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HomeMy WebLinkAboutRte 106 Wine & Spirits 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Snack Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. JOHN MCINTYRE, PRESIDENT BOARD OF HEALTH Whose place of business is: ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET License Number: S_29 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream ❑ MichaeCMcCCean, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET BOARD OF HEALTH License Number: S_29 Permit Expires: December 31, 2016 NichaeCNcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued �i S-29 FOOD ESTABLISHMENT PERMIT APPLICATION __TAAP11c�on mu�e-e-su mi tem afTeast 30 -da ks _b efo re planned opening daw 1) Establishment Name ROUTE 106 WINES & SPIRITS 2) Establishment Address 377 CHAUNCY STREET 3) Establishment Mailing Address (if different) 377 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (774) 719-2817 A" rc � � 5) Applicant Name & Title: JOHN MCINTYRE 6) Applicant Address 421 LANDRY AVENUE, NORTH ATTLEBORO, MA 02760 7) Applicant Telephone No.: (508) 736-8888 24 Hour Emergency No.: (508) 736-8888 8) Owners Name & Title JOHN MCINTYRE 9) Owner Address (If different from applicant) Owner's telephone number 5087368888 j110) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 1 A Corporation t Name - Title Address - i j ❑ An Individual - - ❑ APartnership)�1 - - - - - - ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IiJOHN MCINTYRE - Address: 1421 LANDRY AVENUE, NORTH ATTLEBORO, MA 02760 Telephone No: (508)736-8888 24 Hour Emergency No: (508) 736-8888 FAX: - E-mail: MCINTYRE549(cD-HOTMAIL.COM Alt E -Mail: � 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: 24 Hour Emergency No: E-mail: FAX: - - - -- - - Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 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) ❑ 20) Location: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: 0 Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 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 ❑ 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 ❑ Retail Food $50.00 0 Retail Snack Food $12.50 Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) I(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non -PRFs �❑ Saleof Commercially Pre -Packaged PRFs � [-:—]-Del iveryof 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 Other Food Operations I, the undersigned, attest to the accuracy establishment operation will comply w board of health on how to obtain coja4es c 24) Signature of Applicant: k' Pursuant to MGL Ch.62C, sec. 4 ce and paid state taxes required u , er law. ❑ PHFCooked To Order Preparation of PRFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ 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 and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities E]Prepares Food/Single 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 - -- - ��Total Permit Fee: $12.50 Payment is due with application ❑ waived information provided in this application and affirm that the food MR 590.000 and all other applicable law. I have been instructed by the CMR 590.000 and the federal Food Code. under the penalties of that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 46-0819029 /) 126) Signature of Individual or Corporate Name: �_ i Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S-29 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: ROUTE 106 WINES & SPIRITS LOCATION OF SALE OF TOBACCO PRODUCTS: 377 CHAUNCY STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (774) 719-2817 OWNER OF BUSINESS: JOHN MCINTYRE ADDRESS OF OWNER: 421 LANDRY AVENUE, NORTH ATTLEBOROUGH, MA 02760 TELEPHONE OF OWNER: (508) 736-8888 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Av Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 46-0819029 SIGNATURE: DATE:,, Q CD N N m co r /\ UO t = \ O k ¥® 2 § » \ & m e \ o e / ®� o = a -® § ® q = 3 S /e o -m 0 ) { zU) \c- $ a I _\ 7� o e� m° 0 0 2 » c 2 )/ 2 d_ R f\ q 2§ 7 0 z e L ƒ ® _ V) � °\G WDCo \\ wco f7 # w ■ _ $ ��\ / $u k U C UJ§ eE ® t q K° [w f ( U. $ k. k m \\ to Q- a 0 / 9 77 u ° § Go § § g &/ G k E # = ag ° ` ` m ) 2 r �\ ) z / /�/k >& o e� k m \ ' 3 4 §\ 2 m m » §E I K \ ® W \j E1�, J kb \ )& _../ ƒ fa BE � «&2 E E r /\ 2 2 >® m e%� \ b X c k » u O.E \ ] 2 ) / £ g ®E s E cc:, 2 3 m ®"©� //} kEa-< U) 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) By: C orate Officer (Mandatory, if applicable) tip ** 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.govldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ,()i -e- 06 WICL�e %Vt Address: a PV City/State/Zip: " 14 t.. st hone #: C Are you an employer? Check the appropriate box: BuMail Type (required): 1. 1 am a employer with employees (full and/ 5, or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2, ❑ I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity, [No workers' comp. insurance required] 8• E] Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c, 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp. insurance req.] 1 12.0 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: uhfcb^ I fi t�' Fg Insurer's Address: City/State/Zip: e&cl iqht J- I Policy # or Self -ins, Lie. # ° Expiration Date: 6 140J a] 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 DTA for insurance coverage verification, I do hereby certifys i -n the pains and penalties of perjury that the information provided above is true and correct 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, Bowala Phone A UTICA NATi3ONAL INSURANCE GROUP V 180 Genesee Street New Hartford, NY 13413 Issuing Company: Graphic Arts Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page 1. The Insured and Mailing Address: RT 106 WINE & SPIRITS, INC. DBA RT 106 WINE & SPIRITS PO BOX 1395 ATTLEBORO FALLS MA 02763 Policy Number: 4654952 Prior Policy Nurnber: Producer: Wm.'F. Borhek Ins Agy Inc 311 Plymouth St Halifax, MA 02338 Entity of Insured: Corporation Producer Number: 77377 SIC#: 5921 Other workplaces not shown above: Insured's I.D. Number:. 460819029 NCCI Company Number: 15822 Risk I.D. Number: 2. The policy period .is from 06/10/2016 to 06/10/2017 12:01 AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy 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 $500,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, WY D. This policy includes these endorsements and schedules: 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. Code Premium Basis Rate Per $100 Estimated Annual ❑ See Extension of Information Page Total est. Annual of Premium Classifications No. Remuneration Remuneration Minimum Premium: $ 218 MA Expense Constant $. Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 2,393 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 2,393 Issuing Office: New Hartford, NY 13413 Date of Issue: 05-06-2016 Countersigned by 8 -D -WC Ed. 08-2008 Copyright 1988 National Council of Compensation Insurance UNIBILL NO. 100908900 7F`1'i d.r. kot /) 00 row/ SALES AND USE TAX REGISTRATION CERTIFICATE o® ROUTE 106 WINES SPIRITS INC W.® ROUTE 106 WINES & SPIRITS 421 LANDRY AVE NORTH ATTLEBORO MA 02760-2701 Attached below is your Sales and Use Tax Registration Certificate (Form ST -1). Cut along the dotted line and display at your place of business. You must report any change of name or address to us so that a revised ST -1 can be issued. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re- print a copy of this certificate. DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------- Sys"ic'rf• MASSACHUSETTS DEPARTMENT OF REVENUE Form ST -1 ! n t Sales and Use Tax Registration Certificate This registration must be posted and visible at all times. ROUTE 106 WINES SPIRITS INC Account ID: SLS -12241468-006 ROUTE 106 WINES & SPIRITS Certificate Number: 939216896 377 CHAUNCY ST MANSFIELD MA 02048-1169 This certifies that the taxpayer named above is registered under Chapters 62C, 64H and 641 of the Massachusetts General Laws to sell tangible personal property at retail or for resale at the address shown above. This registration is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: January 1, 2013 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/]icense 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 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05