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HomeMy WebLinkAboutTown News 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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:. DINESH PATEL Whose place of business is: TOWN NEWS 165 NORTH MAIN STREET License Number: S-89 Permit Expires: December 31, 2016 Food Fee: $12.50 Milk & Cream W BOARD OF HEALTH MichaeCvlcCCean, Chairman [--Per or 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: TOWN NEWS 165 NORTH MAIN STREET License Number: S-89 Permit Expires: December 31, 2016 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: DINESH PATEL having a place of business at: TOWN NEWS 165 NORTH MAIN STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: S-89 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-89 FOOD ESTABLISHMENT PERMIT APPLICAI IUN TApp iicafion musf-ue—su- mid asst sV_Vys-byre fhplsnned opening --ate) j 1) Establishment Name TOWN NEWS 2) Establishment Address 165 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 165 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-6745 5) Applicant Name & Title: ANJANA PATEL, PRESIDENT 6) Applicant Address 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 261-1532 24 Hour Emergency No.: (508) 982-8177 8) Owners Name & Title DINESH PATEL 9) Owner Address (If different from applicant) 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 Owner's telephone number 508-261-1532 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W 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.) Name & Title: DINESH PATEL 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 Address: Telephone No: (508) 982-8177 24 Hour Emergency No: (508) 982-8177 FAX: E-mail; PDI NESH68(cDYAHOO.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) i - Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 7 DAYS 5:30 AM - 9 PM 15) SEWAGE DISPOSAL: 16) No. of Food Employees 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: �/❑ Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations 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) TOWN 2 ❑ 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 Retail Snack Food $12.50 W 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 ❑ 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 Other Food Operations ❑ 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 Susceptible Population Facility -- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer --.- - - ❑ 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) ❑ Customer Self -Service - - - ❑ Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged for Retail Sale — ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for —Cate -re -d- Events or Institutional Food Service � -- -- - - -- - ' To be completed by the Board of Health - - ❑ Offers RTE PHF in Bulk Quantities __ F1 Retail Sale of Salvage, Out -Of -Date or Reconditioned Food �- -" -i 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 codes of 105,gMR 590.000 and the federal Food Code. 24) Signature of Applicant: Z �tT / " - - 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: 04-3333-,5772 26) Signature of Individual or Corporate Name: 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: TOWN NEWS ADDRESS: 165 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6745 FAX NUMBER: (508) 339-6744 OWNER OF BUSINESS: DINESH PATEL TELEPHONE OF OWNER: 508-261-1532 FEDERAL ID/SS NUMBER: 04-3333-572 FEE: $5.00 PERMIT NUMBER: S-89 SIGNATURE: DATE: "t C 1 1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S-89 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 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: TOWN NEWS LOCATION OF SALE OF TOBACCO PRODUCTS: 165 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6745 OWNER OF BUSINESS: DINESH PATEL ADDRESS OF OWNER: 4 OLD STABLE DRIVE, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 261-1532 FAX NUMBER: (508) 339-6744 If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 04-3333-572 SIGNATURE: DATE: Z4— W j Form CT -3T 03039 Massachusetts Department of Revenue 2014 - 2016 Cigarette -E Oitse ilfld Retailer License for Sale of Cigarettes and Cigars arid Smoking Tobacco s under 18 years of age are ptohibNed by taw. rsEbe posted and visible at ail times• Sates to Pew �r Date of Issue: er. 29422 tori or Sootal Security Number; 043-35-35 r: ucenas. 11812014 �)xjnq address) zit 1 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. 5::�o-OW2- * Si ature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) oLA- 2 3's91 91— 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 z w Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organizatiott/Individual): Address: �® �Q C�\ N OV City/State/Zip: �� � 0 0M Phone #: V 6S2-- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.F_1 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.17 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: (I l ( Uzi L� Expiration Date: —®ter Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties of perjury that the information provided above is true and correct. Signature:���'" Date: 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone # Apr, 26.2016 10:40AM JK Ol ivieri Ins Agency No, 0793 P. 5/5 VASUC01 np in TI A Rte„ CERTIFICATE OF LIABILITY INSURANCE ° 0412612016ATE "i 04/2612016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER J,K, Oliviers Ins. Agency 64 East Grove SL Middleboro, MA 02346 Kenneth W. Olivleri CONTACT NAME:Kenneth W, Oliviers P Arc Ext :508-947-1818 No ; EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIL B f INSURER A: Technology Insurance Co. 11/30/2015 INSURED Vasudev Corporation dba Town News & Ticket Agency 165 North'Main St INSURER B: NGM Insurance Co. 14788 INSURER 0: INSURER D: Mansfield, MA 02048 INSURER E, GEN'LAGGREGATE LRriITAPPLIES PER: X POLICY ❑ J pT FILOC OTHER: INSURER P : PRODUCTS-COMPIOPAGG $ 2,000,00 l:l1V FFf Ol�F1 f:FK 1IFIL:4.1M NI IMPEFV• MM1101MAI\IIlIffin • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R TYPE OF INSURANCEI.S. POLICY NUMBER MMI�CDJY YY PF MWDDIYYYY LIMITS B COMMERCIAL GENERAL LIABILITY CLAIMS44ADE I OCCURPREMISES X Business Owners f BPF1371Y 11/30/2015 11/30/2016 EACH OCCURRENCE ; 1,000,00 (Ea oo $ 500,004 MED EXP Any one person $ 10,00 PERSONAL &?ADV INJURY $ 1,000,00 GEN'LAGGREGATE LRriITAPPLIES PER: X POLICY ❑ J pT FILOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS-COMPIOPAGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS N�NQWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea a kle BODILY INJURY (Per person) $ BODILYINJURY (For aceldent) $ PROPERTYDAMAGE Perwelda $ $ UMBRELLA LIAR EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEO I I RETENTION 4 $ A WORKERS COMPENSATIONPER ANDEMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERMIEMBER EXCLUDED? a (Mandatory in NH) it yea, describender u DESC I N ERA 0 S below NIA TWC3532727 03/13/2016 03/13/2017 XSTATUTE E.L. EACH ACCIDENT $ 500,00 - El DISEASE - EA EMPLOYEE $ 500,00 - E,L DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Sohedule, may bo attaohod If more spaos Is required) MANST02 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD