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Home My WebLink AboutSubway 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park RowMansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of hapten 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby CHARLES SMITH Whose place of business is: SUBWAY 84 COPELAND DRIVE PERSON(S) IN CHARGE: CHARLES SMITH, PRESIDENT Permit Expires: December 31, 2016 License Number: FS -81 Food Fee: $67.50 Milk & Cream 0 BOARD OF HEALTH wlichaeCMCCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. CHARLES SMITH having a place of business at: SUBWAY 84 COPELAND DRIVE Town of Mansfield 6 Park Row Mansfield, MA 02048 EAM in the Town of Mansfield has b�helicense CommonwealthMILK of Massachusetts, and is subject to the provisions of he Laws o ds relating to the terms and conditions,of Mansfield governing the salto the rules and e establishedons of Milk and Cream the Hoard of Health, of the To1213112016 unless previous to that time is and shall remain in force until suspended or revoked. Expires 1213112016 License No.: FS -81 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Permit # Issued -- ---- -- — FOR BOARD OF HEALTH US Approved By: it Date Inspected: FS -81 I Date received: -_- -- --- _ ening cfafe) - FOOD ESTABLISHMENT PLICATION ERMIT APP _ - F - Tanned op pphca on musfbe submiffecTaf feast 30 bks Uefore the p ---- SUBWAY ---- - -- - - - 1) Establishment Name - -- — - -- -- - - - -- -_-- - — r 2) Establishment Address 84 COPEL_ DRIV � Establishment Mailing Address (if different) 84 COPELAND DRIVE - - - - - Estab MANSFIELD, MA 02048 3) I ---- _ — - — (508) 339-0600 -- — -� 4) Establishment Telephone No _ _ - -- ---- -- j 5) Applicant Name & Title: CHARLES SMITH, PRE ------ TION, --- 02703 ATTLEBORO, M _—_ _ 20 JAKES JUNCTIO - - , _--- _- - -- (508) 639-516 6) Applicant Address --- — — Emergency No.: 254-3461 24 Hour ---- hone No.: - 7) Applicant Telep - CHARLES SMITH --- g) Owners Name & Title _--- --- -- - 20 JAKES JUNCTION, ATTLEBORO, MA 02 703 licant - - g) Owner Address (If different from a (774) 254.3461 - -- -- -- -- __ ---- ive name, title, and home address of officers r Owner's telephone number - — If a corporation or partnership, 9 10) Establishment Owned By: or partner. Address Title P, ❑ An Association Name '''� ®A) W A Corporation I/��,��,� Z_� 3_ El An Individual _-- _- - ❑ APartnership ----- - er etc.) - --- ervisor, man -- e, sup ---- - -- _�- — erson in charge, - ---- I ❑ Other legal Entity O erations (owner, p = -- _- onsible For Daily p __ 12) Person Directly Resp- __- ---- - rName &Title: CHARLES SMITH, PRESIDENT ------------ --- - --- ----- ----------- 20 JAKES JUNCTION, ATTLEBORO, MA 02703 - 508 639-5169 Address: ---- - _ - - No: _ — — _- ------ --- -- 24 Hour Emergency ---� - -. Telephone No. (774) 254-3 _ - - 508)339-00 FAX: (--- - GMAIL.COM E-mail CHUCKSMITH33p _ _ . Alt E -Mail (rf app Ucable l Supervisor 13) District Or Regiona-- - - -- - - -- - Name & Title. -- - _ -- ----- -- Address: --- Emergency No --- 24 Hour mer -- Telephone No: -__ _ --- - E-mail, - FAX: - -1— — -- 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) MON-SUN 7 AM - 9:30 PM 17) DAYS/HOURS: Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 10 18) Name of Person ualsIn harge are certified, Certified in FoodCo complete Pst is on file. rotection Management: If more than 3 Inds Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of UVI lllltia _ 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):- - -- - 20) Location: Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: [j Food Service up to 100 or Up to 10' PHF display $62.50 II Moblie Comments: ---- - __ E]Food Service up to 101 -200 21) Length Of Permit: - I -� or up to 25' PHF display $75.00 0 Annual — -_ S ice up to 201 + ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ Food ery or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) CHARLES D. SMITH HERMANN KONATE ❑ 