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Home My WebLink AboutWest Mansfield Variety 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Retail 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:. HIRENKUMAR PATEL, OWNER Whose place of business is: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 428 ELM STREET Permit Expires: December 31, 2016 License Number: RF -11 Food Fee: $50.00 Milk & Cream V BOARD OF HEALTH NichaeCvlcCCean, 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: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 428 ELM STREET License Number: RF -11 Permit Expires: December 31, 2016 BOARD OF HEALTH wlichaeCMcCCean, 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. HIRENKUMAR PATEL, OWNER having a place of business at: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 428 ELM STREET 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 12/31/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: RF -11 Scott Leite, Health .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 RF -1 1 FOOD ESTABLISHMENT PERMIT APPLIQATIIQN,',fl_, F-- (Application must oe sui)mirrea arieasr,5u uays ouiufu mu piummu up-11fly ucLt;/ 1) Establishment Name ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 2) Establishment Address 428 ELM STREET 3) Establishment Mailing Address- (if different) 6 CO)JNTRY C_ UB AY A_Y r/1 urns I MNOTO)f, M/ro"217 , 6 4) Establishment Telephone No 5) Applicant Name & Title: HIRENKUMAR PATEL, OWNER 6) Applicant Address 6 COUNTRY CLUB WAY, NORTON, MA 02766 7) Applicant Telephone No.: (508) 840.9191 24 Hour Emergency No.: 8) Owners Name & Title HIRENKUMAR PATEL, OWNER 9) Owner Address (If different from applicant) 6 COUNTRY CLUB WAY, NORTON, MA 02766 Owner's telephone number (508) 840-9191 10) Establishment Owned By: 11). If a corporation or partnership, give name, title, and home address of officers * An Association or partner. * A Corporation Name Title Address 0 An Individual D A Partnership 0 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: iHIRENKUMAR PATEL, OWNER Address: 6 COUNTRY CLUB WAY, NORTON, MA 02766 Telephone No: (508) 840-9191 FAX: E-mail:--- —LHIREN31PATEL(cD-GMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) IN -am -e &Title: I Address: 24 Hour Emergency No: Telephone No: 24 Hour Emergency No: FAX E-mail: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: MON-SAT 7:00 AM - SUN 8:00 AM - 8:00 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: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: I 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 0 Milk & Cream $5.00 ❑ Mobile Food & Consession $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 23 Food O erations Definitions: PHF - Potentially hazardous food (time/temperature controls required) p Non-PHFs -non-potentially hazardous food(no time/temperature controls required) Check all that apply): 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 ❑ 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 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) Other Food Operations F]Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin - — -- F1 Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date t - - - ---- - -- - or Reconditioned Food To be completed by the Board of Health -- -- - Total Permit Fee: $50.00 Payment is due with application ❑ waived 1, 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 59pp0,000 and the federal Food Code. 24) Signature of Applicant: � • ( Pu'Ek,t ` 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: 47-392219 ()u �e I 26) Signature of Individual or Corporate Name: A - P 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: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY ADDRESS: 428 ELM STREET TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: HIRENKUMAR PATEL, OWNER TELEPHONE OF OWNER: (508) 840-9191 FEDERAL ID/SS NUMBER: 47-3922519 FEE: $5.00 PERMIT NUMBER: RF -11 SIGNATURE DATE: ia, <,,-- rG_ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -11 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: ADHYA CORP. DBA WEST MANSFIELD VARIETY LOCATION OF SALE OF TOBACCO PRODUCTS: 428 ELM STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: OWNER OF BUSINESS: HIRENKUMAR PATEL ADDRESS OF OWNER: 6 COUNTRY CLUB WAY, NORTON, MA 02766 TELEPHONE OF OWNER: (508) 840-9191 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. *Provide acopy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: 08608 FEDERAL ID/SS NUMBER: 47-3922519 SIGNATURE: ` 1 Pu 2 r '. DATE: 6/1 /2017 I 4- 0 C) ro CU E to o 0 w co m c: C) 0)1 Q) u > 0 0 LO m W E L: ro iu E z 00 0 0 CL U) "0 E E o Z C: 10 -R t IE I( I ro ui co r) UJ U- w W < C) U) Z 0 U) W -J UJ LL U) z M W 00 < 2i 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: Corporate Officer (Mandatory, if applicable) /-I 7-3 q 2 2 -SI y ** 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 Business/Organization Name: AJ 9,cu Ca, P Ae, Address:__A 2 Fr�— City/State/Zip:_►'�')G,� Are you an employer? Check the appropriate box: 1.0 1 am a employer with 2 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.] real estate, auto, etc.) *Any applicant that checks box # ] 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 Insurance Company Name:_s my employees. Below is the policy information. Insurer's Address: 0 Lw City/State/Zip: M;dd1 e 6 C) ,Yv _/�- 9 ez3.1i Policy # or Self -ins. Lie. # WE Loo -f 2S./'7 Expiration Date: `t/ %Z.j aof t, 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 certify, under 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www,mass.gov/dia Phone # ��-•, WESTMA1 OP ID: TL AC pRQ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYVY)05119/2016 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(ies) 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 CONTACT J.K. Olivieri Ins. Agency NAME: Kenneth W. Olivieri 9 y PHONE 64 East Grove St. (AIC, No, Ext): (AIC, No): 08 18 FAX -947-185 Middleboro, MA 02346 EMAIL Kenneth W. Olivieri ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Insurance Co INSURED West Mansfield Variety INSURER B. - - - Adhya Corp, - - t 428 Elm Street INSURER C Mansfield, MA 02048 INSURER l) INSURER E: INSURER F rrweDAnee rGDTIr:lrATF NII IMRGD• RFVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE )DL UBR So WVD POLICY NUMBER POLICY EFF MMlDDlYYYY POLICY EXE MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY L EACH OCCURRENCE $ 1,000,000 r-_ -`_-DAMAGE OCCUR TENTED-.---__ $ occurrence) $ 100,000 ' A X Business Owners ' 09/2512016 ' MFD EXP (Any one person) $ BZS56927776 09/25/2015 MFD EXP (Any 10,000 PERSONAI. 8 ADV INJURY $ 1,000,000 GATE LIMIT APPLIES PER: � AGGREGATE GFNERAL AGGRFGATE $ 2,000,000 PRO- r X N POLICY - I JECT LOC PRODUCTS COMPIOP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident)_. .._,. ANY AUTO' BODILY INJURY (Per person) $ - -- ALL OWNED SCHEDULED '.. BODILY INJURY (Per accident) $ AUTOS AUTOS -I NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS i I AUTOS (Per accident) $ UMBRELLA LIAB ! OCCUR EACH OCCURRENCE S LIAB CLAIMS -MADE _ AGGREGATE $ $ PER OTH— tEXCESS — _.�_. DED RETENTION $ WORKERS COMPENSATION X UTE ER ,AND EMPLOYERS LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y�� —]'N +. -_- �WE159098A ' 09125/2015 09!2512016 F.L�EATCH ACCIDENT $ - 1,000,000 OFFICER/MEMBER EXCLUDED? FN EA S 1,000,000 i(MendatoryIndescribe NH) ry E.l DISEASE If DESCRIPTION OF OPERATIONS below _ _ _ E L DISEASE - POLICY LIMIT - $ T T 1,000,000 A /Business Owners BZS56927776 09125/2015 09/26/2016 ',perperson 1,000,000) Liquor Liability aggregate — 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) i rAKIrGI I ATInK1 MANST02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE I U iutsu-ZUT4 AGUKLJ t,umrJmAI IVIv. /All nynts rasvtvvu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 cavy 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