The URL can be used to link to this page

Home My WebLink AboutD'Angelo's 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health j Permit to Operate a Food Service Establishment j Type: FOOD 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:. BRIAN J. MCLAUGHLIN, PRESIDENT Whose place of business is: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY STREET PERSON(S) IN CHARGE: BETH MASTROIANNI, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -14 Food Fee: $62.50 Milk & Cream BOARD OF HEALTH MichaecmcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: BRIAN J. MCLAUGHLIN, PRESIDENT having a place of business at: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY STREET 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 -14 Scott Leite, Health .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred t-VVV CJ I /At5L.101-11VICIV I rr-mivil I /"1rrLikat.\ i ivly - --Rpplicafion must be submitted at /east 30 days before the planned openrng date I 1) Establishment Name D'ANGELO'S SANDWICH SHOP 2) Establishment Address 260 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 279 WEST BRIDGEWATER, MA 02379 4) Establishment Telephone No (508) 339-8603 5) Applicant Name & Title: MARIVA, INCORPORATED 6) Applicant Address PO BOX 279, WEST BRIDGEWATER, MA 02379 7) Applicant Telephone No.: (508) 586-456 24 Hour Emergency No (508) 922-1594 8) Owners Name & Title BRIAN J. MCLAUGHLIN, PRESIDENT 9) Owner Address (If different from applicant) P.O. BOX 337, WEST BRIDGEWATER, MA 02379 Owner's telephone number (508) 586-8456 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association ! or partner. V A Corporation Name Title Address f l An Individual ❑ A Partnership _i Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: BETH MASTROIANNI, GENERAL MANAGER Address: 138 PURCHASE STREET, MILFORD, MA 01757 Telephone No: ;(508} 478-5732 24 Hour Emergency No: (508) 922-1594 FAX: ,508) 580-0644 - E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No.- FAX: o:FAX: E-mail: 17) DAYS/HOURS: MON-SUN 10 AM -10 PM 18) Name of Person In Charge Certified in Food Protection Management: BETH MASTROIANNI 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): U - 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( 800 Sq. Ft) Milk & Cream $5.00 Moblie End Date: [vjP Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: ± up to 10' PHF display $62.50 ❑ Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: ❑ Food Service up to 101 -200 $12.50/freezer LV:] Annual or up to 25' PHF display $75.00 ❑ Pushcart $12.50 # of Pushcarts: ❑Seasonal ❑ Food Service up to 201 + [] Residential Kitchen $50.00 or 25'+ PHF display $137.50 in Retail Food $50.00 Seasonal Dates: -- ❑ Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary - Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12,50 Temporary End Date: Temporary Time: I Rain Date: Definitions: PHF- Potentially hazardous food (timeRemperature controls required) 23 Food Operations p Non-PHFs - non potentially hazardous food(no timeRemperature 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-PHFs n PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ] Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs I ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially ( to be Prepared by Consumer E]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 Ji and/or HACCP Plan (including bare hand Perishable Foods Only k Ice Manufactured and Packaged for contact alternative, time as a public health F1 Preparation of Non-PHFs Retail Sale control) --- -- ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale I Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for 1 Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date To be completed by the Board of Health or Reconditioned Food - Total Permit Fee: $62.50 Payment is due with application ❑ waived Provded in this application and affirm that the food establishment operation wmply with 105 CMR 59and IIother applicable law. I have been instructed by the I, the undersigned, attest tythn accuracy ofthe informk060 d f h ith how ton cont of 10 CMR 5and he federal Food Code, boar o ea on 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under th_ep and Paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2522583 26) Signature of Individual or Corporate Name: of perjury that I, to my best knowledge and belief, have filed all state tax returns r Application for Milk and Cream Permit Application I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: D'ANGELO'S SANDWICH SHOP ADDRESS: 260 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8603 FAX NUMBER: (508) 580-0644 OWNER OF BUSINESS: BRIAN J. IVICLAUGHLIN, PRESIDENT TELEPHONE OF OWNER: (508) 586-8466 FEDERAL