HomeMy WebLinkAboutBenny's 12/31/2018TEL, (401) 231-1000 FPA (401) 231-1080
January 11, 2018
To Whom It May Concern:
As you may already be aware, Benny's has closed all of its stores as of the end of 2017.
Since our stores are no longer in operation, we will not be renewing our license.
Enclosed we are sending you back your renewal application.
Regards,
yntrollJoWon�fier
FOR BOARD OF HEALTH USE ONLY Permit # Issued RF-2
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name BENNY'S OF MASS
2) Establishment Address 65 COPELAND DRIVE
i
3) Establishment Mailing Address (if different) 65 COPELAND DRIVE
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-6027
5) Applicant Name & Title: HOWARD BROMBERG, PRESIDENT
6) Applicant Address 340 WATERMAN AVENUE, ESMOND, RI 02917
7) Applicant Telephone No.: (401) 231-1000 24 Hour Emergency No.: (401) 231-1000 1
8) Owners Name & Title BENNY S OF MASS, INC.
9) Owner Address (If different from applicant) 340 WATERMAN AVENUE, ESMOND, RI 02917
Owner's telephone number 4012311000
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
An Individual
A Partnership
Other legal Entity -- -
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: VICTOR POLUBINSKI, STORE MANAGER
Address: 1,66 COPELAND DRIVE, MANSFIELD, MA 02048
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
!r
DEP Public Water Supply No: (If applicable) 16) No of Food Employees:
17) DAYS/HOURS: 9 AM-9 PM MON-SAT 9 AM-5 PM SUN
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 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: Yi Permanent Location 22) Establishment Type
Mobile Moblie Start Date: Retail ( Sq. Ft)
Mobile End Date: - ;...J Food Service up to 100 or
Mobile Comments: up to 10' PHF display $125.00
21) Length of Permit: Food Service up to 101 -200
'Vj Annual or up to 25' PHF display $150.00
! i Seasonal - -' Food Service up to 201 +
- or 254 PHF display $275.00
Seasonal Dates:
' Temporary j Food Service - Institution
'. Temporary Start Date: !
( Meals/Day)
1 Temporary End Date: �I
i
Temporary Time:.
Rain Date:
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature Comm
Non-PHFs
- non -potentially hazardous rood(no tim ltempe
'.(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins
'V Sale of Commercially Pre -Packaged Non-PHFs
I PHFCooked To Order
Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Delivery of Packaged PHFs -- -
Cold Holding For Single Meal Service
- -i
Sale of Raw Animal Foods Intended
Reheating of Commercially
to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non-
V1 Customer Self -Service
Perishable Foods Only
Ice Manufactured and Packaged for
1 Preparation of Non-PHFs
Retail Sale
Other Food Operations
now requires retail food permit
�J Caterer $25.00
Milk & Cream $10.00
i..-1 Mobile Food & Consession $75.00
r--, Manufacture Frozen Desserts/Ice Cream
' $25.00/freezer
Pushcart $25.00 # of Pushcarts: 0
_.; Residential Kitchen $100.00
V Retail Food $100.00
j Retail Snack Food $25.00
Tobacco Products $25.00
required)
lure controls required)
Yich need no further processing) j
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
_l Vacuum Packaging / Cook Chili
i ] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health '...
control)
Retail Sale g L_J j Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
--1
To be completed by the Board of Health
Total Permit Fee: $100.00
Payment is due with application ' i 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 105 CMR 590.000 and the federal Food Code.
1 Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
24) Signature of Applicant:
Pursuant to MOIL 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: 05-0299803
26) Signature of Individual or Corporate Name:
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.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
**Social Security No. (Voluntary) or Federal
Identification Number
*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.
R:\Hm1thVane's DocumentsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
k1Vj www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information PIease Print Le: bl
Business/Organization
City/State/Zip:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2: EJ 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 e. 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.]
*Aav aoolicant that checks box #1 must also fill out
Phone M
Business Type (required):
5. ❑Retail
6. Restaurant/Bar/EatingEstablishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11. ❑ Health Care
12.❑ Other
compensation Policy information.
**If the corporate of5cers have c=rupb;d themselves, but the corporation has other employees, a workers compensation po5ry is required and such au
organization should check box 03.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
insurer's
City/State/Zip;
Policy # or Self -ins, Lie. # - 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 a 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 thepains and penaldes of perjury thatthe information provided above is true and correct
Official use only. Do not mite in this area, to be completed by city or town offcciaL
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.gowdia