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Home My WebLink AboutBristol Liquors 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board ofHealth Permit to Operate a Snack 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:. MIGUEL SANCHEZ BOARD OF HEALTH Whose place of business is: BRISTOL LIQUORS 670 EAST STREET License Number: S-4 Permit Expires: December 31, 2018 Food Fee: $25.00 Milk & Cream 1 MichaeCMcCCean, Chairman I Permit for the Sale of'Tobacco Products 11 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: BRISTOL LIQUORS 670 EAST STREET License Number: S-4 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeC-%&CCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued S 4 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address BRISTOL LIQUORS 670 EAST STREET 3) Establishment Mailing Address (if different) 670 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-3782 5) Applicant Name & Title: MIGUEL SANCHEZ, OWNER 6) Applicant Address 75 THURBER AVENUE, BROCKTON, MA 02301 7) Applicant Telephone No.: (781) 405-1016 24 Hour Emergency No, 8) Owners Name & Title 9) Owner Address (If different from applicant) I - _ Owner's telephone number MIGUEL SANCHEZ (781)406-1016 75 THURBER AVENUE, BROCKTON, MA 02301 7814051016 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: !MIGUEL SANCHEZ, OWNER Address: 175 THURBER AVENUE, BROCKTON, MA 02301 Telephone No: (781) 405-1016 24 Hour Emergency No: (761) 405-1016 FAX: E-mail: MIGUEL.A.SANCHEZ(cDME.COM Alt E Mail: MIGSAN(qMSN.COM DIRECTLY TO PHONE 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: - E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN i 15) SEWAGE DISPOSAL DEP Public Water Supply No: (If applicable) 16) No. of Food Employees 17) DAYS/HOURS: MON-THUR 8AM-10PM FRI-SAT 8AM-11PM SUN 12PM-6PM 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: J Permanent Location 22) Establishment Type [ ] Caterer $25.00 Mobile Mobile Start Date: L ; Retail ( Sq. Ft) J Milk & Cream $10.00 Mobile End Date: �... j Food Service up to 100 or I ] Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ,-- Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: [_ j Food Service up to 101 -200 L-, $25.00/freezer I,�/' Annual or up to 25' PHF display $150.00 ❑ Pushcart $25.00 # of Pushcarts: 0 Seasonal [_j Food Service up to 201 + ❑ Residential Kitchen $100.00 Seasonal Dates or 25'+ PHF display $275.00 Retail Food $100.00 I � Temporary Food Service - Institution [VI Retail Snack Food $25.00 1 Temporary Start Date: ( Meals/Day) V Tobacco Products $25.00 SEPTIC Temporary End Date: Temporary Time: Rain Date: _--------------- ------ - _. ---_ 23) Food Operations Definitions.PHF- Potentially hazardous food (timeltemperature 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 turther 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 I Customer Self -Service of Non PHF and Non- i Perishable Foods Only Preparation of Non-PHFs Other Food Operations j PHFCooked To Order F Preparation of PHFs For Hot And Cold Holding For Single Meal Service 1 J Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self Service Ice Manufactured and I Retail Sale 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 Vacuum Packaging / Cook Chill I J Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for F _] Offers Raw Or Undercooked Food Of Retail Sale i Animal Origin I rl 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 j To be completed by the Board of Health -.. -.. - —------- --= Total Permit Fee: $25.00 j 1 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.,,QQ00 and all other applicable law. I have been instructed by the board of health on how to obtain copiesi 105 CMR,SSU.000 and the fedeAl Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, se . 49A, 1ertify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 47-3510984 26) Signature of Individual or Corporate Name: __0 that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Torun of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: S-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 December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: BRISTOL LIQUOURS LOCATION OF SALE OF TOBACCO PRODUCTS: 670 EAST STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 339-37-82 OWNER OF BUSINESS: MIGUEL SANCHEZ ADDRESS OF OWNER: 75 THURBER AVENUE, BROCKTON, MA 02301 TELEPHONE OF OWNER: (781) 405-1016 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. 75 THRUBER AVENUE, BROCKTON, MA 02301 " Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 1438306304 275861604 FEDERAL ID/SS NUMBER: 47-3510984 SIGNATURE: �,rFTT MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T mG Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. JODAMI LIQUORS INC Account ID: CGL-10675585-006 670 EAST ST License Number: 275861504 MANSFIELD MA 02048-2913 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. F ffeGtivA DatQ• DPPPm Imo• ______ --�__ Frn_-_y__�rah�n-tt tr_ -- �`'UrFT MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T = ae y Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. JODAMI LIQUORS INC Account ID: CRL-10675585-009 670 EAST ST License Number: 1438306304 MANSFIELD MA 02048-2913 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective. Date: December8, 2016 Expiration Date: September 30, 2018 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 Individ al or Corporate Name By or rate Officer (Mandatort i Applicable) q 7- a510984 **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:QiealthUan&s Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Z Congress Street, Suite 100 Boston, MA 021I4-2017 n, www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Name:_ Address: In 7n is 24 1 Are y an employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part-time).* 2: ❑ 1 am a sole proprietor or parinersbip 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 c. 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.] Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/Sating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11.❑ Health Care 12.❑ Other °Any applicant that checks box #I 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 #1. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address; P 0 Go k Rey ,i.,;� — �� 9--4 City/State/Zip; 8 rojl ,R"/ T�'/ `% 01 j.. [ 9S / Policy # or Self -ins. Lic. #- t7j5L33 90 3 1 / -7 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. L do hereby certify, under the pains ayd penglties ofperjryy 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 vmw.mass.gov/dia Phan CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 11/21/2017 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 policy(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 endorsement(s). PRODUCER HUB NE Association Programs 299 Ballardvale St, Suite 1 Wilmington, MA 01887 CONTACT NAME PHONE IFAX A/C No EXt : I INC, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: MA Retail Merchants WC Group Inc. _ INSURED INSURER B: INSURER C : Jodami Liquors Inc d/b/a Bristol Liquors-- 670 East Street INSURER D: _ INSURER E: Mansfield, MA 02048 INSURER F : COVERAGES CERTIFICATE NUMBER: 00001 REVISION NUMBER: 00001 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. IXP LBR TYPE OF INSURANCE AINSR suet Me POLICY NUMBER MMIDDL DCD/YYYP MWDWYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 11 OCCUR EACH OCCURRENCE $ DAMAGE TOHEN I ED PREMISES Ea occurrence --- $ MED EXP(Any one person) $ PERSONAL S AOV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC JECT PRODUCTS- COMP/OP AGO $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident)$ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ AOFFICERIMEMBER WORKERS COMPENSATION ANDEMPLOYERS'LIABILITV ANY PROPRIETOR/PARTNER/EXECUTIVE [:] EXCLUDED? (Mandatory in NH) If yyes, describe under DESCRIPTIONOFOPERATIONS W. NIA 014005033803118 1/01/2018 1/0112019 ----- X WC STATU- OTH- TO I S E E.L. EACH ACCIDEM __ $ 100,000 EL DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE - POLICY LIMIT - $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 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 © 1988-2010 ACORD CORPORATION. All ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD