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Home My WebLink AboutDub's Liquor 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:. BERNARD CARP, MANAGER Whose place of business is: DUB'S LIQUORS (DUB'S LIQUORS & FINE WINES) BOARD OF HEALTH 30 CHAUNCY STREET License Number: S-19 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream W1 michaeCMcCCean, Chairman [��Perm�itfor the Sal�qf 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: DUB'S LIQUORS (DDB'S LIQUORS & FINE WINES) 30 CHAUNCY STREET BOARD OF HEALTH License Number: S-19 Permit Expires: December 31, 2016 NichaeCvlcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. BERNARD CARP, MANAGER having a place of business at: Town of Mansfield 6 Park Row Mansfield, MA 02048 DUB'S LIQUORS (DUB'S LIQUORS & FINE WINES) 30 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 12/31/2016 unless previous to that time is suspended or revoked. Expires 12131/2016 License No.: S-19 Scott Leite, Neaah Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY 1 Date received: Date Inspected: Approved By: Permit # Issued S-19 FOOD ESTABLISHMENT PERMIT APPLICATION„. - - -7ic�ion mu��submifiecTas 3�days �efore�ienec7open�ng dam iAPp 1) Establishment Name DUB'S LIQUORS 2 Establishment Address-. -- 30 CHAUNCY STREET _ 3) Establishment Mailing Address (if different) 1 D 4) Establishment Telephone No (508) 339-3454 5) Applicant Name & Title: BERNARD CARP, PRINCIPAL 6) Applicant Address 20 ROBERT BATCHELDER ROAD, NORTH ATTLEBORO, MA 02763 7) Applicant Telephone No.: (508) 446-4280 24 Hour Emergency No.: (774) 244-1094 I 8) Owners Name & Title BERNARD CARP, MANAGER 9) Owner Address (If different from applicant) 20 ROBERT BATCHELDER RD., N. ATTLEBORO, MA 02763 Owner's telephone number (508) 446-4280 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. jV 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: WAYNE SMITH, MANAGER Address: i6 JUDY'S LANE, MANSFIELD, MA 02048 Telephone No: 1(508) 339-8369 24 Hour Emergency No: (7 74) - _- -- 74 244-1094i FAX: x(508) 798-3987 E-mail: iCABERNETP_DUBSONLINE.COM Alt E -Mail: - - 13) District Or Regional Supervisor (if applicable) Name & Title. l� N j Address: Telephone No: (OWNER (508) 754-7733 24 Hour Emergency No: - FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT 8:00-10:00 SUN 12:00-6:00 15) SEWAGE DISPOSAL: TOWN 16) No of Food Employees: 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: Permanent Location Establishment Type❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) i Milk & Cream $5.00 Moblie End Date: (❑ 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: W Annual ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ 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) ❑ $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: 0 ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑d Retail Snack Food $12.50 W Tobacco Products $12.50 Definitions: PHF Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ 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 1 ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) 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 Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service To 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 and a r applicable law. I have been instructed by the board of health on how to obtaiMopies of 105 CMR�90.000 and the feral Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sed 4 A, I certify under the penades of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required u der law. 25) Social Security Number or Federal ID: 47-1090248 26) Signature of Individual or Corporate Name: f�w� lu k I�t`"( (T 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: DUB'S LIQUORS ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-3454 FAX NUMBER: OWNER OF BUSINESS: BERNARD CARP, MANAGER TELEPHONE OF OWNER: (508) 446-4280 FEDERAL ID/SS NUMBER: 47-1090248 FEE: $5.00 PERMIT NUMBER: S-19 SIGNATURE: DATE:'I� l�/l Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S-19 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: DUB'S LIQUORS LOCATION OF SALE OF TOBACCO PRODUCTS: 30 CHAUNCY STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 339-3454 OWNER OF BUSINESS: BERNARD CARP ADDRESS OF OWNER: 20 ROBERT BATCHELDER ROAD, NORTH ATTLEBORO, MA 02763 TELEPHONE OF OWNER: (508) 446-4280 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a cry of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 47-1090248 SIGNATURE: C� DATE: I @_. MASSACH[7SETTS DEPARTMENT OF REVENUE Form CT -3T Retailer -License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AUSTIN DEBUCAS LLC Account ID: CRL -12086867-008 DUBS'S LIQUORS & FINE WINES License Number: 1623564288 30 CHAUNCY ST MANSFIELD MA 02048-1958 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: February 22, 2016 Expiration Date: September 30, 2016 --- — -- -_---- SVCHI,;s� MASSACHUSETTS DEPARTMENT OF NITS Form CT -3D Fa I, Distributor License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AUSTIN DEBUCAS LLC DUBS'S LIQUORS & FINE WINES 30 CHAUNCY ST MANSFIELD MA 02048-1958 Account ID: CRL -12086867-008 License Number: 743530496 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell cigars and smoking tobacco at the address shown above. This license is non- transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: February 22, 2016 Expiration Date: September 30, 2016 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT -3T - n? Retailer License for Sale of Cigarettes 'r'rwr0e This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AUSTIN DEBUCAS LLC DUBS'S LIQUORS & FINE WINES 30 CHAUNCY ST MANSFIELD MA 02048-1958 Account ID: CGL -12086867-005 License Number: 1086693376 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: February 22, 2016 Expiration Date: September 30, 2016 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. LShes �C'L(aD H—C, * Signature of Individual or Corporate Name (Mandatory) (Mandatory, if applicable) tIq- iogoa.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. r 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:�. } hut_" (',�, %. c Address: City/State/Zip: If) an� M Phone #: Are ou an employer? Check the appropriate box: Business Type (required): 5. [21etail 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. $, ❑Nop-profit [No workers' comp. insurance required] 3. ❑ 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]* 11,F] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] I 12.❑ Other *Any applicant that checks box #I 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: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. # 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 the pain s� and penalties ofp�rjuty that the information provi`d`ed above is true ana correcu 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 INFORMATION PAGE Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: MAS Inc Mailing Address: 50 Boston Turnpike Shrewsbury, MA 01545 Other workplaces not shown above SEE SCHEDULE OF OPERATIONS RENEWAL AGREEMENT PRODUCER: Agent# 5020 First American Insurance Agency, T 510 Front Street Chicopee, MA 01013 Carrier Policy #: 014005033232116 Carrier Prior Policy #: 014005033232115 Fein: 273863971 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m, on 1/01/2016 to 12:01 a.m. on 1/01/2017 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states 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 $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: W0000000C(01/15) W0000308(04/84) WC000310(04/84) WC000406(08/84) WC000414(07/90) WC000422B(01/15) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 14,301.00 Minimum Premium $ 268.00 Expense Constant .00 Deposit Premium TIA SCHEDULE OF OPERATIONS FOR: MAS Inc 50 Boston Turnpike Shrewsbury, MA 01545 OTHER WORKPLACES: \ MAS Inc Austin Debucas, LLC 38 Chauncy Street Mansfield, MA 02048 Mailing: 50 Turnpike Shrewsbury, MA 01545 MASFANNON, LLC 212 North Main Street Natick, MA 01760 Mailing: 50 Boston Turnpike Shrewsbury, MA 01545 MAS Inc 20 Boston Turnpike Shrewsbury, MA 01545 MAS Inc. Iandoli Austin's II, Inc. 20 Boston Turnpike Shrewsbury, MA 01545 Mailing: 50 Turnpike agamore Road Shrewsbury, MA 01545 MAS Inc. Austin Liquors Co., Inc. 117 Goldstar Boulevard Worcester, MA 01605 Mailing: 50 Turnpike Shrewsbury, MA 01545 PAGE: 1 Carrier Policy #: 014005033232116 Fein: 273863971 DIV #: 00000 E/L Number: 0000000001 Fein: 471090248 Eff date: 01/01/16 NAICS: 445310 DIV #: 00003 E/L Number: 0000000001 Fein: 474915831 State Risk ID#: 000969387 Eff date: 01/01/16 NAICS: 445310 DIV #: 00005 E/L Number: 0000000001 State Risk ID#: 000969387 Eff date: 01/01/16 NAICS: 541611 DIV #: 00000 E/L Number: 0000000001 Fein: 043496483 State Risk ID#: 26666 Eff date: 01/01/16 NAICS: 445310 DIV #: 00002 E/L Number: 0000000001 Fein: 041051530 State Risk ID#: 182470 Eff date: 01/01/16 NAICS: 445310 DIV #: 00001 E/L Number: 0000000001 SCHEDULE OF OPERATIONS FOR: MAS Inc 50 Boston Turnpike Shrewsbury, MA 01545 OTHER WORKPLACES: MASSTATE, LLC 370 Park Avenue Worcester, MA 01610 Mailing: 50 Boston Turnpike Shrewsbury, MA 01545 MAS Inc 15 Sagamore Rd Worcester, MA 01605 WC 00 00 01 B PAGE: 2 Carrier Policy #: 014005033232116 Fein: 273863971 DIV ##: 00000 E/L Number: 0000000001 State Risk ID#: 000969387 Eff date: 01/01/16 NAICS: 445310 DIV #: 00006 E/L Number: 0000000001 Eff date: NAICS: DIV #: E/L Number 01/01/16 541611 00000 0000000004 NOTICE • DEPARTMENT OF INDUSTRIAL ACCIDENTS 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; MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 02185 ADDRESS OF INSURANCE COMPANY 014005033232116 1/01/2016 - 1/01/2017 POLICY NUMBER EFFECTIVE DATES First American Insurance Agenc 510 Front Street Chicopee, MA 01013 413-592-8118 NAME OF INSURANCE AGENT ADDRESS PHONE # MAS Inc 50 Boston Turnpike Shrewsbury MA 01545 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 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 ser- vices 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 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 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 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 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05