HomeMy WebLinkAboutBricks & Mini Figs 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: RETAIL SNACK FOOD
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:.
CHRIS NOURSE, OWNER
Whose place of business is:
BRICKS & MINI FIGS
280 SCHOOL STREET, SUITE D130
PERSON(S) IN CHARGE:
PATRICK FORD
Permit Expires: December 31, 2018
Food Fee: $25.00
License Number: RS-24
BOARD OF HEALTH
Michael .McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at leastays e ore e p anne open ng a e
1) Establishment Name 6 lj,�,5 1 (t Aj f
2) Establishment Address 2 _Sc, c r> SS
3) Establishment Mailing Address (if different)
4) Establishment Telephone No i
5) Applicant Name & Title:
H72,c_l< r v JC
6) Applicant Address %/6c5 �6,> JF4"'J-!)u}ICA, ,q our 62_360
7) Applicant Telephone No.: % 24 Hour Emergency No.:
E7 J U c
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By:
An Association
❑O A Corporation
0 An Individuals
KA Partnership
Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name � Title Address
g � [
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
9AJ, 46
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Name & Title:
W iL C kph
Address:
Telephone No:
5 AA24 Hour Emergency No
FAX:
E-mail:
----tl_..__`�
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
c2() U
-
C
0
Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
16) No, of Food Employees:
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: f _
_ S
18) Name of Person In Charge Certified in Food Protection Management: /7 �!
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: permanent Location
Mobile Mobile Start Date:
22) Establishment Type
0 Retail � Sq. Ft)
Caterer $25.00
[Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 or
[Ed Mobile Food & Consession $75.00
Mobile Comments:
up to 10' PHF display $125.00
Food Service up to 101 -200
O Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21) Length of Permit:
RAnnuai
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
B Pushcart $25.00 # of Pushcarts:
Residential Kitchen $100.00
Retail Food $100.00
0 Seasonal
Seasonal Dates:
Food Service - Institution
Retail Snack Food $25.00
Temporary
Temporary Start Date:
( Meals/Day)
0 Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions: PHF- Potentially hazardous food (fimefiemperature controls required)
Non-PHFs - non -potentially hazardous food(no 6'me/tempereture controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
i7 Sale of Commercially Pre -Packaged Nan-PHFs
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Q Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
(;'1 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
ry 9
Sale of Raw Animal Foods Intended
to be Prepared by Consumer❑.
c I Reheating of Commercially
Processed Foods for Service Within 4 Hours
Vacuum Packaging / Cook Chill
Ia Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
('I Customer Self -Service of Non PHF and Non-
Perishable Foods Only
`❑-,' Customer Self -Service
'❑_' Ice Manufactured and Packaged for
Retail Sale
F3 Preparation of Non-PHFs
Other Food Operations
/� •!J `
Q Juice Manufactured and Packaged for
Retail Sale
`❑-1 Offers Raw Or Undercooked Food Of
Animal Origin
[a Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
t=7 Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee:
Payment is due with application 0 waived
I, the undersigned, attest to the accuracy of the information provided in
establishment operation will comply with 105 CMR 590.000 and all oth(
board of health on how to ohiairrcopies'of-0r CMR 5W.000 aA the fl
/ A
r[ 24) Signature of Applicant:
Pursuant Pursuant to MGL Ch.62C, sec. 49A, I certify under tl
and paid state taxes required under law.
/_25) Social Security Number or Federal ID: gn
r26) Signature of Individual or Corporate Name: —
lion and affirm that the food
law. I have been instructed by the
Code.
that I, to my best knowledge and belief, have filed all state tax returns
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.
G 00SC_ f3,2 01 i L L C'-
Signature of Individual or Corporate Name
®rr
**Social Security No. (Voluntanj) or Federal
Identification Number
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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
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
Business/Organization N
Address: �- Sedco
City/State/Zip:
W
M ( 1 NO Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
1 I am a employer with employees (full and/ 5. Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I 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.
[No workers' comp. insurance required] 8. ❑ Non-profit
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]** I .❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 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 #I.
I am an employer that is providing rgorkerv,' 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 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 cerliyy-, ur1 ¢erArepq jt9-aWi(penalties ofperjury that the information provided above is try and correct.
N
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 #:
www.mass.gov/dia
F1
MASSACHUSETTS BENEFITS CLAIM AND AGGREGATE DEDUCTIBLE
PROGRAM
Dear Policyholder:
Section 25A of Chapter 152 Massachusetts Workers' Compensation Law requires the Massachusetts Workers'
Compensation Assigned Risk Pool and voluntary market insurers to offer to insureds with workers' compensation policies,
which provide coverage in Massachusetts, a choice of medical and indemnity benefits deductibles.
In accordance with the statute, as amended, the Division of Insurance has approved two separate and distinct deductible
programs, one without an aggregate limit, and one with an aggregate limit. An insured may select either program, or
neither of them. These programs are not available for insureds with retrospectively rated policies.
The first program, Massachusetts Benefits Deductible Program, without an aggregate limit, which has been in effect since
January 1, 1993, is intended for insureds who have the financial ability to handle some losses they incur. This program
allows these insureds to establish an amount of loss they can absorb and purchase insurance only for losses above that
predetermined deductible amount.
Under this program, medical and indemnity deductibles of $500, $1,000, $2,000 and $2,500 shall be offered to every
employer. In addition, an insurer or the Pool, at its option, may offer to any employer providing collateral deemed
adequate by such insurer, a medical and indemnity benefits deductible of $5,000.
The deductible shall apply separately to each claim for bodily injury by disease or accident. The insurer shall pay all
benefits required under the provisions of M.G.L.c.152 directly to the appropriate party. Subsequent to insurer payment of
any amount which falls within the deductible limit on any claim, the insurer may seek reimbursement from the
policyholder. Failure to make complete reimbursement for deductibles within thirty days of receipt of bill from the insurer
shall constitute non-payment of premium and be grounds for termination of the policy.
The entire cost of all claims shall be included in the experience data used to determine the experience modification of the
insured regardless of the requirement that reimbursement must be made for the deductible amount on any claim.
If you wish to elect a medical and indemnity deductible, and your policy is being renewed effective on or after January 1,
1997, you must make your election before the effective date of your policy, otherwise at the next renewal of your policy.
() $ 500 () $ 2,500
() $ 1,000 () $ 5,000
() $ 2,000 () Do Not Elect
----------------------------------------------
() $ 2,500 with Aggregate ( ) Do Not Elect
08 WEC AB5FFY
Loose Bricks, LLC
ROBERT W EAMES INSURANCE AGNCY INC
Form WC 66 0161 A Printed in U.S.A.
Process Date: 04/30/18 Policy Expiration Date: 05/01/19