The URL can be used to link to this page

Home My WebLink AboutMansfield Gas 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:. WISSAM SAMROUT, PRESIDENT BOARD OF HEALTH Whose place of business is: MANSFIELD GAS & SERVICE, INC. 54 CHAUNCY STREET License Number: S-84 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream ❑ MichaeCNcCCean, Chairman Permit for the Sale of 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 GAS & SERVICE, INC. 54 CHAUNCY STREET BOARD OF HEALTH License Number: S-84 Permit Expires: December 31, 2016 NichaeCNcCCean, Chairman FOR BOARD OF HEALTH USE ONLY FDateed: Date Inspected: Approved By: Permit # Issued S-84 eIr n MMI If-% A-rInnl FODU t5 I A LISr1ivir_IV 1 r-CRIVII I ru- 1 1 • pp Ica ion mus esu mi e a eas ays a ore e p anne opening a e stablishment Name MANSFIELD GAS & SERVICE, INC. r2) stablishment Address 54 CHAUNCY STREET 3) Establishment Mailing Address (if different) 54 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-3179 5) Applicant Name & Title: WISSAM SAMROUT 6) Applicant Address 54 CHAUNCY STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508� 498-6401 24 Hour Emergency No.: 508-838-5100508-369-1924508.226-8818 8) Owners Name & Title WISSAM SAMROUT, PRESIDENT 9) Owner Address (If different from applicant) 903 COUNTY STREET, ATTLEBORO,MA 02702 Owner's telephone number 5083393179 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 0 A Corporation Name �`itle Address ❑ An Individual FAX: ❑ A Partnership E-mail: ❑ Other legal Entity r•hnrnc minaniicnr manager etc.) 12) Person urecuy Name & Title: Ke5pun5iuic Ful Lja11y-- WISSAM SAMROUT, MANAGER Address: 9 T, ATTLEBORO, MA 02702 Telephone No: (508) 498-6401 24 Hour Emergency No: 508-838-5100 508-369-1924 50 8-226-8818 (508) 339-1940 1 FAX: E-mail: WISS0180-HOTMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 2 17) DAYS/HOURS: 24 HRS. -7 DAYS PER WEEK 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 [1!9)Person Trainedin Anti -Choking Procedure=(lf25 Seats o�morey. ❑ 20) Location: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: n Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type 0 Retail ( 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 Retail Snack Food $12.50 0 Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature 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 ❑ 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 ❑ 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 ❑ 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 control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 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 all other applicable law. I have been instructed by the board of health on how to obtain c9pies ot,;6 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: _f Pursuant to MGL Ch.62C, sec. 491/1 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: 453 03 0 ,16 26) Signature of Individual or Corporate Name:_J,/ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 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 GAS & SERVICE, INC. LOCATION OF SALE OF TOBACCO PRODUCTS: 54 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-3179 OWNER OF BUSINESS: ADDRESS OF OWNER: WISSAM SAMROUT TELEPHONE OF OWNER: (508) 339-3179 FAX NUMBER: (508) 339-1940 EBORO, MA 02702 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: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 453 03 0816 SIGNATURE: DATE: (',®- 4 — Sincerely, Massachusetts Dept..,, Mas; achuSefts Department Of Revenue Customer servica.sureau PO BOX 7010 Boston, MA 02204 gmt % The vendor heteln name is registered to sell d tangible Personal prQperty at retail or for resale, pursu General Laws, Chapters 62C, 64H and 641, Thisregistration ant t(, specified herein ration is effectlVe only for the registrant at the locati, - Any change of name or address must be reported to the Department of Revenue so that z Correct .$T_1 can be issued. 14ANSFIELD GAS & SERVICE INC 54 CHAWY STREET MANSHELD HA 02049 411L4L3LA4AUVr1 InUHt Do ClIgplayed for customers to see and is 90t assignable or Jawferaj)le. Form CT -3T 06623 MasSachuseto DePaltMent of Revenue 2014-2016 cigarette Excise Unit Retailer License for Sale of Cigarettes and cigars and Smoking Tobacco DUPLICATE IIENSE-DATE OF REPRINTING 10/13/2015 der 18 years *f age are prohibited by 10W. This Ucense must be posted and visible at Bit thM. sales to persons un License Number. Date. of Issue: Number.. 41536 10/JT/20114 ApplWation 06623 Federal Identiricoion or social security Number: 453-03-0810 A f Retail sale location (if ditWent than malfing QddM orl" Retail le mailing addM55 fat 1100n3s'. 6 - MANSFIELD GAS SERVICE & SERVICE INC C Cy 8 ' 'I 54 CHAUNCY ST MANSFIELD GAS M S IrLo M 0 -MANSFIELD, MA 02048 154 CHAUNCY ST MANSFIELD, MA 02048 above urffll This certifiesOVA the taxpayernamed above has paid the requlmd WPM fee and is llwwAd to sell at retail at the Bddress shownSeptember 30,2016. This ll Is Is not imsferable, n and is subject to suspe . sion for failure to ComplyvAth the low.' 453-030 Ism 11/0 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. * Signatof Individual or Corpo ate Name (Mandatory) _ CU i By: Corporate Officer (Mandatory, if applicable) �S�-0_�b -1�It3 ** 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 Address: City/State/Zip: Are you an employer? Check tie appropriate box: 1. 01,iam 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.] 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 1011 Manufacturing 11. ❑ Health Care 12.0 Other *Any applicant that checks box #I must also 611 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' c mpensation insurance for my employees. Beloowi�sPthe policy information. Insurance Company Name:—n a t� c ho wC-1.(6 Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # C C « e� -L�i Expiration Date: / / L% I do I It: 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 under and penalties of perjury that the information provided above is true and correct �<tiW E. 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.gov/dia Phone / 1 ®711/30/2015 A� V CERTIFICATE OF LIAEILIrf INSURANCE E(MM/DDIYYYY) 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 Association Benefits Insurance Agency 299 Baliardvale St, Suite 1 Wilmington, MA 01887 CONTACT NAME: PHONE FAX c o EM No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL # INSURERA: MA Retail Merchants WC Group Inc. INSURED Mansfield Gas & Service Inc. 54 Chauncy St. Mansfield, MA 02048 INSURER B: INSURER C: INSURERD: INSURER E: INSURER F: rnvconr_ca CERTIFICATE NUMRFR' 00001 REVISION NUMBER: 00001 .. 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 CONTRACT OR 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 TERNS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ANSR WVD R POLICY NUMBER MWDWYYYF MWDDYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E OCCUR EACH OCCURRENCE $ DAMAGE TO RENT 1_07 - PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JPECC LOC PRODUCTS- COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIABOCCUR EXCESS LIAB HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? F—]N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below IA 014005032433116 /01/2016 1101 /2017 X VVCSTATU- OTH- I ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V i988-200 ACORE) 6UKrUKA f IUIY. NII r1QrIW fw5cif Vcu. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 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