Loading...
HomeMy WebLinkAboutBG Food 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: FOOD ESTABLISHMENT 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:. JASON SWEENEY Whose place of business is: BG FOOD MANSFIELD LLC DBA- B.GOOD 280 SCHOOL STREET PERSON(S) IN CHARGE: ANTHONY DEPAIVA Permit Expires: December 31, 2016 License Number: FS -165 Food Fee: $62.50 Milk & Cream BOARD OF HEALTH NichaeC-'AVicCCean, 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 j This is to certify that: JASON SWEENEY having a place of business at: BG FOOD MANSFIELD LLC DBA- B.GOOD 280 SCHOOL 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 12131/2016 License No.: FS -165 Scott feite, 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 -165 FOOD ESTABLISHMENT PERMIT APPLICATION a J ,E, �pTca ion musi' be submitted a�Teast �0 Sys before Tie planned opening dale e 1) Establishment Name BG FOOD MANSFIELD LLC DBA- B.GOOD 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET _F_, z 5s § ;�x u_ MANSFIELD, MA 02048 4) Establishment Telephone No ***** 5) Applicant Name & Title: JASON SWEENEY, PARTNER/MANAGER 6) Applicant Address 501 LEXINGTON STREET, UNIT 111, WALTHAM, MA 02452 7) Applicant Telephone No.: (617) 877-0252 24 Hour Emergency No.: 8) Owners Name & Title JASON SWEENEY 9) Owner Address (If different from applicant) 501 LEXINGTON STREET, UNIT 111, WALTHAM, MA 02452 Owner's telephone number (617) 877-0252 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W 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: ANTHONY DEPAIVA Address: 21 PALLAD STREET PROVIDENCE, RI 02903 Telephone No: ;(401) 699-1883 24 Hour Emergency No: FAX: - E -mail IANTHONYDEPAIVA(cD-BGOOD 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 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No, of Food Employees: 17) DAYS/HOURS: SUN -SAT 11 AM - 10 PM TOWN 20 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY DEPAIVA i 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 JASON SWEENEY certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: W Permanent Location ❑ Moblie Moblie Start Date: i Moblie End Date: Moblie Comments: X21) Length of Permit: j Annual { ❑ Seasonal Seasonal Dates: 22) Establishment Type ❑ Retail ( Sq. Ft) ,J 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 Temporary Temporary Start Date: ( Meals/Day) Temporary End Date: i Temporary Time: Rain Date: ❑ 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: 0 ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 I - ---- -- - 23) Food Operations Definitions: PHF Potentiallyhazardous food time/tem(erature controls required) Non-PHFs non -potentially hazardous foodno 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 iV1 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held __ ___ -- -- -- ----- for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And- - - - -- - ---- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs --- -- Susceptible Population Facility ----- - - - - ---- - - - -� ❑ Sale of Raw Animal Foods Intended E] Reheating of Commercially to be Prepared by Consumer 1 ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours --------- -- - -- ---- ❑ Use of Process Requiring A Variance ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only -- - - _-- - contact alternative, time as a public health F-1IceManufactured and Packaged for ❑ Preparation of Non-PHFs Retail Sale control) Other Food Operations F1Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin -- _ E] Prepares Food/Single Meals for ❑ Offers RTE PHF m Bulk Quantities i Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -- - - - or Reconditioned Food To be completed by the Board of Health _-- _ -----_ -- - - - -J Total Permit Fee: $62.50 Payment is due with application E] 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 CNR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify unde he penalties of perjury that I, and paid state taxes required under law. 25) Social Security Number or Federal ID: 38-3970462 26) Signature of Individual or Corporate Name: best knowledge and belief, have filed all state tax returns 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 o Individual or Corporate Name (Mandatory) (�\ A � ) --- d/OAns e Id LL G By: Corporateicer (Mandato , 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. aThe 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: Address: G City/State/Zip: / Irt Anri5 fj'L1 A � 0aO f g Phone #: qo )— ` oo-- L4 11 3 S Are you an employer? Check the appropriate box: 1. f4 I am a employer with S 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.] r B.SGCd 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 11,0 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: R CAir oy f Insurer's City/State/Zip: Policy # or Self -ins, Lic. Expiration Date: .1 ) 116 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 andpenalties Operjury that the information provided above is true and correct Phone #• 01 G 6 � (--/ V -� - ✓ 0 �� a Qfjicial use only, Do not write in this area, to be completed by city or town official City or Town: Permit/License # 11� a r" 6 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 #: ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YYYY) 5/23/2016 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(les) 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 CONTACT NAME: McSweeney & Ricci Insurance Agency, Inc. 420 Washington Street P.O. Box 850984 AIPHCN o Ext -8 O A1C No):781-843-8807 E-MAIL ADDRESS:mrirece tion mcsweene ricci.com INSURERS AFFORDING COVERAGE NAIC # Braintree MA 02185 INSURERA -Arbe la Insurance Group 7000 DAMAGE TO RENTED PREMISES Ea occurrence $500,000 INSURED BGFOO-2 INSURERB:Guard Insurance Group INSURERC: BG Food Mansfield LLC 280 School Street Mansfield MA 02048 INSURER D : $ A INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: 924584960 REVISION NUMBER: 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 TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MWDD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE K OCCUR CCP8500064906 10/31/2015 10/31/2016 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $500,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS -COMP/OP AGG $2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS X AUTOS CCP8500064906 10/31/2015 10/31/2016 COMBINED SINGLE LIMI I Ea ocid.ntl $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per acc dent $ A UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE UMN4600064907 10/31/2015 10/31/2016 EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below N / A BGWC674696 10/1/2015 10/1/2016 X I WC SLATU- OIMITS I EH - TORY — E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Evidence of Coverage Lh_\► VA a 111 14_1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE --Att(,V�� ct ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 2 9 ■ "q 0 \ 0 � ■ d d � � Z LU � �W ■ � 0 m o - U. U. �L)■ / « � � uj « � uw Q � ui L) z LLJ LLI � U) z 0 � � � R 2 E j k $ $ # � / ƒ � 2 k CD ) 0 k 0 r 9 L. * 3 � �� �U- CL o o E LU 0 § < �\ c C oa _ ƒ ( ( } \ } � { ( ' \ ( � . ( } [ * 3 � �� �U- CL o o E LU 0 § < �\ c C oa _ ƒ � \) a O C y w 4 a .w" a � to tip -. N v� Si ..;:N yV J Fl� v y 04 >r. Cd .V14, 0 v cd z U zo N o a qa'U ZWO 0 r N h d a < N IIR =c : M J. ot w o c% y P •r7 �y r u 0 M t r I>LI Itt h713i O C y w 4 .w" a � to tip v� Si a OY C>J' a V •" yV J Fl� v y I>LI Itt h713i 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 (Le, 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