HomeMy WebLinkAboutOrange Leaf Yogurt 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:.
MARIO COSTA
Whose place of business is:
ORANGE LEAF FROZEN YOGURT
321 SCHOOL STREET, UNIT A-120
PERSON(S) IN CHARGE:
DEBRA FITZSIMMONS
Permit Expires: December 31, 2016
License Number: FS -18
Food Fee: $80.00
Milk & Cream V
BOARD OF HEALTH
NichaeCNcCtean, 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.
MARIO COSTA
having a place of business at:
ORANGE LEAF FROZEN YOGURT
321 SCHOOL STREET, UNIT A-120
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 12/31/2016
License No.: FS -18
Scott Leite, Health .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
License to Manufacture Frozen Desserts and/or Ice Cream Mix
The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the
General Laws, as most recently amended, and the regulations made hereunder, hereby issues
ORANGE LEAF FROZEN YOGURT
321 SCHOOL STREET, UNIT A-120
a license for the wholesalelretail manufacture of frozen desserts and ice cream mix.
This license expires December 31st of each year.
License Number: FS -18
Freezers: 8
TOTAL: $100.00
MANSFIELD BOARD OF HEALTH
Scott feite, Heaah .Agent
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By:
Permit # Issued
i
FS -18
FOOD ESTABLISHMENT PERMIT APPLICATION
(App�on mus_Vbe subm- iftec -atTe--a-s-V30 days before� planned -opening date)
1) Establishment Name ORANGE LEAF FROZEN YOGURT#"
2) Establishment Address 321 SCHOOL STREET, UNIT A-120
3) Establishment Mailing Address (if different)
,
061.
4) Establishment Telephone No (508) 339-9020
5) Applicant Name & Title: MARIO COSTA, OWNER
6) Applicant Address 66 FAIRFIELD CIRCLE NORWOOD MA 02062 - 781 I
7) Applicant Telephone No.: (781) 769-2425 24 Hour Emergency No.. ) 640-1055
8) Owners Name & Title MARIO COSTA
9) Owner Address (If different from applicant) 66 FAIRFIELD CIRCLE, NORWOOD, MA 02062
Owners telephone number (781)769-2425 1
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
V 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.)
1 --
Name & Title: ,JA
-��----
v
Address: , P) (A
Telephone No L6
24 Hour Emergency No: (761) 640-1055
FAX: --- - - - -1
E-mail: CNCY0GURT@GMAIL .COM
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name &Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
a
Food Establishment Information
14) WATER SOURCE: % 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees. 10-15
17) DAYS/HOURS: SUN-THURS 11:00 AM 10:00 PM FRI-SAT 11:00 AM - 11:00 PM
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: d❑ Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
V Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
i(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
R Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
wi 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 (timeltemperature 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)
❑ Sale of Commercially Pre -Packaged Non-PHFs
j ❑ Sale of Commercially Pre -Packaged PHFs
❑ Delivery of Packaged PHFs
j ❑ 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
Other Food Operations
I, the undersigned, attest to the accuracy of the inform
establishment operation will comply with 105 CMR 59
board of health on how to obtain co_pi�1el2b
❑ PHFCooked To Order
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
Customer Self -Service Iand/or HACCP Plan (including bare hand
- - -- ---
❑ Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale control)
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Offers RTE PHF m Bulk Quantities
Prepares Food/Sin le Meals for
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 ❑ waived
it' n provided in this application and affirm that the food
q0 and all other applicable law. I have been instructed by the
Q. 00 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, se . 49 , I c ify unler the penalties of perjury that I, to
and paid state taxes required under law.
