HomeMy WebLinkAboutPaper 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:
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:.
ROBERT ANDERSON, OWNER
Whose place of business is:
THE PAPER STORE
280 SCHOOL STREET, SUITE F180
PERSON(S) IN CHARGE:
WENDY WHITE, MANAGER
Permit Expires: December 31, 2016
License Number: S-30
Food Fee: $12.50
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH,USE ONLY
j Date received: Date Inspected: Approved By: Permit # Issued
S-30
FOOD ESTABLISHMENT PERMIT APPLICATION
--- -- - pica Ion mu be submitfdef leas�a �s before the planned opening crate)
1) Establishment Name THE PAPER STORE
2) Establishment Address 280 SCHOOL STREET, SUITE F180
3) Establishment Mailing Address (if different) 20 MAIN STREET
ACTON, MA 01720
4) Establishment Telephone No (978) 263-2198 I
5) Applicant Name & Title:
6) Applicant Address 20 MAIN STREET, ACTON, MA 01720
7) Applicant Telephone No.: (978) 263-2198 24 Hour Emergency No.: (508) 280-8992
8) Owners Name & Title ROBERT ANDERSON, OWNER
9) Owner Address (If different from applicant)
Owner's telephone number 1
10) Establishment Owned By:11) If a corporation or partnership, give name, title, and home address of officers
11 An Association or partner.
❑ A Corporation Name Title Address
❑ An Individual _ -
V A Partnership
❑ Other legal Entity j
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.
Name & Title: `
Address:aO
Telephone No: �4 Hour Emergency No:�e-8 J 1}4�0ct�l
FAX:
E-mail: ,
Alt E -Mail:
--=--
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
g/5--�-73y
i
Acio
I
978) 263-2198 24 Hour Emergency No:
- i
E-mail:
Food Establishment, Information
14) WATER SOURCE: I 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
SUN 10:00 AM - 6:00 PM
17) DAYS/HOURS: - M Y_V�OT) --
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 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: ❑ Food Service up to 100 or
Moblie Comments: i up to 10' PHF display $62.50
21) Length of Permit:
W Annual I
❑ 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 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 & Consc-ssion $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts: 0
❑ 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)
❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
- - ---- -- - Cold Holding For Single Meal Service
I❑ Delivery of Packaged PHFs - -- --
__--____ __ ____ __ _ ❑ Sale of Raw Animal Foods Intended
❑ Reheating of Commercially to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non -
I Perishable roods Only
-❑ P ._.----------._--
Pre aration of Non-PHFs
Other Food Operations
❑ 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
control)
❑ Manufactured and Packaged for I ❑Offers
Animal Origin
Or Undercooked Food Of
Retail Sale it
�❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service J'I
❑ Retail Sale of Salvage, Out Of -Date- - - _ -
or Reconditioned Food FTo be completed by the Board of Health
— _ Total Permit Fee: $12.50
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 copies of 105 CMR 590.000 aqd til a 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
and paid state taxes required under law.
25) Social Security Number or Federal ID: 47
26) Signature of Individual or Corporate Name:
and belief, have filed all state tax returns
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.
* ignature of Individual or
Corporate Name (Mandatory)
By: orate 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 52C, 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:
Address: � q[�) :�)C
City/State/Zip:
0dYY
Phone #: 5-0
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. (�Zetail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ 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. ❑ Manufacturing
no employees, [No workers' comp, insurance required]* 1111 Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers', comp. insurance req.] 12.0 Other
*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 # I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: 16g'Gtf
Insurer's Address: Pa
City/State/Zip:�C��►
Policy # or Self -ins. Lic. # Q t L/ OV S-0 3 0 ll Expiration Date: 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under Oy 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
City or Town:
by city or town official
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 #
NO'T'ICE
r TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.tis/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:
MA Retail Merchants WC Group Inc.
NAME OF INSURANCE COMPANY
PO Box 859222-9222 Braintree, MA 02185
ADDRESS OF INSURANCE COMPANY
0110050301951 t6 1/01/2016 - 1/01/2017'
POLICY NUMBER EFFECTIVE DATES
Association Benefits Insurance 299 BallardvaIe St, Suite 1 Wilmington, MA 01887
NAME OF INSURANCE AGENT ADDRESS PHONE -fl
The Paper Store LLC 20 Main Street Acton, MA 01720
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 filmish 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 ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary aid
reasonably connected to the work related injury. III cases requiring hospital, attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
INFORMATION''PAGE RENEWAL AGREEMENT
Insurer:
MA Retail Merchants WC Group Inc.
PO Box 859222-9222
Braintree, MA 02185
(Carrier Code: 34355)
1. The Insured: The Paper Store LLC
Mailing Address: 20 Main Street
Acton, MA 01720
Other workplaces not shown above:
SEE SCHEDULE OF OPERATIONS
PRODUCER: Agent# 5960
Association Benefits Insurance Age
299 Ballardvale St, Suite 1
Wilmington, MA 01887
Carrier Policy #: 014005030195116
Carrier Prior Policy #: 014005030195115
Fein: 471892442
Type of Business: Corporation
Risk ID: 913616138
2. The policy period is from 12:01 a.m. on 1/01/2.016 to 12:01 a.m. on 11'Q1 -L20 17
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 $__. .100,_000._ each accident
Bodily Injury by Disease $...___ 500,,.000 policy limit
Bodily Injury by Disease $ 100-1-9-0()L.. each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC00000C(01/15) WC000310(04/84) WC000406(08/84) WC000414(07/90) WC000422B(Ol/15)
WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200306B(06/13) WC200405(06/01)
WC200601A(07/08)
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.
Classifications Code Premium Basis Rate Per Estimated
No. Total Estimated $100 of Annual
Annual Remuneration Remuneration Premium
SEE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $ 121,143.00
Minimum Premium $ 486.00 Expense Constant .00 Deposit Premium
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. 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