HomeMy WebLinkAboutCafe on the Common 12/31/2018m
Commonwealth 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:.
DIANE BEATTY, PRESIDENT
Whose place of business is:
CAFE ON THE COMMON, INC.
12 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
CODY BROWN & RYAN BEATTY & BILL FISHER
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-6
BOARD OF HEALTH
Michae(McC(ean, Chairman
Milk & Cream W
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that.
DIANE BEATTY, PRESIDENT
having a place of business at:
CAFE ON THE COMMON, INC.
12 SOUTH MAIN 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-6
Board of Health
.MicGtae(NcCCean, 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-6
FOOD ESTABLISHMENT PERMIT APPLICATION
i
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name
2) Establishment Address
CAFE ON THE COMMON, INC.
12 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 16 AUDUBON DRIVE
WALPOLE, MA 02081
4) Establishment Telephone No (508) 339-9130
5) Applicant Name & Title: DIANE BEATTY, PRESIDENT
6) Applicant Address 16 AUDUBON DRIVE, WALPOLE, MA 02081
7) Applicant Telephone No.: H (508) 666-0231
24 Hour Emergency No.: (508) 666-0231 DIANE BEATTY C (603) 817.
6393 BILL FISHER (774) 526-9053
8) Owners Name & Title DIANE BEATTY, PRESIDENT
9) Owner Address (If different from applicant) 16 AUDUBON DRIVE, WALPOLE, MA 02081
Owner's telephone number (508) 668-0231 C (603) 817-6393
10) Establishment Owned By: i 11) If a corporation or partnership, give name, title, and home address of officers
J An Association or partner.
A Corporation 1Name Title ^Ad ress
An Individual `J Iare__,3ea44-__.A-eStdoe4 ��� °n Pr - ---
A Partnership ✓ Wn -0,i . r Qa08
Other legal Entity_- — - -- - - - - -
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ICODY BROWN & RYAN BEATTY & BILL FISHER, *,kt4l j'nr3,
Address: 12 SOUTH MAIN STREET, MANSFIELD, MA 02048
Telephone No: ( $� ,3,39 7130 24 Hour Emergency No: (508) 668.0231 DIANE BEATTYC (603)
817.6393 BILL FISHER(774) 526.9053
FAX:
E-mail: IDIANEBEATTY519@GMAIL.COM
Alt E Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title DIANE BEATTY, PRESIDENT
i
Address: 16 AUDUBON DRIVE, WALPOLE, MA 02081
Telephone No: 1(508) 668-0231 24 Hour Emergency No: C (603) 817.6393
E-mail: DIANEBEATTY 519@GMAIL.COM
FAX (508)668-0231
14) WATER SOURCE. TOWN
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) _ 16) No. Of Food Employees: ..21 a(o
17) DAYS/HOURS: 7 DAYS 6 AM-3 PM
18) Name of Person In Charge Certified in Food Protection Management: WILLIAM FISHER
If more than 3 individuals are certified, complete list is on file.
Required as of 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
!I 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: h/1 Permanent Location 122) Establishment Type
Mobile Moblie Start Date:
i.:. Retail ( Sq. Ft)
Mobile End Date:
I.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
I-/ Annual
or up to 25' PHF display $150.00
:] Seasonal
L_'I Food Service up to 201 +
or 25'+ PHF display $275.00
Seasonal Dates:
- --
_
[_-J Temporary
- Food Service - Institution
' Temporary Start Date:
( Meals/Day)
!, Temporary End Date:
Temporary Time:
Rain Date:
CODY M. BROWN
[j Caterer $25.00
jj Milk & Cream $10.00
] Mobile Food & Consession $75.00
F-i Manufacture Frozen Desserts/Ice Cream
' $25.00/freezer
I- Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
❑ Retail Food $100.00
I_IRetail Snack Food $25.00
] Tobacco Products $25.00
23)Food Operations Definitions:PHF - Potentially hazardous food(timeRemperature 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 further processing)
I 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
j Customer Self -Service of Non PHF and Non -
Perishable Foods Only
_ ] Preparation of Non-PHFs
Other Food Operations
el PHFCooked To Order 1, Hot PHF Cooked and Cooled or Hot Held
! - ---- for More Than a Single Meal Service
Preparation of PHFs For Hot And -_--_ - - --__-
Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highll
- -- Susceptible Population Facility
i 1 Sale of Raw Animal Foods Intended
to be Prepared by Consumer I Vacuum Packaging / Cook Chill
Ice Manufactured and Packaged for
Retail Sale
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
11 Juice Manufactured and Packaged for _l Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
I Offers RTE PHF in Bulk Quantities II. -] Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage Out -Of -Date -- --- - ---
or Reconditioned Food '�I To be completed by the Board of Health
-- -------_-- Total Permit Fee: $12500
_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: e
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties ofKrrjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
26) Social Security Number or Federal ID: 04-355f2 .4 J /5< �a n� cl1�
26) Signature of Individual or Corporate Name: �L // (��"CQr! (,i� //
Cxp' rry, �t� Col"I"M 7bc .