25) Social Security Number or Federal ID: 46-4522605
26) Signature of Individual or Corporate Name:
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: ORANGE LEAF FROZEN YOGURT
ADDRESS: 321 SCHOOL STREET, UNIT A-120
TELEPHONE AT LOCATION: (508) 339-9020
FAX NUMBER:
OWNER OF BUSINESS: MARIO COSTA
TELEPHONE OF OWNER: (781)769-2425
FEDERAL ID/SS NUMBER: 46-4522605
FEE: $5.00
PERMIT NUMBER: FS -18
SIGNATURE:
DATE:
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix
To the Board of Healih at the Town of A4ansfreld:
In accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recenlly amended, and
the regulations made thereunder, the undersigned hereby applies•for a license,for a 14"HOLESALEIRETAIL
manufacture of frozen desserts and ice cream mix and submits the following information:
I
Full name of applicant: ORANGE LEAF FROZEN YOGURT
2. Business address 2 INNNES CIRCLE
MEDFIELD, MA 02052
3, ifapplicani is an individual
Full name: MARIO COSTA, OWNER
Residence: 66 FAIRFIELD CIRCLE, NORWOOD, MA 02062
3u. ff applicant is a partnership, fall name and residence oj'all partners:
3b, ffapplicant is a corporation: State of incorporation:_ MASSACHUSETTS
Date of incorporation: __1-14-2014
Fall name and address of : Principal office: 2 INNNES CIRCLE
President MARIO COSTA
4.
Treasurer: KATHLEEN NEE
Clerk.
Location of Plants: 321 SCHOOL STREET, MANSFIELD, MA 02048
S. Names of brands and trade or corporation name., ijfanv, under which the products are to be sold:
6. Alumber and capacity of freezers and fees.
7. Is the rnix purchased? YES
8 Fee: ($12.50 perfr•eezer) $ 100
If so, from whom purchased?
8. Is the mix pasteurized of not? YE5
9. Number ofgallons oj;fr-oxen desserts and/or ice cream mix to be sold in Massachusetts during the licensing
period 5000
10. Nrnnber ofgallons of frozen desserts and%or ice cream prix sold in Massachusetts chu•ing the previous licensing periost
11. Is tlae plant eorrstraeetecl and equipped as pr•ovicled in Ilse regilalions? YES
12. Is the water supply public or not? YES
13. Have you received a copy of the regulations? YES
I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of
the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts
Department of Public Health de thereunder and will be manufactured under sanitaryconditions. I attest that the information stated
in this application i tr a curate under the pains and penalties of perjury.
( a o ner/officer's ignature) (DATE)
-- ---
(Title) (City or Town)
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.
* ig at a oi�lndiVidual OY
C rp rate Name (Mandatory)
�oxporgw V er
(Mandatory, if pplicable)
LJ (0 - q S- D�)' (
** 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 Name: 1 c � S ( \C'
Address: `Z -DA sc�a_�cA' :sLQ_�A-
City/State/Zip: M NK ` i'1'I Phone #: 8
Are you an employer? Check the appropriate box:
1. ❑ I 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. gRestaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
1011 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 insurgnce for my employees. Below is the policy information.
Insurance Company Name: ' _ ()"
Insurer's Address: ��l U-)
City/State/Zip:
N
Policy # or Self -ins. Lic. #� - l_,l_J (d 1 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
Investieations of the DIA for insuralke coverase verification,
I do hereby
() - (0�5
of perjury that the information provided above is true and correct
r . cz-- 1 _ I l„
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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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: DEBRA FITZIMMONS
Certificate Number: 2329573
Date of Completion: 511512015
Date of Expiration: 5/15[2021
The above-named person is hereby issued this cert�6cate
for completing an allergen awareness trainingprograrn
recognized by the Massachusetts Department of Public Health
in accordance with 105 CMR 590.009(G)(3)(a).
This cert�6cate will be valid fw five (5) years front date ofcom#etion.
Issued By:
MRI
NATIONAL;'
RESTAURANT
Massachusetts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
www.restaurant.org
Southborough, MA 01772
508-303-9905
www. marestaurantassoc. org
NOTICE
TO
EMPLOYEES
�ti
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
I Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Quincy Mutual Fire Insurance Company
NAME OF INSURANCE COMPANY
57 Washington Street Quincy MA 02169
ADDRESS OF INSURANCE COMPANY
WC 001621 02/18/2016 To 02/18/2017
POLICY NUMBER EFFECTIVE DATES
EQUIRVAIN93=10��.
