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Home My WebLink AboutMansfield Deli 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 °ermit to Operate a Food Service Establishmen 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:. THOMAS E. REILLY Whose place of business is: MANSFIELD DELI 72 PRATT STREET License Number: FS -37 Permit Expires: December 31, 2016 BOARD OF HEALTH Food Fee: $62.50 Milk & Cream W -MichaeC-McCCean, Chairman Permtt or the Sale o 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: MANSFIELD DELI 72 PRATT STREET License Number: FS -37 Permit Expires: December 31, 2016 BOARD OF HEALTH MichaeCvicCCean, 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: THOMAS E. REILLY having a place of business at. MANSFIELD DELI 72 PRATT 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 -37 Scott Leite, Heaah Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -37 FOOD ESTABLISHMENT PERMIT APPLICATION ( pp icafTon musfb-e—submi�db-tTe-ast-3D-c7ay�fore-the pVa-nn-ecTopenmg dat7 1) Establishment Name MANSFIELD DELI 2) Establishment Address 72 PRATT STREET 3) Establishment Mailing Address (if different) 72 PRATT STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-2994 5) Applicant Name & Title: THOMAS E. REILLY 6) Applicant Address 3 GROVER LANE, FOXBORO, MA 02035 7) Applicant Telephone No.: (508) 543-2405 24 Hour Emergency No.: (774) 571-0215 8) Owners Name & Title THOMAS E. REILLY 9) Owner Address (If different from applicant) 3 GROVER LANE, FOXBORO, MA 02035 Owner's telephone number (508) 543-2405 10) Establishment Owned By 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. li V 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: ITHOMASE.REILLY Address: 3 GROVER LANE, FOXBORO, MA 02035 Telephone No: (774) 571-0215 24 Hour Emergency No: (774) 571-0215 FAX: - E -mail: TEREILLY97000MCAST.NET Alt E -Mail - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: I -------__- �- - ---- - - _ -- _ -1 Telephone No. IS 24 Hour Emergency No: - L E-mail: -� M c,3i. w1 FAX: - ' Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) �16) No. of Food Employees: 16 17) DAYS/HOURS: 7 DAYS MON-SAT 6 AM - 7 PM SUN 7 AM - 3 PM 18) Name of Person In Charge Certified in Food Protection Management: CAROL D'AMBRA 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 GARRET certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: W Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: Retail ( Sq. Ft) Moblie End Date: (� Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: J 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) ❑ 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 ❑ 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) Sale of Commercially Pre -Packaged Non -PRFs li 0 Sale of Commercially Pre -Packaged PRFs F./I Delivery of Packaged PH Fs 0 Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Customer Self -Service of Non PHF and Non - Perishable Foods Only PHFCooked To Order Preparation of PRFs 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 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 L] Preparation of Non-PHFs- Retail Sale control) Other Food Operations 0 Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin �Fooeals for ❑ Offers RTE PHF in Bulk Quantities P teraed res Events or/Single Institutional Food Service Retail Sale of Salvage, Out -Of -Date - — - -- - or Reconditioned Food To be completed by the Board of Health - - Total Permit Fee: $62.50 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 all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 0.000 and the federal Food Code. 24) Signature of Applicant: L.AJ'-- 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: 04-30260$5 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: MANSFIELD DELI ADDRESS: 72 PRATT STREET TELEPHONE AT LOCATION: (508) 339-2994 FAX NUMBER: OWNER OF BUSINESS: THOMAS E. REILLY TELEPHONE OF OWNER: (508) 543-2405 FEDERAL ID/SS NUMBER: 04-3026085 FEE: $5.00 PERMIT NUMBER: FS -37 SIGNATURE: CL All" DATE: S " S' co Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS -37 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: MANSFIELD DELI LOCATION OF SALE OF TOBACCO PRODUCTS: 72 PRATT STREET TELEPHONE AT LOCATION: (508) 339-2994 OWNER OF BUSINESS: THOMAS E. REILLY ADDRESS OF OWNER: 3 GLOVER LANE, FOXBORO, MA 02035 TELEPHONE OF OWNER: (508) 543-2405 FAX NUMBER: 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: 04-3026085 SIGNATURE: DATE: S' -r' oEPAArMFtir Form CT -3T j 01735 Massachusetts Department of Revenue 2014 - 2016 m Cigarette Excise Unit 1 Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco 1 ooa This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by taw. application Number: 47537 License Number: Date of Issue: Federal Identification or Social Security Number: 200-14-5412 01735 09/11/2014 , Mailing address for license: Retail sale location (if different than mailing address) MANSFIELD DELI LLC MANSFIELD DELI 72 PRATT ST 72 PRATT ST MANSFIELD, MA 02048 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. "LJ * Signature of Indivi ual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) L 00 of S' 4 ('-L-- Social "L 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 nnlicant Information MANSFIELD DELI, LLC Please Business/Organization Name: 72 PRATTST REET MANSFI 2048 Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I 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.] Phone #: 501'115-11!J 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 10.0 Manufacturing I l.