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Home My WebLink AboutWines & More 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health j 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:. KATHLEEN HARONIAN Whose place of business is: WINES & MORE - MANSFIELD 280 SCHOOL STREET Permit Expires: December 31, 2016 License Number: RF -4 Food Fee: $62.50 Milk & Cream ❑ BOARD OF HEALTH AichaeCNcCCean, Chairman Permit 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: WINES & MORE - MANSFIELD 280 SCHOOL STREET License Number: RF -4 Permit Expires: December 31, 2016 BOARD OF HEALTH AichaeCwicCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit #Issued I! RF -4 --- - - - -- FOOD ESTABLISHMENT PERMIT APPLICATION p7�cation mus s mined a�asf30-days be�ore�Tie p�ne�openTng�c atm 1) Establishment Name WINES & MORE - MANSFIELD 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 1405 DOUGLAS AVENUE NORTH PROVIDENCE, RI 02904 4) Establishment Telephone No (508) 33976900 5) Applicant Name & Title: KATHLEEN HARONIAN, PRESIDENT 6) Applicant Address j 7) Applicant Telephone No.: (401) 353-4400 24 Hour Emergency No.: (401)455-2627 8) Owners Name & Title KATHLEEN HARONIAN 9) Owner Address (If different from applicant) 15 NOTO DRIVE, NORTH PROVIDENCE, RI, 02904 -------------- -- - -- -- j Owner's telephone number 4013534400 10) Establishment Owned By:11) If a corporation or partnership, give name, title, and home address of officers � El An An Association P jjW A Corporation me Tit)e Address ❑ An Individual �(� � � --- � - l 0UI_�✓-'aP VC-' ❑ A Partnership ❑ Other legal Entity ---- ---------- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc Name & Title: TKATHLEEN HARONIAN, PRESIDENT Address: 115 NOTO DRIVE, NORTH PROVIDENCE, RI, 02904 Telephone No 1(401) 353-4400 FAX: i(401) 353-4469 4 E-mail: LFINN@WSRETAILERS.COM -------- Alt - Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: jCRAIG POWER, VICE PRESIDENT OPERATIONS Address: 94 WENDELL ROAD, WARWICK, RI 02888 I -- Telephone No !(401) 465-2527 24 Hour Emergency No: (401) 465-2527 FAX: 1 (401) 353-4469 E-mail: LFINN@WSRETAILERS.COM Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT 9 AM - 10 PM SUN 12 PM - 6 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 15 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: V Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: W Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type Retail (101#410000 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: ❑ Residential Kitchen $50.00 n Retail Food $50.00 ❑ Retail Snack Food $12.50 W Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 0 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 I ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Preparation of PHFs For Hot And nd _.---__-_- _-- __-- 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 ❑ Customer Self -Service and/or HACCP Plan (including bare hand —_ - -- -- - -- -- "--- ❑ Ice Manufactured and Packaged for Icontact alternative, time as a public health Retail Sale ---- control) -- - - ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health -- - -- —" Total Permit Fee: $50.00 - i- 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 rtopieVof 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, 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: 27 2176p6-r-� �� OFTtt 26) Signature of Individual or Corporate Name: ((�� Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF -4 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: WINES & MORE - MANSFIELD LOCATION OF SALE OF TOBACCO PRODUCTS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 339-6900 OWNER OF BUSINESS: KATHLEEN HARONIAN ADDRESS OF OWNER: I N ®-ro 6911k;' TELEPHONE OF OWNER: (401) 353-4400 FAX NUMBER: (401) 353-4469 If a corporation or partnership, give name, title, and home address of officers or partner. KATHLEEN HARONIAN, PRESIDENT 15 NOTO DRIVE, NO. PROVIDENCE, RI 02904 ......... ..... . * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: kA 601 - ---- -- FEDERAL ID/SS NUMBER: SIGNATURE: DATE: i® 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. 197-19-7-1441- N C'' 6/A 's Si na ure of Individual or Corporate Name (Mandatory) By: Cor orate Officer (Mandatory, if applicable) Qt�,�24�6496 ** 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 WUT 600 Washington Street Boston, MA 02111 tvww, mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Nam CTI - 01 -A 5C&0�, Address: 10 U City/State/Zip: M& pab,d an employer? Check t appropriate box: AYl Brsines Type (required): 5, Wetail 1am a employer with employees (full and/ or part-time),* I 6,, ❑ Restaurant/Bar/Eating Establishment 2, ❑ 1 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, 8• E] Non-profit [No workers' comp. insurance required] 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] *4 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. Other ❑ with no employees. [No workers' -comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their **If the corporate officers have exempted themselves, but the corporation has other workers' compensation policy information, 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 for my employees. Below is the policy information, Insurance Company Name: MA RETAIL MERCHANTS WC GROUP, INC. Insurer's Address: P.O. BOX 859222-9222 City/State/Zip: BRAINTREE, MA 02185 Policy # or Self -ins, Lie. # 014 0 0 5 0 3 2 9 8 2116Ex t - p• ration -Dater — -1 1117 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, Ido hereby cc , un er the pains andpenalties of perjury that the information provided above is true and correct i 1"_ _Z. . / Date: 4/6/16 (401) 353_-4400 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 11 Contact Person: - Phone #: 11 www,mass.gowaia �LN t- The Commonwealth o ' f Massachusetts DEPARTMENT, OF INDUSTRIAL ACCIDENTS 1 Congress Sheet, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www,state.ma.us/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 42185 ADDRESS OF INSURANCE COMPANY 014005032982116 1/01/2016 - 1/01/2017 POLICY NUMBER EFFECTIVE DATES Hadley Insurit Group Insurance 246 Durfee St Fall River, MA 02720 NAME OF INSURANCE AGENT ADDRESS PHONE # _Wines And More Mansfield 1405 Douglas Ave N Providence, RI 02904 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish 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 and reasonably connected to the work related injury. In 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 I I OCT. 15. 2015 .12:13 PM i+ �i U 'I Ird DEPT OF REVENUE-, _ _ �� _ 9 _ -1 N0. 4740, i P. 9_ saozo 4 'a 'I Form CT4T 03294 n, 9 Massachusetts department of Revenue 2014-2016 - m Cigarette Excise Unit Waim; Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco oR DUPLICATE LICENSE -DATE OF REPRINTING 10/13/2015 a This License trust be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law, Applidation Number: AA667 License Number: Date of Issue: Federal Identification or Social Security Number: 272®17-6426 03294 09/19/2014 I Mailing address for license: Retail sale location (If different than mailing address) I GT RETAIL, INC. WINES AND MORE -MANSFIELD 1250 SCHOOL ST 280 SCHOOL STREET MANSFIELD, MA 02045 MANSFIELD, MA 02045 This certifies that the taxpayer named above has paid the required license fee and is licensed to sell at retail at the address shown above until September 30, 2016. This license is not transferable, and Is subject to suspension for fallure to comply with the law, UL 0 t Massachusetts Department of Revenue PO Box 7004 o� Boston, MA 02204-7004 Ls. --- t Massachusetts Department of Revenue PO Box 7004 o� Boston, MA 02204-7004 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