CNC YOGURT INC 321 SCHOOL ST MANSFIELD MA 02048
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to
the injured employee. The employee may select his or her own physician. The reasonable cost of
the services provided by the treating physician will be paid by the insurer, if the treatment is
necessary and reasonably connected to the work related injury. In cases requiring hospital attention,
employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL
TO BE POSTED BY EMPLOYER
ADDRESS
00159
AGENCY:
NAMAKSY-ZAMMITO INS. AGCY INC
955 WASHINGTON ST.
NORWOOD MA 02062-3479
POLICY NUMBER: WC 001621
05/10/2016
CNC YOGURT INC
66 FAIRFIELD CIR
NORWOOD MA 02062-5564
QUINCY MUTUAL GROUP
�Ilkj 57 Washington Street, Quincy, MA 02169
Enclosed is a recent endorsement or change to your policy.
Please feel free to contact your Agent at (781) 762-6732 with any questions you may have regarding this
policy endorsement transaction.
This is not a bill, an invoice will be mailed separately. You can find our billing and payment options at
www.quincymutual.com/billing
INSURED COPY
DECLARATION PAGE
•QUINCY MUTUAL GROUP ACCESS CODE: D8GQFW
57 Washington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
WC 001621 fEE02/18/2016 02/18/2017= QUINCY MUTUAL FIRE INSURANCE COMPANY 00159
1.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
NAMED INSURED IS: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE.
FEDERAL ID NO: XXXXX5684 RISK ID NO:
2. POLICY PERIOD: FROM 02/18/2016 TO 02/18/2017
12:01 AM STANDARD TIME AT THE INSURED'S MAILING ADDRESS.
POLICY CHANGE EFFECTIVE: 04/18/2016
3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS
COMPENSATION LAW OF THE STATES LISTED HERE: MA
3.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
3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
LISTED HERE: ALL STATES EXCEPT ND, OH, WA, WV, WY.
3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:
FORMS FLAGGED WITH AN * CAN BE FOUND ON A PREVIOUS ENDORSEMENT OR POLICY. FORMS
NOT FLAGGED WITH AN * ARE ATTACHED.
*WC 00 00 00 A *WC 20 03 02 A *WC 20 03 03 D *WC 20 06 01 A *WC 00 04 20
*WC 20 QM 01 *WC 20 01 01 *WC 20 03 01 *WC 20 04 01 *WC 20 04 05
*WC 20 06 04
4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES AND RATING PLAN. ALL INFORMATION REQUIRED BELOW IS
SUBJECT TO VERIFICATION AND CHANGE BY AUDIT:
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL
NO REMUNERATION PREMIUM
(SEE EXTENSION OF INFORMATION PAGE)
TOTAL ESTIMATED PREMIUM $1,343.00
DIA ASSESSMENT ( 5.750%) $58.00
TERRORISM RISK INSURANCE CHARGE ( 3.000%) 9740 $27.00
MINIMUM PREMIUM $218.00 TOTAL ESTIMATED COST $1,428.00
DEPOSIT PREMIUM $1,704.00
WC 00 00 01 B CONTINUED ON NEXT PAGE
INSURED COPY
DECLARATION PAGE
• R%I�CY MUTUAL GROUP ACCESS CODE: D8GQFW
Washington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
4=DfE
WC 001621 02/18/2016 02/18/2017 QUINCY MUTUAL FIRE INSURANCEMOMPA�NYJR0159
1.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE:
WC 00 00 01 B CONTINUED ON NEXT PAGE
INSURED COPY
04/19/2016
DECLARATION PAGE
• Rwa NCY MUTUAL GROUP ACCESS CODE: D8GQFW
Washington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
lig
EMEMMM
001621 02/18/2016 02/18/2017 PRINYCMUTUAL FIRE INSURANCE COMPANY"00159
l.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
** E X T E N S I O N O F I N F O R M A T I O N P A G E **
THIS IS AN EXTENSION OR ALTERATION OF ITEM 4 OF THE INFORMATION PAGE OF THE POLICY.
