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HomeMy WebLinkAboutCannan Fuel 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health 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:. BOARD OF HEALTH SAMEH KANAN Whose place of business is: CANNAN FUEL 157 PRATT STREET License Number: S-5 Permit Expires: December 31, 2018 Food Fee: $25.00 Milk & Cream f _ I 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: CANNAN FUEL 157 PRATT STREET License Number: S-5 Permit Expires: December 31, 2018 BOARD OF HEALTH NichaeCiWcCCean, Chairman 5-1, FOR BOARD OF HEALTH USE ONLY Permit #Issued S-5 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name CANNAN FUEL 2) Establishment Address 157 PRATT STREET 3) Establishment Mailing Address (if different) 157 PRATT STREET MANSFIELD, MA 02048 4) Establishment Telephone No (509) 339-3317 5) Applicant Name & Title: SAMEH KANAN 6) Applicant Address 108 HIGHLAND AVENUE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (617) 407-9977 (508) 824-1300 24 Hour Emergency No.: (617) 372-5716 (617) 4074977 8) Owners Name & Title SAMEH KANAN 9) Owner Address (If different from applicant) 108 HIGHLAND AVENUE, MANSFIELD, MA 02048 Owner's telephone number 6174079977 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers CI Association or partner. A Corporation Name Title Address An Individual A Partnership 5rmeil, iCiv% ... A W rt.✓ 1 5:1 V J 454__. Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager -etc.) Name & Title: !,SAMMY KANAN, MANAGER Address: 108 HIGHLAND AVENUE, MANSFIELD, MA 02048 Telephone No: (508) 339-3317 24 Hour Emergency No: (617) 372-5716 (617) 407-9977 FAX: (508) 339-3392 E-mail: IKANAN.FIRSTCAPITALGROUP.SAMEH(a)GMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: i Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN ail DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 3 17) DAYS/HOURS: M-F 6-9 SAT 7-9 SUN 8-9 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: ICI Permanent Location 22) Establishment Type ❑Cr $25.00 -__; Moblie Moblie Start Date: I [;a Retail ( 700 Sq Ft) I atere1 Milk & Cream $10 00 Moblie End Date: Moblie Comments: 21) Length of Permit: '.vl Annual [_ j Seasonal Seasonal Dates: 1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: (._ I Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer f Pushcart $25.00 # of Pushcarts: 0 J Residential Kitchen $100.00 ❑ Retail Food $100,00 ❑d Retail Snack Food $26.00 [yJ Tobacco Products $25.00 Rain Date. 23) Food Operations Definitions:PHF - Potentially hazardous food(timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no t/me/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 j F] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held - -- --- -- Sale of Commercially Pre Packaged PHFs --i -- - --- -- ----- i ,Preparation of PHFs For Hot And-_ for More Than a Single Meal Service _ _--_-_ - Delivery of Packaged PHFs - Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly I --- - -- -- --- jI -- - __-- ---- ) Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer �_] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours i ---- ----- ---- - I Customer Self -Service of Non PHF and Non- � ---- - - -- �i Customer Self -Service Use of Process Requiring A Variancei -, and/or HACCP Plan (including bare hand Perishable Foods Only - - [ ]Ice Manufactured and Packaged for contact alternative, time as a public health ! ] Preparation of Non PHFs Retail Sale � control) � Other Food Operations Juice Manufactured and Packaged for [ ] Offers Raw Or Undercooked Food Of Retail Sale i Animal Origin Offers RTE PHF in Bulk Quantities j Prepares Food/Single Meals for -_.i Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date Reconditioned Food -- -- r- - - -- To be by Board or completed the of Health --_-- --- --_-- -- Total Permit Fee: $25.00 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 C-_R 90.000 and the ral-F-oode. 24) Signature of Applicant: 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: 263-69-8693 �-+ 1' 26) Signature of Individual or Corporate Name: A(Jw� /1 y'. y"_7 i 0 J 1 V\ C Town of Mansfield Town of 'Hansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: 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: CANNAN FUEL LOCATION