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Home My WebLink AboutNorth Main St. Cafe 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: 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:. STEPHEN CERULLO Whose place of business is: NORTH MAIN STREET CAFE 240 NORTH MAIN STREET PERSON(S) IN CHARGE: STEPHEN CERULLO, OWNER Permit Expires: December 31, 2016 License Number: FS -2 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH MichaeCMcCCean, 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: STEPHEN CERULLO having a place of business at: NORTH MAIN STREET CAFE 240 NORTH MAIN 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 -2 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 Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: h AV- mewN S t 2) Establishment Address: A) VX V " \rCLWS 6 . o JV► CI `iii e 3) Establishment Mailing Address (if different): N . 4) Establishment Telephone No: c_0 V C V%6 0' X (# � A 5) Applicant Name & Title: 6) Applicant Address: r C\ 0 N 0 A 0 vJ AA 0 7) Applicant Telephone No: :�� L1 ®� 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: m An association ¢as A corporation An individuate m A partnership m Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address V��$41u v�kLl ��' \r.ICo�t�?dtl R►� ,V o\ W AA1 Mc&a . wy 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: t 7� � �v, 00wi V`® 0VJVX&V7 Address: JCj, kkkjwin,x�°. QO Q vN30 A QAJ ft'� MLU Telephone No: 0?),-IFax: Emergency Telephone No: 13 District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: 590appl ication6-2. doe Food Establishment Information 14) Water Source: `-�o W t'i 15) Sewage disposal: DEP Public Water Supply No: (if applicable) 10.W E.,,i 16) Days and Hours of Operation: 10 AAA , � ( PM 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: Required as of 10/1/2001in accordance with 105 CMR 590.003(A) Pleweatlachco o/cer ate. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes ® No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer / (check one) LlRetail ( LA o0 Sq. Ft) L3Food Delivery Residential Kitchen for Sale ❑/ Permanent Structure [;/ Food Service - ( �, Seats) ❑ Retail ❑ Mobile [/ Food Service - Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service - Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) ❑ Annual ❑ Seasonal/Dates: ❑ Temporary/Dates/Time: Definitions: PHF— potentially hazardous food(time/temperature controls required) 23) Food Operations: Non-PHFs — non- potentially hazardous food (no time/temperature controls required) (C ck all that apply): RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre- PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service. ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Delivery of Packaged PHFs ❑ Sale Of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer. Reheating of Commercially ❑ Customer Self -Service ❑ Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service Of Non- ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Only. Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -of Date or Total Permit Fee: Reconditioned Food I Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and I 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 7FPd Code. 24) Signature of Applicant: 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 orederal ID 0 H d 26) Signature of Individual or Corporate Name: Com-' 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. I I 1A NAME OF BUSINESS: I ADDRESS: TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: TELEPHONE OF OWNER: Ci 3 FEDERAL ID/SS NUMBER:� 2- FEE: $5.00 PERMIT NUMBER: SIGNATURE: DATE: TAX CERTIFICATION FORM 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 () (_\ 22'-1 -1 'Z-0 *"Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) 'This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc l The Commonwealth of Massachusetts Department of Industrial Accidents .10 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly s Business/Organization Name: C<o,kyn(xv\ j , � �� Norte vim(,%vj %� Co Pe Address: a A o Al , V1 \aI VI 'A City/State/Zip: AA Lijol � Phone #: l 5`0 F �1 (965-) Are you an employer? Check the appropriate box: 1. [YI 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. ❑ 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 1521Mookk i1 (I �vea S�,10 (� *Any applicant that checks box # I 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: �� Q 0- V3t(�Cc c,�v l L '►� �� (�"i�� Insurer's Address:? �A" o&e-x A -(u L ) City/State/Zip: vi m{ 0 W 1'0 i X �- s Policy # or Self -ins. Lic. # .1(0 we 1 isU l ' Expiration Date: T' '1 r .10 i 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 o, 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 As-- 16- 101 Phone #• 1 '6_0 ? 'I I v' N9 14 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: Phone #: www.mass.gov/dra IVIQYr V.7/GV I V V.G I .JG /-NIVI r'H T Urlr—A IINJU 0000000000 r ,1 CERTIFICATE OF LIABILITY INSURANCE 4/4 JAB DATS(MM1DD/YYYV) R045 [4/1"3/2016 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATIO CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CON REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS MEND, EXTEND OR ALTER THE COVERAGE! AFFORDED BY THE POLICIES TiTUTE A CONTRACT BETWEEN THE ISSUING INSURER(&), AUTHORIZED HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSU terms and oondltlons of the policy, certain pollcle9 may requlr certlflcete holder In lieu of such andomement(s). D, the polloy(les) must be endorsed, If SUBROGATIONIS WAIVED, subject to the an endorsement, A statement on this certificate does not confer rights to the PAOCIVOUR PAYCHEX INSURANCE AGENCY INC/PAC 210764 P; F:(1388) 443-6112 PO BOX 33015 SAN ANTONIO TX 78265 JIM (Aid, No, Ext) (Nc,No)I (888) 443-6112 AODREe01 INSURER(D)AFFOROINOCOVIM02 NAICO INSVRIRA; Hertford Abcident L Indemnity Co 22357 INSURED CATnMAN ENTERPRISES INC DBA MAIN $TREE CAC E 240 MAIN ST ,FOXBORO MA 02035 AUrNOA1YIDREPABSENTAFIVE INIURlR9; INSURER C: INSURER O: INSURERS INSURER P: COVERAUEU CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION CERTIFICATE MAY BE 18SUE0 OR MAY PERTAIN, THE INSURJ TERM8,EXCLU SION$ AND CONDITIONS OF SUCH POLICIES, LIMITS S BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE OWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, INSR rVPDOPYN6VRdNC6 L= JIM P0LICYNV114611 POLICVEPI' Auun POLICVQYh LlAllrB AUrNOA1YIDREPABSENTAFIVE COMMERCIAL OENERAL LIABILITY CLAIMS -MADS []OCCUR J4ML AOCREOATE LIMIT APPLIES PER; POLICY PRC' F7 (� LOO OTHER; BOSTON, MA 02114 EACH OCCURRSN08 9 PRAMAGQ HMIS T RINTIOanPnOY ME0 EXP (Any On/ P1reeA) PERSONAL A AOV INJURY GENERAL AOOR80AT8 PRODUCTS • COMPIOP A00 a AVTOMOOILE LIABILITY ANY AUTO ALL OWNED SCHEDULID AUTOS AUTOS HIRED AUTO$ NON -OWNED AUTOS COM♦3INEo 9INOla LIMIT 0 Es eeetdenq EDGILY INJURY IRV person) s OOD:LY INJURY per 6ee1denll PROPERTY DAMA05 (Por eoolden0 UMBRBLLA LIAM !XQR$6 LIAO OCCUR CLAIMS -MADE EACH OCCURRENCE 0 A00REOATB os p REreNneN 1 A WOR neeSCDAf16NS,Irlav AND RAIPI.01'D1t411,1AA1111TY ANY PR0PRIV0FVPARTNER/EXECUTIV8 YIN OPPICewmaMBER EXCLUDE07 (MandelorylnNhi) N yye8, deeedbe under O68CRIPTION OF OPERATIONS below NIA 76 WEG 216645 05/01/2016 05/01/2017 orN. X STAYU7E E 91, EACH ACCIDENT '100,000 e.L.DI8EAK,F.AEMPLOY88 1001000 B.L.olat'AaE •POLICY LIMIT '5 0 0 I 000 DEOCRW770N OP OPIRATIONS I L00AYI0N9 /VEHrOLE9 (ACORO 101, Addlllonal Remarks It Those usual to the Insured's Operations. hoilolo, may 0011110hed If more epaoe la roQoirod) CERTIFICATE H04DER CANCELLATION 01986 -MA AdORO CORPORATION, All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Department; of Industrial Accidents AUrNOA1YIDREPABSENTAFIVE 1 CONGRESS ST STE 100�,� BOSTON, MA 02114 01986 -MA AdORO CORPORATION, All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient. Stephen Cerullo Certificate Number: 638049 Date of Completion: 11/8/2011 Date of Expiration: 11/8/2016 The above-named person is hereby issued this certificate %r completing an allergen awareness training program recognized by the Massachusetts Depattment of Public Health in accordance with 105 CMR 590.009(G)(3)(a), Deis cert�6caie will be valid for five (5) years from date of completion. �w- Issued By. \Massachusetts Rcsmuurrant Association 333 Turnpike Ro2d, Suite 102 Soutblx,rouoh,MA 01772 509-303-9905 mm.matrsmuranacsm.orz; A C =R m 800.765.2122 w m.testaumnt.org