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Home My WebLink AboutWest Mansfield Variety 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Retail 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:. Whose place of business is: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 428 ELM STREET Permit Expires: December 31, 2018 License Number: RF-1 Food Fee: $100.00 Milk & Cream ICI BOARD OF HEALTH MichaeCNcCCean, 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-1 Permit Expires: December 31, 2018 BOARD OF HEALTH NichaeCMcCCean, 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: RF-1 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred �✓ FOR BOARD OF HEALTH USE ONLY Permit # Issued RF. FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name ADHYA CORPORATION DBA WEST MANSFIELD VARIETY 2) Establishment Address 428 ELM STREET NOV 13 Z811 3) Establishment Mailing Address (if different) 428 ELM STREET y, ( - MANSFIELD, MA 02048 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. V, 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: HIRENKUMAR PATEL, OWNER Address: 6 COUNTRY CLUB WAY, NORTON, MA 02766 Telephone No: I(508) 840-9191 24 HourEmergencyNo: FAX: E-mail: HIREN3IPATEL(ai)GMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: i FAX: 24 Hour Emergency No: -i - I E-mail: , I R t%lav 13 PM 1 t 5 N Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 117) 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 101112001 in accordance with 105 CMR 59(l 003(A) Please attach copy or certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) I 20) Location: i I Permanent Location ' 22) Establishment Type Moblie Moblie Start Date: II, I._] Retail ( Sq. Ft) Moblie End Date: Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Food Service up to 101 -200 1 or up to 25' PHF display $1 %00 Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) SEPTIC J Caterer $25.00 Milk & Cream $10.00 1._ Mobile Food & Consession $75.00 I- Manufacture Frozen Desserts/Ice Cream $25.00/freezer i Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 [J] Retail Food $100.00 -] Retail Snack Food $25.00 ] Tobacco Products $25.00 Temporary Time: .. Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous rood (time/temperature controls required) 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) J: Sale of Commercially Pre -Packaged Non-PHFs ! 1, 1 PHFCooked To Order I ; Hot PHF Cooked and Cooled or Hot Held _ -- r - - -- 41 Sale of Commercially Pre Packaged PHFs � (� Preparation of PHF r Hot And for More Than a Single Meal Services Fo Delivery of Packaged PHFs Cold Holding For Single Meal Service I_] PHF and RTE Foods Prepared For Highly ---- --- Susceptible Population Facility Reheating of Commercially -- -- Sale of Raw Ammal Foods Intended to be Prepared by Consumer �J Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours —. --- _ ---- r ] Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non ; ] Customer Self-ServicePerishable and/or HACCP Plan (including bare hand Foods Y I IceManufactured and Packaged for contact alternative, time as a public health P - Preparation of Non-PHFs P ' Retail Sale control) -. -- j Other Food Operations °I Juice Manufactured and Packaged for 1 '�- 9 _ 1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ,Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date ___ or Reconditioned Food i To be com leted by the Board of Health p i - Total Permit Fee: $100.00 I 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 1055��CMR 590.000 and the federal Food Code. H � f 59 24) Signature of Applicant: , -Pc i C.,e-� 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: 47-3922519 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 December 31st of each year. NAME OF BUSINESS: ADHYA CORPORATION DBA WEST MANSFIELD VARIETY ADDRESS: 428 WLM 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. $10.00 PERMIT NUMBER: RF-1 SIGNATURE: H 1(4 R-11 _,e ) _ DATE: v\ \ \ 2\y- — Town of Mansfield Town o f Mans feld - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: RF-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 December 31st 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 a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 910479360 1722626048 FEDERAL IDISS NUMBER: 47-3922519 SIGNATURE DATE: 11 /16/2016 p n 7 ,• Ketailcr License fur Sale of Cigarot uc, "Phis license mull be posted and eisiba al all iimcs.'l,hc,.dc of tubncco products to anyone under M years or age is prohibited. ADHYA CORPORATION Account ID: ('GI-10�10964-0(1v WEST MANSFIFIA) VARIETY License Number: 91�;479Kn 128 ELM S'1' MANSFIELD MA 02048-2610 This certifies that the taxpayer named above is licensed under Chapter 64C of ;ha Massachuscus Cienar;l I_;m, In sell at retail at the address shown above. This license is non- vansferable and may be mNpcndcd nr revoked A failure to comply with state laws and regulations, Effective Date: Octohcr l3. 