OF SALE OF TOBACCO PRODUCTS: 157 PRATT STREET TELEPHONE AT LOCATION OWNER OF BUSINESS: ADDRESS OF OWNER: (508)339-3317 SAMEH KANAN 108 HIGHLAND AVENUE, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (617) 407-9977 FAX NUMBER: (508) 339-3392 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: 870461440 FEDERAL ID/SS NUMBER: 263-89-8693 s' SIGNATURE: DATE: RETAILER LICENSE FOR SALE OF CIGARETTES rIPIIIIIrIIII�I11d1dI11d�uPllhl�llrvlhh�hlllllllrvl CANNAN GROUP INC CANNAN FUELS 157 PRATT ST MANSFIELD MA 02048-1555 --- -Attached below is ya rr RetailerLicenseforCutalongthe dotted line - and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ----------------------------- i,c'rFT MASSACHUSETTS DEPARTMENT OF REVENUE N k - Retailer License for Sale of Cigarettes `c;tiS This license must be posted and visible at all times. The sale of tobacco Form CT-3T products to anyone under IS years of age is prohibited. CANNAN GROUP INC Account ID: CGL-11310564-006 CANNAN FUELS License Number: 870461440 157 PRATT ST MANSFIELD MA 02048-1555 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 revolted for failure to comply with state laws and regulations. Effective Date: November 22, 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 Individual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. R:\Hn1th\Jane's Doo=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of lndush ial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization t: Are you an employer? Check the appropriate box: Business Type (required): I am a employer with — employees (full and/ 5. ❑ Retail or part-time).* 6. FIRestaurant/Bar/Eating Establishment 2, E] 1 am a sole proprietor or partnership and have no ?. Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per e. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑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 #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 M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ).. C it tS ro %, f Insurer's ILISo City/State/Zip: 1 V\ i Oct le be) Vey M H- C) `L_? Policy # or Self -ins, Lic. #- ( �� 7 . 1) J ggjf ei%ii j Expiration Date: V.� ]� Attach a copy of the workermpensation 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 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: Phon A CERTIFICATE OF LIABILITY INSURANCE 7'12'17 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 policy(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statDment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: GdlMlona Inaurance Agency PHONE 508 947-3960 FnX No: (508) 947-6844 328 Bedford Street nooREss: info@ anlmonsinsurance.com PO Box 1235 Lakeville, MA 02347 INSUAFFORDING COVERAGE NAICN INsuRERA: Travelersers Inaurance Co INSURED INSURERS: Cannan Group, Inc INSURERC: PO Box 13 INSURERD: _ Taunton, MA 02780 [HIP/4:LCH:&�N4:i1Nit tNs\I:111lap] 91-14 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 LTR TYPE OFINSURANCE ADDL SUER POLICY NUMBER POLICY EFF MIOOIY POLICY UP NMIDD'YVYY LIMITS GENERALLIABILITY COMMERCIAL GENERAL LIABILITY CIAIMS-MADE I_] OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED _EREMLSES_lEasuurtrtsnce)—. ME D ExP („ry one mssm) _ $ $ PERSONAL& ADV INJURY $ GENERAL AGGREGATE $ GEN' L AGGREGATE POLICY LIMIT APPLIES PER PRO- LM PRODUCTS AGO $ -- $JECT AUTOMOBILE LIABILITY ANYAUTO ALLOWPED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINEDlild.ccSILIMIT$ BODILY INJURY (Per parson) $ SODILYINJURY(Per eccideni) $ PROPERTY DAMAGE era cadent),___,___-_ $ $ UMERELLALIAB EXCESSLIAB OCCUR CLAIMS -MADE EACHOCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIE70RIPARTNERIE XECUTNE OFFICER(MEMBER EXCLUDED? (Manila Wry in NH) Ues, desalbe under SCRIPTION OF OPERATIONS below NIA IHUB8G46476A17 2/14/17 2/14/18 WC STATU- OTH- E.L. EACHACCICENT --- 1001000 -' E.L. DISEASEEAEMPLOYEE $ 100,000 ---'-- E.L. DISEASE -POLICY LIMIT $ 500,000 MSCRIPnON OF OPERATIONS I LOCATIONS I VEHICLES (Mach ACORD Ili, Additional Remains Schedule, if more space is required) fNtla�ItllN3�y:fN\Ny: N�1. rNtl��311(N. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN Town OP Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATNE Mansfield, MA 02048 Robyn McCarthy © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: