very important
that you use your EIN and complete name and address exactly as shown above. Any variation
may cause a delay in processing, result in incorrect information in your account, or even
cause you to be assigned more than one EIN. If the information is not correct as shown
above, please make the correction using the attached tear off stub and return it to us.
Based on the information received from you or your representative, you must file
the following form(s) by the date(s) shown.
Form 941 07/31/2015
Form 940 01/31/2016
If you have questions about the form(s) or the due date(s) shown, you can call us at
the phone number or write to us at the address shown at the top of this notice. If you
need help in determining your annual accounting period (tax year), see Publication 538,
Accounting Periods and Methods.
We assigned you a tax classification based on information obtained from you or your
representative. It is not a legal determination of your tax classification, and is not
binding on the IRS. If you want a legal determination of your tax classification, you may
request a private letter ruling from the IRS under the guidelines in Revenue Procedure
2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note:
Certain tax classification elections can be requested by filing Form 8832, Entity
Classification Election. See Form 8832 and its instructions for additional information.
If you are required to deposit for employment taxes (Forms 941, 943, 940, 944, 945,
CT -1, or 1042), excise taxes (Form 720), or income taxes (Form 1120), you will receive a
Welcome Package shortly, which includes instructions for making your deposits
electronically through the Electronic Federal Tax Payment System (EFTPS). A Personal
Identification Number (PIN) for EFTPS will also be sent to you under separate cover.
Please activate the PIN once you receive it, even if you have requested the services of a
tax professional or representative. For more information about EFTPS, refer to
Publication 966, Electronic Choices to Pay All Your Federal Taxes. If you need to
make a deposit immediately, you will need to make arrangements with your Financial
Institution to complete a wire transfer.
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 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 cavy 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 (i.e. a dog license or permit to bum 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-NIASSAFE
Fax # 617-727-7749
www.mass,gov/dia
Form Revised 5-26-05