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Home My WebLink AboutBGFood 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD SERVICE 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:. JASON SWEENEY Whose place of business is: BG FOOD MANSFIELD LLC DBA - B.GOOD 280 SCHOOL STREET PERSON(S) IN CHARGE: ANTHONY DEPAIVA Permit Expires: December 31, 2018 Food Fee: $126.00 License Number: FS-4 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream O Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: JASON SWEENEY having a place of business at: BG FOOD MANSFIELD LLC DBA - B.GOOD 280 SCHOOL STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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.: FS-4 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 FS-4 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name BG FOOD MANSFIELD LLC DBA - B.GOOD 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET)�� MANSFIELD, MA 02048 4) Establishment Telephone No p (617)877-0252 _ 5) Applicant Name & Title: JASON SWEENEY, PARTNER/MANAGER 6) Applicant Address 501 LEXINGTON STREET, UNIT 111, WALTHAM, MA 02452 7) Applicant Telephone No.: (617) 877-0252 24 Hour Emergency No.: 8) Owners Name & Title JASON SWEENEY 9) Owner Address (If different from applicant) 501 LEXINGTON STREET, UNIT 111, WALTHAM, MA 02452 Owner's telephone number (617) 877-0252 10) Establishment Owned By: i 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: !ANTHONY DEPAIVA Address: 121 PALLAD STREET, PROVIDENCE, RI 02903 Telephone No (401) 699- 1883 24 Hour Emergency No: FAX: E-mail: ANTHONYDEPAIVA@BGOOD.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) 1 17 MV 2.P.. pv,2:55 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 1 DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 20 17) DAYS/HOURS: SUN -SAT 11 AM - 10 PM 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY DEPAIVA 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): Ill 20) Location: IV] Permanent Location 22) Establishment Type Mobile Mobile Start Date:-� Retail ( Sq. Ft) Moblie End Date: ill 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 dl Annual or up to 25' PHF display $150.00 Seasonal '_ Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates. - _ - - - L Food Service - Institution Temporary Temporary Start Date: ( Meals/Day) III 'll Temporary End Date: Temporary Time: Rain Date: JASON SWEENEY ❑ Caterer $25.00 Milk & Cream $10.00 i ] Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 1 Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 11 Retail Food $100.00 [_ I Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23)Food Operations Definitions: PHF Potentially hazardous rood(time/temperature confrols required) Non-PHFs - non -potentially hazardous food(no time/femperature controls required) i,(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 VI PHFCooked To Order Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service L—I PHF and RTE Foods Prepared For Highly Susceptible Population Facility [] Vacuum Packaging / Cook Chill - -- -- -- I I Use of Process Requiring A Variance Customer Self -Service - and/or HACCP Plan (including bare hand L ] Ice Manufactured and Packaged for I contact alternative, time as a public health Retail Sale Other Food Operations i_] Juice Manufactured and Packaged for i.__i Offers Raw Or Undercooked Food Of Retail Sale Animal Origin 1 Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service _-! Retail Sale of Salvage, Out -Of -Date i- --- __ --__ or Reconditioned Food To be completed by the Board of Health i --- _- --- _--- Total Permit Fee: $125.00 j 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 105 CMR 590,000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certify under the penalties of perjury the,, to my best knowledge and belief, have filed all state tax returns and paid slate taxes required under law. 25) Social Security Number or Federal ID: 38-3970462 R /' 26) Signature of Individual or Corporate Name: I� l7 (OGA A (An5 & id 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: BG FOOD MANSFIELD LLC DBA - B.GOOD ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (617) 877-0252 FAX NUMBER: OWNER OF BUSINESS: JASON SWEENEY TELEPHONE OF OWNER: (617) 877-0252 FEDERAL ID/SS NUMBER: 38-3970462 FEE; $10.00 PERMIT NUMBER: FS-4 SIGNATURE: DATE: --- ) ah I I -- - 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. l�(, Uw -JAY Signature of Individual or Corporate Name By: Corporate Officer ( nd ory, il'Applicable) c- 3q 70 q �a **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:�He IthUane's DoeumentAPERMIT APPLICATIONMAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /�"" Please Print Legibl Business/Organization Name: g (a FOo q,, S -Fa t ld Address: <C �rol St- City/State/Zip: 04jrFielA Al N O� C )iAt Phone#: rD17 77'015�k Are you an employer? Check t e appropriate box: Business Type (required): 1. lama employer With employees (full and/ 5. ❑ Retail or part-time).