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 I' ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 i Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non PHFs - non potentially hazardous food(no time/temperature controls required) RTF - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non_PHFs Sale of Commercially Pre -Packaged PHFs- ❑ Delivery of Packaged PHFs - i� Reheating of Commercially - Processed Foods for Service Within 4 Hours - f N Customer Self -Service oon PHF and Non - Perishable Foods Only - - ❑ Preparation of Non PHFs - Other Food Operations ---- — Hot PHF Cooked and Cooled or Hot Held ❑ PHFCooked To Order for More Than a Single Meal Service Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ Susceptible Population FacilitPHF and RTE Foods yFor Highly ❑ Sale of Raw Animal Foods Intended ---Vacuum Packaging I Cook Chill ❑ to be Prepared by Consumer - ---- ❑ Use of Process Requiring A Variance ___ El Customer Self Service CCP lan (including timeasa public health -- ❑ Ice Manufactured and Packaged for contact alternative, I control) --- - Retail Sale-- for Or Undercooked Food Of ❑ ❑ Juice Manufactured and Packaged Animaloffers origin— Retail Sale -_____— — -- [i --Offers- RTE PHF in Bulk Quantities _ - ---- - 'IW Prepares Food/Single Meals for I Catered Events or In Food Service ❑ Retail Sale of Salvage, Out -Of -Dae --- -- To be completed by the Board of Health or Reconditioned Food _ __------------- Total Permit Fee: $62.50 Payment is due with application E] waived is on and affirm the food I, the undersigned, attest it the accuracy itof the information provided in 105 CMR 590.000 and all otherhappppa'ble'law. I have beentinstructed by the establishment operation will comply and board of health on how to obtain ies of 105 CMR 590.000the federal Food Code. 24) Signature of Applicant:l� rjury that I, to my best knowledge and belief, ha Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of peve filed all state tax returns and paid state taxes required under law. ` 25) Social Security Number or Federal ID: 27-1418387 / 26) Signature of Individual or Corporate Name: �/ 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. a t L "'6' Ic * Signature of Individual or Corporate Name (Mandatory) "x' gy: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federalldentification Number *This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will bewhetheeyou have met tax filing to the or ax Department of Revenue to determine or a ment obligations. Licensees who fail to cation. orrectTh s requ'estgis made delinquency y payment under will be subject to license suspension or revocation, 62C, Section 49A. the authority of Mass. General Laws, Chap The Commonwealth of Massachusetts Department of Industrial Accidents 171 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le:ribly Business/Organization Name: Address: (7ity/State/Zib: r �, M M Cf Phnne # 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, F] We are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp, insurance req.] (G,or X S-0 Z-- 33,'_ 64O6 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 IL 0 Health Care 12.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation poircy miu,111MI-1. **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. ! am an employer that is providing workers' compe7atio i insurance for my employees. Below is thepolicy information Insurance Company Name: I VLf-��pp w L/ Insurer's Address: 3 % ®o 1N i �, er 9 c— / City/State/Zip:-Al rv r - �jL� Expiration Date:_ Policy # or Self -ins. Lic. #^ , - , ,;, ,, nnmhor A Attach a copy of the worxers, r--•--4 -- - . 