HomeMy WebLinkAboutOld Country Store 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:.
CHRISTOPHER D. BAKER
Whose place of business is:
OLD COUNTRY STORE AND EMPORIUM, INC.
26 OTIS STREET
PERSON(S) IN CHARGE:
LAURYN S. BAKER, VICE PRESIDENT
Permit Expires: December 31, 2016
License Number: FS -79
Food Fee: $62.50
BOARD OF HEALTH
MichaeCNcCtean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -79
FOOD ESTABLISHMENT PERMIT APPLICATION
1) Establishment Name OLD COUNTRY STORE AND EMPORIUM, INC.
2) Establishment Address 26 OTIS STREET
3) Establishment Mailing Address (if different) 26 OTIS STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-8128
5) Applicant Name & Title: CHRISTOPHER D. BAKER, PRESIDENT
6) Applicant Address 26 ELMWOOD AVENUE, BRAINTREE, MA 02184
7) Applicant Telephone No.: H (781) 849-1018 24 Hour Emergency No
8) Owners Name & Title CHRISTOPHER D. BAKER
9) Owner Address (If different from applicant) 26 ELMWOOD AVENUE, BRAINTREE, MA 02184
Owner's telephone number 7818491018
10) Establishment Owned By: r 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
W A Corporation NameTy'� Address
l
ElAn Individual ah An 2P 3G d'►'�'siu� �— �//✓2( � �-�i�A
- - -
❑ A Partnership ✓
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: LAURYN S. BAKER, VICE PRESIDENT
Address: 26 ELMWOOD AVENUE, BRAINTREE, MA 02184
Telephone No: H (781) 267-4593 24 Hour Emergency No: c (781) 267-4593
FAX: (508) 339-8845
E-mail: OLDCOUNTRYSTOREMAc@NERIZON.NET 1�
Alt E -Mail: CDBAKER13@BELD.NET
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX: E-mail:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: MON-SAT 10 AM - 6 PM SUN 11 AM - 5 PM
15) SEWAGE DISPOSAL: SEPTIC
16) No. of Food Employees: 6
18) Name of Person In Charge Certified in Food Protection Management: y ��
If more than 3 individuals are certified, complete list is on file. �(I
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: Permanent Location 22) Establishment TypeCaterer $12.50
❑ Moblie Moblie Start Date: I F-1Retail( Sq. Ft) ❑ ilk & Cream $5.00
Moblie End Date:
Moblie Comments:
21) Length of Permit:
i- Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
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)
❑ 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
❑ 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)
[V1 Sale of Commercially Pre -Packaged Non -PRFs
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
❑ Hot PHF Cooked and Cooled or Hot Held
-- -
for More Than a Single Meal Service
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
F]Sale of Raw Animal Foods Intended
Susceptible Population Facility
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
F] Use of Process Requiring A Variance
❑ Customer Self -Service
and/or HACCP Plan (including bare hand
❑ Ice Manufactured and Packaged for
contact alternative, time as a public health
Retail Sale
control)
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale i Animal Ongin --
- - - - - ❑ ❑Offers RTE PHF in Bulk Quantities i Prepares Food/Single Meals for
- _ Catered Events or Institutional Food Service
F Retail Sale of Salvage, Out-Of-Dateor Reconditioned Food To be completed by the Board of Health
- _- - -- Total Permit Fee: $62.50
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 of 105 (AMR 59;Q.000 and the federal Food 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 or Federal ID: 27-12702'j�, I�
26) Signature of Individual or Corporate Name: Ul ('�,� �` C ❑` y ir?
I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
00�M_ 'No 0)'0 � r�
* Signature of Indi idual 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
U 0 Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeLyibly
Business/Organization Name:
Address:
City/Stat
Are on an employer? Check the appropriate bot.:
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.]
Busin ss Type (required):
5. LZRetail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
l l.❑ Health Care
12. ❑ Other
real estate, auto, etc.)
*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
I am an employer that is providing workers'Vompensation insurance for my employees. Below is the policy information.
Insurance Company Name: aY �'Fd � -7mr XYJw) � � O''`
(./
Insurer's Address: ra,, HCAA+-f ,o pl o ` O
City/State/Zip: &V Yo`` �^�-� 061 S�
Policy # or Self -ins. Lic. #, 76 W� G6 3S-6 p Expiration Date: //01 1 -
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
Investitrations of the DIA for insurance coverage verification.
I do hereby eIf,
, under the p nsd p nalties of perjury that the information provided above is true and correct
At
o:,.....,s,.re. X-41,)Il V�cy. AA_ late,
Phone #:
�t�l d 7 - �
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/dia
Phone
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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. *IlAhere 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
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68 (Policy Provisions: WC 00 00 00 B)
35
GG INFORMATION PAGE
WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 20605
Company Code: G
POLICY NUMBER: 176 WEG GG3568
Previous Policy Number: FT6 WEG GG3568
HOUSING CODE: 76
1. Named Insured and Mailing Address: OLD COUNTRY STORE & EMPORIUM, INC.
(No., Street, Town, State, Zip Code)
FEIN Number: 271270212
State Identification Number(s):
UIN:
26 OTIS STREET
MANSFIELD, MA 02048
The Named Insured is: CORPORATION
Business of Named Insured: GENERAL STORE
Other workplaces not shown above: 2 6 OTIS STREET
MANSFIELD MA 02048
2. Policy Period: From 01/29/16 To 01/29/17
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: HARTFORD FIRE INSURANCE COMPANY
PO BOX 33015
SAN ANTONIO, TX 78265
Producer's Code: 250805
Issuing Office: THE HARTFORD
3600 WISEMAN BLVD.
SAN ANTONIO TX 78251
(877) 287-1316
Total Estimated Annual Premium: $2,450
Deposit Premium:
Policy Minimum Premium: $219 MA
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Suffix
LARS RENEWAL
02
Countersigned by <--f OL" a, 12/13/15
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 12/13/15 Policy Expiration Date: 01/29/17
ORIGINAL
Policy Number: 76 WEG GG3568
3. A. Workers Compensation Insurance: Part one of the p licy applies to the Workers Compensation Law of the
states listed here: 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 $100,000 each accident
Bodily injury by Disease $500,000 policy limit
Bodily injury by Disease $100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND
STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsementsand schedule:
WC 00 04 03 WC 00 04 22B WC 20103 03D WC 99 03 OOD WC 00 04 14
WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A
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
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
8017 192,400 1.12 2,155
STORE: RETAIL NOC
MA RATE DEVIATION PREMIUM CREDIT (.15) (9037) -323
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 1,832
MA - MERIT RATING DEBIT (9886) 1.050
PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 1,924
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,924
EXPENSE CONSTANT (0900) 338
MASSACHUSETTS DIA ASSESSMENT 5.750 PERCENT 130
TERRORISM (9740) 192,400 .030 58
TOTAL ESTIMATED ANNUAL PREMIUM 2,450
Total Estimated Annual Premium: $2,450
Deposit Premium:
Policv Minimum Premium: $219 MA
Interstate/Intrastate Identification Number: / 000850665
NAILS:
Labor Contractors Policy Number: SIC: 5399
UIN:
NO. OF EMP: 000010
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 12/13/15 Policy Expiration Date: 01/29/17