010 1, Xpiratiun Daw: ;';. 'W , MASSACIIUSETTS DEPAR AIVNT OF RKVENt'1C Form (T _il Retallcr License for Sale of (;igars and .Smoking Tobacco 3 {.; This license must be posted and visible at all times. "1'he sale of tobacco products to anyone under 18 years or age is prohibited. ADHYA CORPORATION Account ID: CKIA0510964-009 WF,ST MANSFIFI D VARIFI Y License Number: 172202001E -128 EL,M S'f MANSFIFLD NIA 02048-2610 This ceiffies that the taxpayer named above is licensed under Chapter 64C ofto Massachusetts Uener:d 12"s to sell at retail at the address shown above. This license is non-vansferahle and may he suspended or re Nal Pnr failure to comply with state laws and regulations. [affective Date: October 12. 2016 Fspiretion Dam: ticlnuml,er U;_ .'018 TAX CERTIFICATION FORM 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. � A,(_� Pcl-Ve-\ Signature of Individual or Corporate Name 14 _-�-3 9 2 .2S—) I "*Social Security No. (Voluntanj) or Federal Identification Nmnber By: Corporate Officer (Mandatonj, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. C: Users\sleite\Desktop\Scotts DOCOmentMood Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information 1 Please Print Leeibly Business/Organization Name:_ P-Jca C� k4e rJJ6Q CUs r lur+.s h7Plci v&raT2/-7, Address: C1Z&' C—rI-, , S% City/State/Zip: ) u �—f 1 , (c (�®2uL1 Phone #: -- a&-4- 4 3 9 2 Are you an employer? Check the appropriate box: Business Type (required): 1. KI I am a employer with employees (full and/ 5. Q'Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales (incl, real estate, auto, etc.) employees working for me. in any capacity. 8. ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We by 11, Health Care are a non-profit organization, staffed volunteers, with no employees, [No workers'.comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation pal icy 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 for my Insurance Company Name: ,T .1-Gr Q �T,s . Insurer's Address: G Zt C ,s G.-a ,-e- S+F Below is the policy information. City/State/Zip: K`j f cL J V e- J0 0t ' l/ C 2- 3 Gt -6 Policy # or Self -ins. Lic. # is & (S-'l G `[ �;_/- Expiration Date: 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 thee pains and penalties ofperjury that the information provided above is true and correct Signature• 1_ I-1�1/e _t � e I Date: [ 1 I) ?J 1 '4- Phone #: � -1 15 t 0 --9 � ) 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 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: Phone www.mass,gov/dia WESTMA1 OP ID: TL DATE (MMIDWYYYY) CERTIFICATE OF LIABILITY INSURANCE 11108/2017 _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 1"HIS 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on INSURED West Mansfield Variety - - Adhya Corp, 428 Elm Street Mansfield, MA 02048 'PHONE A PVC. No Exu 508-947-1816..... - -.IA c. Nco E"MAIL ADDRESS'. INSURER(S) AFFORDING COVERAGE i INSURER A. Liberty Mutual Insurance Co INSURERThe Norfolk & Dedham Group INSURER C: INSURER D : INSURER E rcorinrn Tc nu IMQCO. oClnclnnl nu lMOGo. NAIL 6 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 REOLIIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH IHIS 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. PIERTYPEOF INSURANCE 'I.UDLSUBR POLICY' POLICY NUMBER EFFYyY, POLICY E%PGcyYyY,., LIMITS COMMERCIAL GENERAL LIABILITY (EACH OCCURRENCE ,_$ III 1,000,000 CLAIMS MADE j XI' OCCUR DAMAGE TO RENTED 1,000,000 _ PREMISES (ET cc ¢cote) $ _ A X Business Owners ''.BZS56927776 0912512017'',09/25/20181 MED ESP (Any one person) 5 15,000 _. _. _..-.. 1,000,000 PERsoNAL&ADV INJURY 5 2,000,000 GEN'L AGGREGATF LIMIT APPLIES PER. OLNERAL ACS;FH CALL 5 X POLICY'. PRO LC1C JECT PRODUCTS COMPUPAGG S 2,000,000 OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea aQcid.LO 5 . ANY AUTO ., BODILY INJURY (Per person) 5 I ---. OWNED -''. SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Pe, accident) S HIRED( NONOWNEDPROPERTY . AUTOS ONLY ( AUTOS ONLY DAMAGE (Per rl,,, l) UMRRELLALIAB OCCUR EACH OCCURRENCE EXCESS HAS CLAIMSMADEnccREcnre "DLD RETENTIONS... 13 WORKERS COMPENSATION X PER SIAIUIF OOUH AND EMPLOYERS' LIABILITY Y I N' WE159098A 09/2512017 g912512018 1,000,000 ANY PROPRIETORIPARTNERIEXECUTNE E L EACH ACCIDENT 5 'OFFFICERIMEMBER EXCLUDED? N NIA( 1,000„000 HhtanBriery In NH) EL DISEASE "EA EMPLOYEE,.S It yes describe under �'. 1,00Q000 DESCRIPTION OF OPERATIONS below I I E L DISEASE - POLICY LIMIT A Business Owners '.. 'BZS56927776 09125/2017I. 09125/2018 per perso 1,000,000 Liquor Liability ''. aggregate 1,000,000 DESCRIPTION Or OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Addelonal Romarks SUndulo may be MWched 11 more space Is nadni-ed) �! 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 ACORD 25 (2016/03) V 1988-201.5 ACORU CORPORA I ION. All rights reserved. The ACORD name and logo are registered marks of ACORD