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Home My WebLink AboutWicked Vaped 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit for the Sale of Tobacco Products 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:. ANDREW POIRIER 147 SO. MAIN STREET. APT 203, MANSFIELD, MA 02048 Whose place of business is: WICKED VAPED 266 NORTH MAIN STREET., MANSFIELD, MA 02048 License Number: CT -3T Number TOBACCO -1 Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Permit Expires: December 31, 2016 BOARD OF HEALTH Catherine Ann Memory, Chairperson FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued TOBACCO - 1 - -- - FOOD ESTABLISHMENT PERMIT APPLICATION pplica ion musTbe suT�miffed at Tease 3adaysbefore fTie planned opening date) 1) Establishment Name WICKED VAPED 2) Establishment Address 266 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 266 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (5081272-2704 5) Applicant Name & Title: ANDREW POIRIER 6) Applicant Address 266 NORTH MAIN STREET, MANSFIELD, MA 02048 ------------- - -- --- - - 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title ANDREW POIRIER MA 02048 MANSFIELD, , 9) Owner Address (If different from applicant) 147 SOUTH MAIN STREET,I! Owner's telephone number 5082722704 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 0 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. ANDREW POIRIER, OWNER i Address: 147 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 272-2704 24 Hour Emergency No: FAX: E-mail: I Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: I Address: - _ - Telephone No: 24 Hour Emergency No: i FAX: E-mail: 14) WATER SOURCE: DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: Food Establishment Information 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 L9) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: k Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: W Annual ❑ Seasonal Seasonal Dates: J 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: 0 ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) 23 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 -PRFs ❑ 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 O--y ---- - - Susceptible Population Facility Sale of Raw Animal Foods Intended - , to be Prepared b Consumer ❑ Vacuum Packaging / Cook Chill __ _- ---- ❑ Use of Process Requiring A Variance ❑ Customer Self -Service and/or HACCP Plan (including bare hand ------- -- ---- contact alternative, time as a public health ❑ Ice Manufactured and Packaged for control) Retail Sale _----_.-- ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin — ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salva �- completed . -- -- ---- J F] Retail Out -Of -Date Salvage, or Reconditioned Food �o be com leted b 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 copie_ s_Qf_1M]3 599 000 and the 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 knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 463-560-212 26) Signature of Individual or Corporate Name:' Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: TOBACCO - 1 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: WICKED VAPED LOCATION OF SALE OF TOBACCO PRODUCTS: 266 NORTH MAIN STREET., MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 272-2704 OWNER OF BUSINESS: ANDREW POIRIER ADDRESS OF OWNER: 266 NORTH MAIN STREET, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 272-2704 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. WICKED VAPED, INC. ANDREW POIRIER (OWNER) 147 SO. MAIN STREET. APT 203, MANSFIELD, MA 02048 * Provide a copy of current Dppartment of Revenue CT -3T Retail Excise Unit License FEE: $12.50 CT -3T NUMBER: FEDERAL IDISS NUMBER: 463-560-212 SIGNATURE: r DATE: 5/4/2015 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. . tce * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) m ** 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. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. I AWC-400-7031769-2015A PRIOR NO. I AWC-400-7031769-2014A ITEM 1. The Insured: Wicked Vaped Inc DBA: Mailing address: 266 North Main Street Unit 2 FEIN: **-***7421 Mansfield, MA 02048 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 10/22/2015 to 10122/2016 12:01 a.m. 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 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: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 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 Premium Basis Rates Code Estimated Per $100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 1069901 INTER SEE CLASS CODE SCHEDU E Minimum Premium $218 GOV GOV STATE CLASS MA 8017 Total Estimated Annual Premium $1,534 Deposit Premium $1,601 State Assessments/Surcharges $1,165.00 x 5.7500% $67 This policy, including all endorsements, is hereby countersigned by 10/28/2015 Authorized Signature Date Service Office: Barrows insurance Agency Inc 54 Third Avenue 215 North Main St Burlington MA 01803 Mansfield, MA 02048 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. 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: City/State/Zip: _ . 0:4Phone #: 77,1y Are u an employer? Check the appropriate box: I . 1 am a employer with Q7 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. ❑ 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.] Bu='etail ype (required): 5. 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing IL FJ Health Care 12.❑ 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 provi ing workers' compensation ipsurance for my employees. Below is the policy information. v_, ffi _ Insurance Company Name: rN J- Insurer's Address: `` City/State/Zip: ') � N Policy # or Self -ins. Lie. # q00 - 0 1 4 t Expiration Date:- A "-h o ..any of the wnrkPrO PmmnP.nsatinn nolicv declaration nat=e.(showint=_ the uolicv number and expiration date). Failure to secure coverageas 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 WO UK 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, pacns an enalties 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone 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 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05