❑ Health Care 12.❑ 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 'T HL" r H ARI E0rn n r Insurer's Address: 0"--poy �ku— 3UJ S'7g7c $�• �� l(N� City/State/Zip: S y, p l co i `' /y�'' Policy # or Self -ins. Lic. # 0 S ' W F t-• — 'C5 d t (' Expiration Date: q'114_0 Attach a rcopy 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. c; .. �t„rA• --%a—_ �_ 0, , Date: s 01 b t-1— Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www,mass.gowuia Phone / 16WC 00 00 00 B) (Policy Provisions: 14 TJ INFORMATION PAGE WEE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD CASUALTY INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 14397 Company Code: 3 0 d+ N 0 C POLICY NUMBER: 08 WEC TJ1416 _ CD Previous Policy Number: 08 WEC TJ1416 HOUSING CODE: DW v 1. Named Insured and Mailing Address: MANSFIELD DELI & LIQUORS LLC 00 (No., Street, Town, State, Zip Code) 0 N 0 72 PRATT STREET 'n FEIN Number: 042766918 MANSFIELD, MA 02048 M State Identification Number(s): UIN: The Named Insured is: LIMITED LIABILITY COMPANY Business of Named Insured: DELICATESSEN Other workplaces not shown above: 72 PRATT STREET MANSFIELD MA 02048 2. Policy Period: From 04/24/16 To 04/24/17 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: C&S INSURANCE AGENCY INC/PHS 301 WOODS PARK DRIVE CLINTON, NY 13323 Producer's Code: 088597 Issuing Office: THE HARTFORD 301 WOODS PARK DRIVE CLINTON NY 13323 (866) 467-8730 Total Estimated Annual Premium: $5,081 Deposit Premium: Policy Minimum Premium: $232 MA Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Suffix LARS RENEWAL 1 09 Countersigned by f 03/05/16 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 03/05/16 Policy Expiration Date: 04/24/17 ORIGINAL INFORMATION PAGE (Continued) Policy Number: 08 WEC TJ1416 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation L states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 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: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A 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. MA RATE DEVIATION PREMIUM CREDIT (.05) (9037) -243 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 4,616 MA - MERIT RATING CREDIT (9885) .950 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 4,385 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 4,385 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMENT 5.750 PERCENT 265 TERRORISM (9740) 309,500 .030 93 TOTAL ESTIMATED ANNUAL PREMIUM 5,081 Total Estimated Annual Premium: $5,081 Deposit Premium: Policy Minimum Premium: $232 MA Interstate/Intrastate Identification Number: Labor Contractors Policy Number: Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 03/05/16 / 000363379 NAICS: SIC: 5812 UIN: NO. OF EMP: 000007 Page 2 Policy Expiration Date: 04/24/17 Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8006 309,500 1.57 4,859 STORE: DELICATESSEN - RETAIL MA RATE DEVIATION PREMIUM CREDIT (.05) (9037) -243 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 4,616 MA - MERIT RATING CREDIT (9885) .950 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 4,385 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 4,385 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMENT 5.750 PERCENT 265 TERRORISM (9740) 309,500 .030 93 TOTAL ESTIMATED ANNUAL PREMIUM 5,081 Total Estimated Annual Premium: $5,081 Deposit Premium: Policy Minimum Premium: $232 MA Interstate/Intrastate Identification Number: Labor Contractors Policy Number: Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 03/05/16 / 000363379 NAICS: SIC: 5812 UIN: NO. OF EMP: 000007 Page 2 Policy Expiration Date: 04/24/17 CFtf� ^ str MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L2054830080 C}- J PO BOX 7044 Notice Date: April 19, 2016 Account ID: SLS -10938204-005 BOSTON > ; , MA 02204-7044 CONTACT CENTER ' 7off (617) 887-6367 SALES AND USE TAX REGISTRATION CERTIFICATE Q = MANSFIELD DELI LLC o— MANSFIELD DELI 72 PRATT ST MANSFIELD MA 02048-1927 Attached below is your Sales and Use Tax Registration Certificate (Form ST -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 revised ST -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 ---------------------------------------------------------------------------------------------------------------------------------------------- ``'`H"r�T MASSACHUSETTS DEPARTMENT OF REVENUE Form ST -1 Sales and Use Tax Registration Certificate This registration must be posted and visible at all times. jvr o� g MANSFIELD DELI LLC Account ID: SLS -10938204-005 MANSFIELD DELI Certificate Number: 421191680 72 PRATT ST MANSFIELD MA 02048-1927 This certifies that the taxpayer named above is registered under Chapters 62C, 64H and 64I of the Massachusetts General Laws to sell tangible personal property at retail or for resale 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: December 1, 2003 H k, IN O Ln W Ln 0 u 0 boo —,(uLl V, < > LU 4� > Fn 0U In0 w E2 - co 7� 9 0 � O .4 %D c :2 o u 0 Lu (-, I 0 2 c m — to bo, CA .2 U c) 41 Ln LE V) ro r - m u Oc)o � I -� =io 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 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 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