HomeMy WebLinkAboutJustice 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: RETAIL SNACK
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:.
TWEEN BRANDS, INC.
Whose place of business is:
JUSTICE #559
280 SCHOOL STREET, SUITE J 145
PERSON(S) IN CHARGE:
ESTHER TOUCH, STORE MANAGER
Permit Expires: December 31, 2016
License Number: S-17
Food Fee: $12.50
BOARD OF HEALTH
NichaeCNcCdean, Chairman
Date received:
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By: Permit # Issued
S-17
FOOD ESTABLISHMENT PERMIT APPLICATION
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1) Establishment Name JUSTICE #559
1I
2) Establishment Address 280 SCHOOL STREET, SUITE J 145
3) Establishment Mailing Address (if different) TAX DEPARTMENT, P.O. BOX 360807, '
COLUMBUS, OH 43236
4) Establishment Telephone No (508) 339-0599
5) Applicant Name & Title: BELINDA REVERCOMB, AUTHORIZED AGENT
6) Applicant Address P.O. BOX 360807, COLUMBUS, OH 43236-0807 TAX DEPARTMENT
7) Applicant Telephone No.: (614) 223-2334 24 Hour Emergency No.: (soa) 207-6415 l614> 775-3500
8) Owners Name & Title TWEEN BRANDS, INC.
9) Owner Address (If different from applicant) 8323 WALTON PARKWAY, NEW ALBANY, OH 43054
Owner's telephone number
6147753500 i
10) Establishment Owned By:
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: ESTHER TOUCH, STORE MANAGER
Address:
280 SCHOOL STREET, SUITE J 145, MANSFIELD, MA 0204
Telephone No:
(508) 207-6415 24 Hour Emergency No: (508) 207-6415 (614) 775-3500
FAX:
--
r
E-mail:
ETOUCH4(aD_YAHOO.COM
FAlt E Mail:
13) District Or Regional
Supervisor (if applicable)
Name & Title:
DIANE MALLOY DUSZAK, DISTRICT MANAGER
RI 02828
Address
3 WADE DRIVE, GREENVILLE,
Telephone No:
1(401) 440-5231 24 Hour Emergency No: (401) 440-5231
FAX:
j E -mall: DMALLOY@TWEENBRANDS.COM
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: MALL HOURS
Food Establishment Information
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: W Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
V Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply):
22) Establishment Type
❑ Retail ( 3,363 S 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
❑ 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
❑d Retail Snack Food $12.50
❑ 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)
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
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
❑ 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
❑ Customer Self -Service and/or HACCP Plan (including bare hand
❑ Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale control)
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
�� Offers RTE PHF in Bulk Quantities i ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
F1 Retail Sale of Salvage, Out -Of -Date -- - - - --
Total Permit Fee: $12.50
or Reconditioned Food To be completed by the Board of Health
Payment is due with application
❑ waived
wa J
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 105 CMR 590.000 and Pe federal Food Code.
24) Signature of Applicant: m'�-
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: 31-1
26) Signature of Individual or Corporate Name:
1�
I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
'3u'�ce-
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
31 - 13 37�) 930
** 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: Q-9—
Address:
City/State/Zip:
0 Se�o D\
KO.^ S- ,% ALQ
Are y u an employer? Check the appropriate box:
1. I am a employer with employees (full and/
or part-time).*
2.0 I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.0 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]*
4.0 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers'. comp. insurance req.]
Phone #
Business Type (required):
5. 0 Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. 0 Non-profit
9, 0 Entertainment
10.0 Manufacturing
11.0 Health Care
12.0 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:.
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
Investigations of the DIA for insurance coverage verification,
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct?
1%
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/ala
Phone
NOTICE
TO
RaL
NOTICE
TOEMPLOYEES
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:
Safety National Casualty Corporation
NAME OF INSURANCE COMPANY
1832 Schuetz Road St. Louis, MO 63146
ADDRESS OF INSURANCE COMPANY
LDC4042557 08/01/2015 - 08/01/2016
POLICY NUMBER EFFECTIVE DATES
ECBM, L. P.
NAME OF INSURANCE AGENT
ASCENA RETAIL GROUP, INC.
EMPLOYER
300 CONSHOHOCKEN STATE
ROAD
SUITE 405
WEST CONSHOHOCKEN, PA
19428
ADDRESS
ATTN: VP
BENEFITS/CORPORA
TE INSURANCE
933 MACARTHUR
BLVD
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY)
Third Party Administrator:
MEDICAL TREATMENT
(610) 668-7100
PHONE #
MAHWAH, NJ 07430
DATE
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 services
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
Justice, Store #0559 1 Claims Reporting:
280 School Street Suite J145, ® BE POSTED BY EMPLOY] Sedgwick CMS, Inc.
Mansfield, MA 02048 PO Box 14492
Lexington, KY 40512
rl.,;, r 1 Qcc ')n-' 41 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 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. %ere 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 1 -877 -MASSA -FE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05