HomeMy WebLinkAboutBenny's 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 FOOD LICENSE
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:.
BENNY'S OF MASS, INC.
Whose place of business is:
BENNY'S OF MASS
65 COPELAND DRIVE
PERSON(S) IN CHARGE:
VICTOR POLUBINSKI, STORE MANAGER
Permit Expires: December 31, 2016
License Number: RF -110
Food Fee: $50.00
BOARD OF HEALTH
MichaeCMcCCean, Chairman
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FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
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RF -110
FOOD ESTABLISHMENT PERMIT APPLICATION
-
--(Application mustTesubmitted at Feasf30 days before the planned opening date)
1) Establishment Name BENNY'S OF MASS
2) Establishment Address 65 COPELAND DRIVE
3) Establishment Mailing Address (if different) 65 COPELAND DRIVE
MANSFIELD, MA 02048
r4) Establishment Telephone No (508) 339-6027
5) Applicant Name & Title: HOWARD BROMBERG, PRESIDENT
6) Applicant Address 340 WATERMAN AVENUE, ESMOND, RI 02917
7) Applicant Telephone No.: (401) 231-1000 24 Hour Emergency No.: (401) 231-1000
8) Owners Name & Title BENNY'S OF MASS, INC.
9) Owner Address (If different from applicant) 340 WATERMAN AVENUE, ESMOND, RI 02917
Owner's telephone number 4012311000
10) Establishment Owned 13y: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
0 A Corporation Name Title Address
❑ An Individual Howard Bromberg - - President3.40 Waterman_ Ave._, Esmond, RI 102917
i ❑ A Partnership- - -
Judith Rosenstein
El Other legal Entity
V. PrPresident_-340 Waterman- Ave_,_-, Esmon , RI ;02317
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: �CTOR POLUBINSKI, STORE MANAGER
Address: 65 COPELAND DRIVE, MANSFIELD, MA 02048
Telephone No: 1(508) 339-6027
--...--_-._—__-
FAX:
E-mail:
Alt E-mail:
13) District Or Regional Supervisor (if applicable)
�--Name-& Title:
Address:
Telephone No:
FAX: E-mail:
24 Hour Emergency No: (401) 231-1000
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees:
17) DAYS/HOURS: 9 AM -9 PM MON-SAT 9 AM -5 PM SUN
j 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): ❑ N/A
20) Location: Permanent Location
2) Establishment Type
❑ Moblie Moblie Start Date: )M 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: i ❑ Food Service up to 101 -200
�/❑ Annual or up to 25' PHF display $75.00
j❑Seasonal i ❑ Food Service up to 201 +
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
or 25+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
N/A
❑ 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
❑ Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
23) Food Operations INon-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 ❑ PHFCooked To Order ❑Hot PHF Cooked and Cooled or Not Held
for More Than a Single Meal Service
Sale of Commercial) Pre -Packaged PHFs —� Preparation of PHFs For Hot And
Delivery of Packaged PH Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
I ❑ Y 9 -- -
❑ rY g --- - - Susceptible Population Facility
❑
S
Reheating of Commercially I ❑ tolbe Prepared ' ended
by Consummal Foods er
Vacuum Packaging / Cook Chill -
Processed Foods for Service Within 4 Hours ❑ ------ --_- _ - -_-- II ❑and/or HACCP Plan (incUse of Process
A Variance
a hand
❑d Customer Self -Service of Non PHF and Non- I d Customer Self -Service i
Perishable Foods Only h - -- -- - — ---
❑ Ice Manufactured and Packaged for contact alternative, time as a public health
- - -- _ - - control)
❑ Preparation of Non-PHFs Retail Sale
Other Food Operations
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
now requires retail food permitPrepares
- -- eals for
E] Offers RTE PHF in Bulk Quantities ❑
Catered Events olngle r Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date - -
or Reconditioned Food To be completed by the Board of Health
L- - — - - - ----- Total Permit Fee: $50.00
Payment is due with application ❑ waived
I, the undersigned, attest to the cur cy of the i
r ation provided in this application and affirm that the food
establishment operation will cp p th 105 Cy
90.¢00 and all other applicable law. I have been instructed by the
board of health on how to o�taln ies of 105,
R 590.000 and the federal Food Code.
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24) Signature of Applicant:
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Pursuant to MGL Ch.62C, seq. 49A, I certify under the pen ties of perjury that I, to my best knowledge an0,15el f ave filed all state tax returns
and paid state taxes required' under law.
25) Social Security Number or Federal ID: 05-0299803
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26) Signature of Individua'I'or Corporate Name:
'"
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.
* Signature of Individual or
Corporate Name (Mandatory)
ndatory, 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
IF 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
. Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: BENNY' S of MASS, INC.
Address:
65 COPELAND DRIVE
City/State/Zip: MANSFIELD, MA 02048 Phone #: (508) 339-6027
Are you an employer? Check the appropriate box:
1. ❑ 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.]
Business Type (required):
5. jq Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11.❑ 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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Argonaut Insurance c/o AON Risk Services, Tnc_ of RT
Insurer's Address:
City/State/Zip:
50 Kennedy Plaza, 10th Floor
Providence, RI 02902-2392
Policy # or Self -ins. Lic. # 928018245184 Expiration Date: 4/01/17
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 verif}emtign. 1'
I do hereby c rtify, under the pains and penalties
SiLrrtature:
provided above is true and correct
7 7 /6
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
Argonaut Insurance Company
225 West Washington Street, 24th Floor, Chicago, IL 60606
P.O. Box 469011, San Antonio, TX 78246 WC 00 00 01A
NCCI CARRIER CODE NO. 14095
INFORMATIONWORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLIC
1. The Insured: Benny' s Inc
Mailing address: 340 Waterman Avenue
Smithfield, RI 0291.7-2525
Other workplaces not shown above: See Schedule
Policy No. WC 9281.38245184
Renewal of:WC 928018245184
Individual Partnership
X Corporation or
Federal Employers I.D.# See Schedule-
Inter/Intrastate Risk I.D. # 910343815
Other I.D. #
2. The policy period is from 0-4/01 0 12:01 a.m. to G 101 L1.7' 12:01 a.m. standard time 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: CT, 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 $ 1, 00.0 , 00:0 each accident
Bodily Injury by Disease $ 1, 0 0 0',.0 0 0 policy limit
Bodily Injury by Disease $ _ .1., OQO , Q.00 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except states designated in Item 3.A. of the Information. Page
and ND,OH,RI,WA,WY
D. This policy includes these endorsements and schedules: See Schedule
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.
Premium Basis Rate Per
Code Total Estimated $100 of Estimated
Classification No. Annual Remuneration Remuneration Annual Premium
See Item 4. Extension WC 00 00 01A
See Item 4. Extension WC 00 00 01A - Tax/Surcharge/Assessments
Total Estimated Annual Premium and Surcharges $
Deposit Premium $
Minimum Premium $ (CT)8380 Expense Constant $
Premium Adjustment Period: Annual Countersigned by:
Servicing Office: 9209 - Chicago, IL. (800) 422-9120 Date:O,./0:42:O1,E
Producer: TRIDENT INSURANCE SERVICES, LLC
175 E. HOUSTON, SUITE 1300
San Antonio, TX 78205
Producer Code: 920A-DO9
Copyright 1987 National Council on Compensation Insurance,
Original
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