* 6. bgRestaurant/Bar/EatingEstablishment 2: ❑ 1 am a sole proprietor or partnership and have no ?, ❑ 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. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12, ❑ Other *Any applicant that checks box #1 most also fill out the section below showing their Workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employccs, a workers' compensation policy is required and such ao ' organization should check box 41. I am an employer that is providipg workers' compensation insurance for my employees. Below is the policy informadcni. Insurance Company Name: yrie Insurer's Address: q 'r "I G City/State/Zip: tjof-c es+e c/V I!V 1 (4,53 Policy 4 or Self -ins, Lie. # W Z %_— bn 5 G1 ^d-I �-q 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 the pains and penaltiesp_Cperjury 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: 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 Contact Person: Phone A�RO® CERTIFICATE OF LIABILITY INSURANCE DATEhMM/D Y) 17 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 poiicy(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 endomement(s). PRODUCER Agency, Inc. i£ n cci Street 420McSweeneyWashington 420 Washington Street Braintree MA 02185 NAME:CONTACT _ PHONE FAX (AIC No. €XS4 781-848-8600____.____ I LAlc. rvot: 781-843-8807 ADDRIESS, mrirece lion mC weene ricci.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: The Hanover Insurance GrouQ _ _ 22292 INSURED BGFOO�2 BIG Food Mansfield:LLC INSURER B : 280 School: Street#D115 INSURER C_ ----- INSURER Or Mansfield MA 02048 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 990853989 REVISION 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. INBR R TYPE OF INSURANCE [map WVD SUER POUCYNUMBER MM/DDY/YYYY MM/DDYIYYYY LIMITS A GENERAL LIABILITY ZBND05450700 1013112017 10131/2018 EACH OCCURRENCE $1.000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea owurrance) S 1_000,000 CLAIMS -MADE 111 OCCUR _ MED EXP(Any one person) $5.000 PERSONAL S ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,09__ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGO $2,o0D,000 $ POLICY PRO IOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per aWdent) $ PROPEWZDAMAGE Perecdtlenl $ _ NON —OWNED HIRED AUTOS AUTOS 8 A X UMBRELLALIAB X OCCUR UHNDOfi554500 10/3W017 10/31/2018 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 EXCESS UAB CLAIMS -MADE DED I X I RETENTION$ 10000 1 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN W2ND05921300 10M12017 1011/2010 '- WC STATU- OTH- IMITS.---ER_ E.L. EACH ACCIDENT $1,000,000 ANY FFICERIMEM ER EXCLUDED? ECUTIVE NIA (Mandatory in NH) EL DISEASE - EA EMPLOYE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY UNIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES fAttach ACORD IDi, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION 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 Evidence of Coverage �"'"" ` /""' /`'•`-`a`y 1 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Insured Insurer AM Best Rating Policy Number Policy Term WORKERS COMPENSATION COVERAGE BG Food Mansfield LLC Hanover A W2ND05921300 10/01/17 to 10/01/18 WORKERS COMPENSATION BENEFITS (A) States: MA Important Note: If you have operations or employees working in states other than your state of domicile, your policy must be endorsed accordingly. EMPLOYER'S LIABILITY (B) COVERAGE LIMIT PER Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury Policy Limit $1,000,000 Policy Limit Bodily Injury by Disease $1,000,000 Each Employee Rate Deviation - .80 • JASON SWEENEY AND LARS MOHLIN -EXCLUDED ( LETTER OF INCLUSION IS REQUIRED TO "OPT IN") ESTIMATED PAYROLL CLASSIFICATION Restaurant STATE CODE PAYROLL RATE MA 9079 $146,000 1.15 At your request, we will conduct a medical bill review on your smaller "medical only" Workers Compensation claims. Your charges will be compared to the state fee schedule in an effort to reduce the medical charges and the impact on your mod and premium. E