ID/SS NUMBER: 04-2522583 FEE: $5.00 PERMIT NUMBER: FS -14 SIGNATURE: DATE: 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 IndivIdduaf or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** 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 oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information \ 1Please Print Lel?ibly S�� `�Business/Organization Name: Z Address: 19 — (� D;J-Y J City/State/Zip:W . ,J(�tdq eUJ R�t'�' MA Phone #: Are Y991an employer? Ch ck the appropriate box: 1.9 1 am a employer with_ 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. ❑R - 6. estaurant/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 41 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. X am an employer that is providing workers' compeqsation.insurapce for my empl eeA Below is the policy information. Insurance Company Name: insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 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 Investil;ations of the DIA for insurane covArage verification. X do hereby ce ify, un r the pain nd p=altiesofry that the information provided above is true and correct. Si nature: Date: Q_ Phone #: 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.gov/dia ri:nr.aif. 4e709Z nAN[,FLnINC ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 4/04/2016 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB International New England 299 Ballardvale St Wilmington, MA 01887 978 657-5100 CONTACT HUB International New England PHONE 978 657-5100 ac, No ; 978-988-0038 AIC No Ext E-MAIL nee.certificates@hubinternational.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Valley Forge 20508 INSURED D'Angelo, Inc. 323 Manley Street West Bridgewater, MA 02379 INSURER B: Continental Casualty Company 20443 INSURER C; National Fire Ins Co of Hartfor 20478 INSURER D: Continental Insurance Co 35289 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION 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 CONTRACTOR 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP IMMIDDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 51 OCCUR __(MMIDDIYYYYI 6023612989 1/01/2016 01101/2017 EACHOCCURRENCE $1,000,000 PREMISES Ea occurrence $300,000 MED EXP (Any one person) s15,000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATELIMIT APPLIES PER: J.— POLICY PRO LOC PRODUCTS -COMP/OPAGG $2,000,000 $ D AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 602312958 1/01/2016 01/01/201 Ea accideDlSINGLELIMIT 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PerraccidenROPERTY DAMAGE $ $ B X UMBRELLA LIAB EXCESS LIAB I X OCCUR CLAIMS -MADE 6023612961 1/01/2016 01/01/2017 EACH OCCURRENCE $20000000 AGGREGATE $20OOO OOO DED X RETENTION $1 OOOO $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? 5N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A C6023612975 12/31/2015 12/31/2016,X WCSTATU- OTH- IMITS FR E.L. EACH ACCIDENT $500OOO E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance ACORD 25 (2010/05) 1 of 1 #S1586029/M1565821 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (9) 1!JUtS-ZU1U AL;UKU UL)KYUKAI IUN. All rlgnis reserve0. The ACORD name and logo are registered marks of ACORD CS001 0 U. X ui LLM UA O V) 0 Z OD CD 0 m LL %0 m om qt 0o W r 6 6 z < E z ui < v 0 Z OC U A Ak ui L2 < 4 0 U. X ui LLM UA V) 0 Z is c 03 W < E N0 v ui VA 0 I 9 a r ❑ ❑i�' ❑ as c ,o a� E LM 0 a offmom U o T a Q a r ❑ ❑i�' ❑ as Sr'c"(Xit MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L0569747456 PO BOX 7044 Notice Date: March 14, 2016 BOSTON, MA 02204-7044 Account ID: MLS -11997906-012 CONTACT CENTER Q (617)887-6367 SALES TAX ON MEALS AND BEVERAGES REGISTRATION CERTIFICATE �IIIII��IJI�1111'llll��ll'lllll'�'ll'�II I��I�I��III�I111�1��1') MARIVA INC g^ D'ANGELO SANDWICH SHOP 323 MANLEY ST WEST BRIDGEWATER MA 02379-1022 Attached below is your Sales Tax on Meals and Beverages Registration Certificate (Form MT -1). Cut along the dotted line and display at your place of business. You must report any change of name or address to us so that a correct MT -1 can be issued. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re- print a copy of this certificate. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form MT -1 Sales Tax on Meals and Beverages Registration Certificate ov�� This registration must be posted and visible at all times. MARIVA INC Account ID: MLS -11997906-012 D'ANGELO SANDWICH SHOP Certificate Number: 1628987392 CHAUNCY ST RTE 106 MANSFIELD MA 02048 This certifies that the taxpayer named above is registered under Chapters 62C and 64H of the Massachusetts General Laws to sell meals and beverages at the address shown above. This registration is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2009