HomeMy WebLinkAboutMansfield Service 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:.
ELIAS KAZAN
Whose place of business is: MANSFIELD SERVICE, INC.
189 CHAUNCY STREET
Permit Expires: December 31, 2016
License Number: RF -48
BOARD OF HEALTH
Food Fee: $67.50
Milk & Cream
AichaeCvlcCCean, 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 SERVICE, INC.
189 CHAUNCY STREET
License Number: RF -48
Permit Expires: December 31, 2016
BOARD OF HEALTH
NichaeCvlcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
ELIAS KAZAN
having a place of business at:
MANSFIELD SERVICE, INC.
189 CHAUNCY 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 1213112016 , unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: RF -48
Scott Leite, Heaah .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
,J
S 0 FR 'a I v_1 F N
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit# Issued
RF -48
FOOD ESTABLISHMENT PERMIT APPLICATION
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1) Establishment Name MANSFIELD SERVICE, INC.
12) Establishment Address 189 CHAUNCY STREET
3) Establishment Mailing Address (if different) 189 CHAUNCY STREET
MANSFIELD, MA 02048
EstablishmentTelephoneNo (508) 339-9054 _j
5) Applicant Name & Title: ELIAS KAZAN, PRESIDENT
6) Applicant Address 18 TALBOTT FARM DRIVE, MENDON, MA 01756
7) Applicant Telephone No.: (508) 473-2722 24 Hour Emergency No.: (774) 573-7465 (508) 339-2074
8) Owners Name & Title ELIAS KAZAN
9) Owner Address (If different from applicant) 18 TALBOTT FARM DRIVE, MENDON, MA 01765
Owner's telephone number (508) 473-2722
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
El An Association or partner.
k A Corporation Name Title Address
0 An Individual
11 A Partnership
0 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, man - ager etc.
Name & Title: ELIAS KAZAN, PRESIDENT
CAdd_re ss--: 18 TALBOTT FARM DRIVE, MENDON, MA 01765
Telephone No: (508) 473-2722 24 Hour Emergency No: (774) 573-7465 (508) 339-2074
FAX:
E-mail: IEKAZAN(ciN)ERIZON.NET
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
'Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: 7 DAYS - 24 HRS,
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:
Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply):
22) Establishment Type
❑ 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
0 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)
d C 1 d H t Held
❑ Sale of Commercially Pre -Packaged Non-PHFs
__
PHFs
1 L PHFCooked To Order I
__--- -- --
❑ Preparation of PHFs For Hot And
❑ Hot PHF Cooked an oo a or o
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs
_._ --- _-- ---
---_ __ — ---_— - -
❑ Sale of Raw Animal Foods Intended
Susceptible Population Facility
- -
❑ Reheating of Commercially
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours-
- —
- - ss Requiring - 1
❑Use of PRequiring A Variance
❑ Customer Self -Service of Non PHF and Non-
Customer Self -Service
and/or HACCP Plan (including bare hand
PerishableFoods Only
-- -" —
Ice Manufactured and Packaged for
Q-
contact alternative, time as a public health
— _
❑ Preparation of Non-PHFs
Retail Sale
control) -
-- — - -
Juice Manufactured and Packaged for,
F] Offers Raw Or Undercooked Foo d Of
Other Food Operations
Retail Sale
Animal Origin
-------- --
--
❑ Prepares Food/Single Meals for
tional Food 'ce
ed Events or uBoard
-- - — -- -
❑ Offers RTE PHF in Bulk Quantities
❑ Retail Sale ofSalvage, Out -Of -Date
-To
or Reconditioned Food
bercompleted by the 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.
f A 1' t* `
24) Signature o pp scan .
Pursuant to MGL Ch.62C, sec. 49A, I certify under the
and paid state taxes required under law.
25) Social Security Number or Federal ID: 74-3234559
26) Signature of Individual or Corporate Name:
alties of perjury that I, to my best knowledge and belief, have filed all state tax returns
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 SERVICE, INC.
ADDRESS: 189 CHAUNCY STREET
TELEPHONE AT LOCATION: (508) 339-9054
FAX NUMBER: (508) 339-2074
OWNER OF BUSINESS: ELIAS KAZAN
TELEPHONE OF OWNER: (508) 473-2722
FEDERAL ID/SS NUMBER: 74-3234559
FEE: $5.00
PERMIT NUMBER: RF -48
SIGNATURE:
DATE:
x
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
PERMIT NUMBER: RF -48
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 SERVICE, INC.
LOCATION OF SALE OF TOBACCO PRODUCTS: 189 CHAUNCY STREET
TELEPHONE AT LOCATION: (508) 339-9054
OWNER OF BUSINESS: ELIAS KAZAN
ADDRESS OF OWNER: 18 TALBOTT FARM DRIVE, MENDON, MA 01765
TELEPHONE OF OWNER: (508) 473-2722
FAX NUMBER: (508) 339-2074
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: 74-3234559
SIGNATURE:?`,
DATE:12'1-1m
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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.
ri .
* Signat a of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** 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 N
Address: / °3 o i u, V1
City
AVey,, u an employer? Check the appropriate box:
lI 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.]
a'
Phone #
Bu'Koestaurant/Bar/Eating
s Type (required):
5. ,etail
6. Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10, ❑ Manufacturing
U. . ❑ 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.
1 am an employer that is providing workezrs' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: /` , Y;V j,., - , �;F`� r .r 1 4i,, 1, 1 v
Insurer's Address: ic4ill e,6" ` ;=
City/State/Zip: '`Wi`
(A � 0 2 i
Policy # or Self -ins, Lic. # G` f," `._. / 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.
1 do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct
Signature < — A__\ Date: v
-° ` I SIT: ��``.
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/d ia
Phone
�f
HARTFORD
f,
VDAC
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-9701 L87-6-15)
RENEWAL OF (6S6OUB-9701L87-6-14)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1.
NCCI CO CODE: 10456
INSURED: PRODUCER:
MANSFIELD SERVICE INC R D MURPHY INS AGENCY
189 CHAUNCY STREET 75 HANCOCK STREET
MANSFIELD MA 02048-1355 BRAINTREE MA 02185
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 11 -25-15 to 11-25-16 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
0
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
0
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
N
D. This policy includes these endorsements and schedules: -
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0
4. The premium for this policy will be determined by our, Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 11 -02-15 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: R D MURPHY INS AGENCY 75TBC
010397
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 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-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05