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL
NO REMUNERATION PREMIUM
TOTAL LOCATION PREMIUM
TOTAL PREMIUM SUBJECT TO THE EXPERIENCE MODIFICATION
PREMIUM MODIFIED TO REFLECT EXPERIENCE MODIFICATION OF 1.0000
TOTAL ESTIMATED STANDARD PREMIUM
EXPENSE CONSTANT CHARGE
TOTAL ESTIMATED PREMIUM
DIA ASSESSMENT ( 5.750%)
TERRORISM RISK INSURANCE CHARGE ( 3.000%) 9740
MINIMUM PREMIUM $218.00 TOTAL ESTIMATED COST
DEPOSIT PREMIUM
RETURN PREMIUM
WC 00 00 01 B CONTINUED ON NEXT PAGE
INSURED COPY
$1,005.00
$1,005.00
$1,005.00
$1,005.00
$338.00
$1,343.00
$58.00
$27.00
$1,428.00
$1,704.00
$232.74 -
DECLARATION PAGE
•Y MUTUAL GROUP ACCESS CODE: DBGQFW
RNUEWashington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
WC 001621 02/18/2016 02/18/2017 QUINCY MUTUAL FIRE INSURANCE COMPANY 00159
1.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
** E X T E N S I O N O F I N F O R M A T I O N P A G E **
THIS IS AN EXTENSION OR ALTERATION OF ITEM 4 OF THE INFORMATION PAGE OF THE POLICY.
LOCATION PREMIUM
PREMIUM BASIS RATE PER ESTIMATED
TOTAL ESTIMATED $100 OF ANNUAL
CODE ANNUAL REMUNERA- PREMIUM
ST LOC CLASSIFICATIONS NO REMUNERATION TION
20 001 STORE - RETAIL NOC 8017 89,688 1.1200 $1,005.00
TOTAL LOCATION PREMIUM $1,005.00
WC 00 00 01 B
CONTINUED ON NEXT PAGE
INSURED COPY
op DECLARATION PAGE
•QUINCY MUTUAL GROUP ACCESS CODE: DBGQFW
57 Washington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
WC 001621 1 02/18/2016 02/18/2017 QUINCY MUTUAL FIRE INSURANCE COMPANY 00159
1.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
** E X T E N S I O N O F I N F O R M A T I O N P A G E **
THIS IS AN EXTENSION OR ALTERATION OF ITEM 4 OF THE INFORMATION PAGE OF THE POLICY.
PREMIUM ADJUSTMENTS
ESTIMATED
CODE ANNUAL
ST CLASSIFICATIONS NO RATE PREMIUM
20 EXPENSE CONSTANT 0900 0.0000 $338.00
20 FOREIGN TERRORISM 9740 1.0300 $27.00
20 DIA ASSESSMENT (MASS) 5.7500 $58.00
TOTAL PREMIUM ADJUSTMENTS $423.00
WC 00 00 01 B
CONTINUED ON NEXT PAGE
INSURED COPY
DECLARATION PAGE
0 • QUINCY MUTUAL GROUP ACCESS CODE: DSGQFW
57 iVashington Street BILL TO: CUSTOMER
Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 04/18/2016
CHANGE PAYROLL-EMPL HRS REDUCED
MA TAXPAYER ID NO: XXXXX5684
NCCI NO: 32247
- -s - er • -• r ,
WC 001621 02/18/2016 02/18/2017 1 QUINCY MUTUAL FIRE INSURANCE COMPANY 1 00159
l.CNC YOGURT INC NAMAKSY-ZAMMITO INS. AGCY INC
66 FAIRFIELD CIR 955 WASHINGTON ST.
NORWOOD MA 02062-5564 NORWOOD MA 02062-3479
(781) 762-6732
** E X T E N S I O N O F I N F O R M A T I O N P A G E **
** L0CATI ONS **
LOCATION
NUMBER ADDRESS
001 CNC YOGURT INC
321 SCHOOL ST
MANSFIELD MA 02048
FEDERAL ID: XXXXX5684
EFF: 02/18/2016 EXP: 02/18/2017
WC 00 00 01 B
INSURED COPY
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 pennit/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 bum 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