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: CAFE ON THE COMMON, INC.
ADDRESS: 12 SOUTH MAIN STREET
TELEPHONE AT LOCATION: (508) 339-9130
FAX NUMBER:
OWNER OF BUSINESS: DIANE BEATTY, PRESIDENT
TELEPHONE OF OWNER: (508) 668-0231 C (603) 817-6393
FEDERAL IDISS NUMBER: 04-3552431
FEE: $10.00
PERMIT NUMBER: FS-6
SIGNATURE: v—DY~ ' , &4--
DATE: -_//a i�, O'y // _. ----
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.
V(/&4& - ,a2'k,?
Signature of Individual or orate Name By: Corporate Officer
Oil
"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:\I-IealthVane's Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
r www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /1 Please Print Ledbly
Business/Organization Name: C/�
Ca 'P / [f Y► T C cgm m or
City/State/Zip:
Are you an employer? Check the appropriate box:
1.2rI am a employer with _M.employees (full and/
or part-time).*
2: ® 1 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 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.]
to
#: 6M-339- 913o
Business Type (required):
5. ❑Retail
6,�Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (inel. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.❑ Other
*Any applicant that checks box #1 must also fi[tout the section below showing their workers' compensation policy information.
**If the eorpomte of icers have exempted themselves, but the corporation has other employees, a workers' compensafion policy is required and such an
organization should check box #].
lam an employer that is providing workers' conipensation insurmrAfor my employees. Below is the policy informatloh.
Insurance Company Name:_
Insurer's Address:
City/State/Zip: ) 7 n
Policy # or Self -ins, Lie. #--4
Attach a copy of the workers'
6
L /V r. (Owl, I Gt Expiration Date: CI 71V t j /b
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 penalties of
plrjury 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
www.mass,gov/dia
Phone
12 (Policy Provisions: WC 00 00 00 C)
62
NK INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: TWIN CITY FIRE INSURANCE COMPANY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 14974
Company Code: 7
POLICY NUMBER: 108 WEC NK6212
Previous Policy Number: 108 WEC NK6212
HOUSING CODE: DW
1. Named Insured and Mailing Address: CAFE ON THE COMMON INC
(No., Street, Town, State, Zip Code)
16 AUDOBON RD
FEIN Number: 043552431 WALPOLE, MA 02081
State Identification Number(s):
UIN:
The Named Insured is: CORPORATION
Business of Named Insured: RESTAURANT FAMILY STYLE: FRANC
Other workplaces not shown above: 12-14 MAIN ST
SFIELD MA 02048
2. Policy Period: From 04/01/17 To 0F/Oel�/sl8
12:01 a.m., andard time at the' mailing address.
Producer's Name: UNDERWRITERS INS BKGE INC/PHS
301 WOODS PARK DRIVE
CLINTON, NY 13323
Producer's Coder OBB324
Issuing Office: THE HARTFORD
THE it
HARTFORD
Suffix
LARS RENEWAL
12
301 WOODS PARK DRIVE
CLINTON NY 13323
(866) 467-8730
Total Estimated Annual Premium: $6, 597
Deposit Premium:
Policy Minimum Premium: $267 MA (INCLUDES INCREASED LIMIT MIN. PREM. )
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative
Countersigned by a 02/09/17
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 02/09/17 Policy Expiration Date: 04/01/18
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