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Home My WebLink AboutThe Store 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail 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:. HITESH KUMAR PATEL, OWNER Whose place of business is: KANKU, INC. dba THE STORE 213 SOUTH MAIN STREET Permit Expires: December 31, 2016 License Number: RF -31 BOARD OF HEALTH Food Fee: $50.00 Milk & Cream W MichaeCMcCCean, Chairman L Permit for the Sale of Tobacco Products j Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: KANKU, INC. dba THE STORE 213 SOUTH MAIN STREET License Number: RF -31 Permit Expires: December 31, 2016 BOARD OF HEALTH NichaeCNcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: HITESH KUMAR PATEL, OWNER having a place of business at: KANKU, INC. dba THE STORE 213 SOUTH MAIN STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 12/3112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: RF -31 Scott Leite, Heaah ,Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 3 FOR BOARD OF HEALTH USE ONLY Date Inspected: Approved By: Permit # Issued Date received: p RF -31 I FOOD ESTABLISHMENT PERMIT APPLICATION - — —_ — 7ica on mustbe suTmittedat-eaV3a-cfays before nie pTannec-opening date) -- - pP 1) Establishment Name KANKU, INC. dba THE STORE 2) Establishment Address 213 SOUTH MAIN STREET _ j 3) Establishment Mailing Address (if different) 213 SOUTH MAIN STREET MANSFIELD, MA 02048 508 261-1369 4) Establishment Telephone No ( ) --- --- — 5) Applicant Name & Title: MADHUBEN R. PATEL, PRESIDENT 6) Applicant Address 213 SOUTH MAIN STREET, MANSFIELD MA 02048 — - --- 7) Applicant Telephone No.: (5os zs�-�ss9 24 Hour Emergency No.: ( �$�� ( � 58 5 508 409-9228 -- 8) Owners Name & Title MADHUBEN R. PATEL 2 LONG DRIVE, WESTBORO MA 9) Owner Address (If different from applicant) 22 s i ---Owner's telephone number (508) 836-2615 r10) Establishment Owned By: T 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association I or partner. i Address V A Corporation Name Title i�th, ❑ An Individual \3 5D\+� Sk ) ( 1 ❑ A Partnership - - - mew-, 12❑ Person DiirectltftRes Responsible - - - Other 9 y - -- - y p For Daily Operations (owner, person in charge, supervisor, manage Name & Title: IBHIKHAJI PARMAR, MANAGER Telephone No: FAX 3 SOUTH MAIN STREET, MANSFIELD, MA 02048 409-9228 24 Hour Emergency No: (506) 836-2615 (506) 409-9223 (508) 261-1369 261-1369 (508) 836-393 - E-mail: HITESH198789(@YAHOO.COM Alt E -Mail: -- 13) District Or Regional Supervisor (if applicable) Name & Title: �BHIKHAJI S. PARMAR Address: 3 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 1(508) 261-1369 FAX: 24 Hour Emergency No: (508) 409-9228 E-mail -- Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) NO of Food Employees 3 17) DAYS/HOURS: MON-SAT 6:30 AM -9 PM SUN 7 AM -9:00 PM 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 -- 119) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ — i 20) Location: Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: W Annual ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: 22) Establishment Type Retail ( 3,200 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 W Retail Food $50.00 ❑ Retail Snack Food $12.50 n Tobacco Products $12.50 Temporary Time: 1 Rain Date: — - - -- - Definitions: PHF Potentially p hazardous food (hme/temp perature controls required) processing) - i 23) Food Operations i Non-PHFs - non -potentially hazardous food(no time/tem erature controls required) i(Check all that apply): I _ -- -- - Order - - _❑ Hot PHF Cooked and Cooled or Hot Held RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further -- - ❑ Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Ord { for More Than a Single Meal Service — - - -- � - ---- Pre aration of PRFs For Hot An - - ❑ Sale of Commercially Pre -Packaged PHFs P -- --] Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly —_ - F .I•t Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Customer Self -Service of Non PHF and Non - Perishable Foods Only ---- -- ---- ❑ Preparation of Non-PHFs Other Food Operations Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale Susceptible Population aci i y ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin -- - I F1 Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service IT] Retail Sale of Salvage, Out -Of -Date- -- --- - - or Reconditioned Food To be completed by the Board of Health - J 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 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 the federal Food Code. 24) Signature of Applicant: H 'Q ` i1 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: 04-3521128 Q � 26) Signature