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 herebySgjVfy, under the pains and penalties of perjury that the information provided b ve is true and correct. Phone #: 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/dia 09 (policy Provisions: WC 00 00 00 B) ' IL 0'7 PAGE, IA PAGE EMPLOYED GC INFORMATION AN® S WEG S C®MPERI�AiIN �IRKER COMPANY OF THE MI 0615 INSURER, HARTFORD INSURANCEE PLAZA, HARTFORD, CONNECTICUT ONE HARTFORD 20605 AR'T F®RD NCCI Company Number: Company Code: G suffix LARS RENEWAL CD 76 WEG GC 709 02 POLICY NUMDER, 09 76 WEG GC07 ious Policy Number: Prev1-1 C) C) HOUSICSSCSUB° INC 0 1. Named Insured and Mailing Address: Zip Code) CD (No. Street, Town, State, 74 TAUNTON AVE N SEEKONK, MA 02771 Ln FEIN Number: 271418387 " State Identification Numbers -- UIN : The Named Insured is: CORPORATION FULL SERVICE RESTAURANT - I3usiness of Named Insured: AVE above: 74 TAUNTON MA 02771 i Other workplaces not shown SEEKONK 12/09/16 From 12/09/15 To mailing address. policy Period: Standard time at the insured s _ 2 12:01 a.m., BENEFIT SOLUTIONS/PAC COMPLETE producer's Name: .' PO BOX 33015 TX 78265 S N ANTONIO, --- producer's Code: 250837 THE HARTFORD Office: Issuing 3600 WISEMAN BLVD* TX 78251 SAN ANTONIO (877) 287-1316 $1,776 -total Estimated Annual Premium: T Deposit Premium: $216 MA _ policy Minimum premium, installment Term resentative. ANNUAL our authorized rep Audit Period: countersigned by The policy is not binding unless "fue �'Gz4-r�� 10/24/1E Date Countersigned by Authorized Representative Page 1 (Continued on next p� g � 16 printed in U.S.A. Policy Expir ®ate: WC 00 00 01 A (1) Foration m process Date: lo/24/15 ORIGINAL Policy Number: 76 WEG GC0709 3-A. Workers Compensation, Insurance: Part one ofthe o p lacy 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 endorsements and schedule: WC 00 04 03 WC 00 04 22B WC 20 03 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 9079 140,900 1.15 1,620 RESTAURANT NOC MA RATE DEVIATION PREMIUM CREDIT (.15) (9037) -243 1,377 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 950 MA - MERIT RATING CREDIT (9885) 1,308 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 1,308 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 338 EXPENSE CONSTANT (0900) 88 MASSACHUSETTS DIA ASSESSMENT 5.750 PERCEN40900 .030 42 , TERRORISM (9740) 1,776 TOTAL ESTIMATED ANNUAL PREMIUM Total Estimated Annual Premium: $1,776 Deposit Premium: Policy Minimum Premium: $216 MA Interstate/intrastate Identification Number: NAICS SIC: 5812 Labor Contractors Policy Number: UIN'. NO. OF EMP: 000006 Page 2 12/09/16 Form WC 00 00 01 A (1) Printed in U.S.A. Policy Expiration Date: Process Date: 10/24/15 0 1-40 0 r - C) U N 0 0 0 0 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS Suite 100, Boston, Massachusetts 02114-2017 1 Congress Street, 617-727-4900 — http:l/www.state.ma.us/dia assachusetts General Law, Chapter 152, Sections 21, 22, 30, this will As required by M meat to our in employees under the give you notice that I (we) have provided for pay insuring with: above mentioned chapter by i INSURANCE COMPANY OF THE NAME OF INSURANCE COMPANY ONE PARK PLACE, 300 S. STATE ST ADDRESS OF INSURANCE COMPANY 7TH FLOOR 76 WEG GCO709 POLICY NUMBER COMPLETE BENEFIT SOLUTIONS/PAC NAME OF INSURANCE AGENT CSS SUB INC EMPLOYER PO BOX 33015 SAN ANTONIO ADDRESS 74 TAUNTON AVE TX 78265 12/09/15 EFF VE DATES DAT! EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) ®IAL TREATMENT ersonal injuries arising out of and in the course c adequate and reasonable hospital and medical services in accordance given tto th th th The above named insurer is required in cases of p ort of Injury employment to furnish q compensation Act. A copy of the First Rep provisions of the Workers Comp Select his or her own physician. The reasonable cost ssary andt reasonab injured employee. The employee may h sician will be paid by the insurer, if the treatment)o e s are hereby notified th provided by the treating p Y In cases requiring hospital attention, emp y connected to the work related injury. the insurer has arranged for such attention at the NAME OF HOSPITAL POSTED �r EMPLOYER TO BE Form WC 88 20 01 D Printed in U.S.A. co M 0 0 0 0 M 0 0 U N 0 0 0 0 AND BENEFITS AGGREGATE MASSACHUSETTS PROGRAM Dear Policyholder: Section 25A of Chapter 152 Massachusetts Workers' Compensation Law requires the Massachusetts Workers' Compensation Assigned Risk Pool and voluntary markece' of medical and indemnity be deductiblesnsurers to otter to insureds with workers ompensation p policies, which provide coverage in Massachusetts, a Choi In accordance with the statute, as amended, the Division of Insurance has approved two separate and distinct limit, and one with an aggregate limit. An insured may select either deductible programs, one without p oaggregate program, or neither of them. These programs are not available for insureds with retrospectively rated policies. The first program, Massachusetts Benefits Deductible Program, without an aggregate limit, which has been in effect andle losses ey incur. to h since January 1, 1993, is intended for insureis ds who have ttheyfinancan abscial orb b and purchase einsu insurance ti only for loes program allows these insureds to establish an amount of toss above that predetermined deductible amount. 000 and $2,500 shall be offered to every Under this program, medical and indemnity deductibles of $500, $ ooer0 to any employer providing collateral deemed employer. In addition, an insurer or the Pool, at its option, may adequate by such insurer, a medical and indemnity benefits deductible of $5,000. separately to each claim for bodily injury by disease or accident. The insurer shall pay all The deductible shall apply p Y a Subsequent to insurer payment pY benefits required under the provisions of M.G.L.c.152 directly tothe mppropriate r may seek reimbursement from the of any amount which falls within the deductible limit on any for ductibles within thirty days of receipt of bill from the policyholder. Failure to make comp)ete burse ent groundsfor termination of the pol cy. insurer shall constitute non-payment premium erience modification of The entire cost of all claims shall be included in the experience data used to determine the exp claim. the insured regardless of the requirement that reimbursement must be made for the deductible amount on Venon or after ff If you wish to -elect a medical and indemnity deductible, and your policy is being renewed e e otic otherwise at the next renewal of January 1, 1997, you must make your election before the effective date of your policy, your policy. ( ) $ 2,500 ( ) $ 500 ( ) $ 5,000 ( ) $ 1,000 ( ) $ 2,000 Do Not Elect ( ) ( ) $ 2,500 with Aggregate ( ) Do Not Elect Policy Number 76 EG GC07 0 ®ate Signature and Title Employer Name CSS SUB INC ®ate Signature Agent Name Form WC 66 01 51 A Printed in U.S.A. Process Date: 1-0/24/15 Policy Expiration Date: 12 / 0 9 / 16 4 for successfully completing the- stwid-C15 5e -I (0111) for the sel,Sale� Food P, -lection Mn.ger cc,iiLotion Examination, which is accredited by the Atni;con National Standards lnslitute fANSI1-Conference for F,—I P,-tcIti-vt (CFP) 765187 U 10440 c ;C,% i", N, B L K I 9120/2020 DATC OF EPIRATIOINI for —crIlifl—i)-4 -qui—,ntv Alk3A, Ly WINTER ATCHISON for successfully completi rig& standards set forth for ifle Set Safe Food Pic-dion manager C iiai-lien b",mirldiol which is accredited by ilie American National Standards insiiuSa (ANSI)—Cnnferen— ici Food Protech.n (CFP , 10/6-40 EX,,t r F0RP1, NUMBS 9/20/2020 DA7c OF EXPIRAiiO[�I €o� �rcErtif:ccaon :rquirernents. 0 0 E m K w 0 u v u 00 0 0 u v 0 a 0 0 0 u x x -C LU LUT CN L a 0 0 0 LU 0 L 3 a a 0 ro �v N V) O W w+ t N 0® ®®1e® Ie® O N ; N N >. Q W C 0- _ - LO m LO rs�me z o- N � d N F R w 0 \"O ` J Z=) 2� or�� O O 0 0 U N N O U _ z N Q - � 4 - � � � C G C - Q � U7 O I - @ C O J U O c _ � ti O I U O (6 I s O c CL � � za m a N CL U I �I� `6 z - (��„d� Q X p' � X O o Z m Z U LO CO ��` - LO ry C N o m O O 5 m > - m � a ,o oa Q.- Oak o _ z d O� EN W4 u LM Q� z z*mm� z W-4 c� T I 19 Es U) U) �n 0 tu (4-4 T I 19 Es 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 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 (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