of Individual or Corporate Name: ` 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: KANKU, INC. dba THE STORE ADDRESS: 213 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-1369 FAX NUMBER: (508) 836-3934 OWNER OF BUSINESS: MADHUBEN R. PATEL 1� TELEPHONE OF OWNER: (508) 836-2615 _S 0 FEDERAL ID/SS NUMBER: 04-3521128 FEE: $5.00 PERMIT NUMBER: RF -31 SIGNATURE: - \j _ - DATE: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield MA 02048 PERMIT NUMBER: RF -31 -_- -- --__ - 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: KANKU, INC. DBA THE STORE LOCATION OF SALE OF TOBACCO PRODUCTS: 213 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-1369 OWNER OF BUSINESS: MADHUBEN R. PATEL ADDRESS OF OWNER: 22 LONG DRIVE, WESTBORO, MA 01581 0 IVA Q "JAN-, V"C-i Nt1 S -fit - TELEPHONE OF OWNER: (508) 836-2615 4-0 34 FAX NUMBER: (508) 261 -7172 ------------- If a corporation or partnership, give name, title, and home address of officers or partner. MADHUBEN R. PATEL1i------� - - - 22 LONG DRIVE, WESTBORO, MA 01581 _ ��S (� _'R ►. ( 1 R- - * Provide a copy _of -current Department of Revenue CT -3T Retail Excise UnitLicense._ - - FEE: $12.50 CT -3T NUMBER: - -0 VA ; FEDERAL ID/SS NUMBER: 04-3521128 SIGNATURE: - -" I \ '-_VC 7 - - -- DATE: C., - . -` Forrn CT -3T Massachusetts Department mf Revenue —~^~~= �� Cigarette Excise Unit 2014-2016 metamnLicense for Sale mf Cigarettes and Cigars and Smoking Tobacco Dovt This License must uePosted and visible atall times. Sales to Persons under 1nyears mage are pmxw��uv| law. Application 4H433 Federd|«*»UU«o��norGoo�)amu�YNumhec ��D_�� 11�Q License Number: Date ofIssue: - 84888 09/26/2014 Mailing address for license: ------- KANKU |NC 213GMAIN ST MANSFIELD, MA 02048 Retail sale location (if different than Mailing address) THE STORE 213SMAIN GT MANSFIELD, MA 02048 This certifies that the taxpayer named above has p~~ the required license fee and is licensed to sell at retail at the address shown above until September ao. 2016. This license is not transferable, and is subject tosuspension for failure tocomply with the law. '— |---� 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. Vo W- �) \ �Q * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 3Sj-_�\'�- ** 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 beWhetheedMassachusetts or tax Department of Revenue to determine you have met tax f I ng payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension ral Laws, Chapter 62C, Section request is made under the authority of Mass. Gen 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 o n Address: \ _� t,s �i1 MCS n s �k: Ti City/State/Zip:1_'\,QI CA Are you an employer? Check the appropriate box: LS 1 am a employer with employees (full and/ or part-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.] (hone #: );� o S `- 4 � ` ,- \ 5 L CA 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.❑ Manufacturing 11. F1 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: M_ 'e A chi Cir C) cA4'\ CA _ c�1�VNI c Insurer's Address: -2- j - C� City/State/Zip: �fe i ®aN Policy # or Self -ins, Lic, #,1(1 i ti Expiration Date: 0 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 DTA for insurance coverage verification, I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: • t 4%/ A Date: t) � \ — � 6 T 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 #: INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent# 5960 MA Retail Merchants WC Group Inc. Association Benefits Insurance Age PO Box 859222-9222 299 Ballardvale St, Suite 1 Braintree, MA 02185 Wilmington, MA 01887 (Carrier Code: 34355) Carrier Policy 014005032484116 Carrier Prior Policy 014005032484115 1. The Insured: Kanku, Inc. The Store Mailing Address: 213 South Main St. Mansfield, MA 02048 Fein: 043521128 Other workplaces not shown above: NO OTHER WORKPLACES FOR THIS POLICY Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1/01./20.16to 12:01 a.m. on 1101/2017_ at the insureds 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 $ 100,000 _ each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000310(04/84) 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 $ 649.00 Minimum Premium $ 234.00 Expense Constant .00 Deposit Premium 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 applicantwho 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 ent of Industrial Accidents, Should you that the application for the permit or license is being requested, not the Departm 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 f le 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 1477-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05