HomeMy WebLinkAboutCanoe River Campground 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
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:.
GONSALVES FAMILY
Whose place of business is: CANOE RIVER CAMPGROUND
137 MILL STREET
License Number: FS-7
Permit Expires: December 31, 2018
Food Fee: $125.00
Milk & Cream ill
BOARD OF HEALTH
34ichaeCMcCCean, 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:
CANOE RIVER CAMPGROUND
137 MILL STREET
License Number: FS-7
Permit Expires: December 31, 2018
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
GONSALVES FAMILY
having a place of business at:
CANOE RIVER CAMPGROUND
137 MILL 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-7
Board of Health
a 4ichaeCNcCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Manufacture Frozen Desserts and/or Ice Cream Mix
The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws,
as most recently amended, and the regulations made hereunder, hereby issues
CANOE RIVER CAMPGROUND
137 MILL STREET
a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This
license expires December 31 st of each year.
License Number: FS-7
Freezers: 2
TOTAL: $50.00
MANSFIELD BOARD OF HEALTH
MichaeC cCiean, Chairman'
FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-7
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name CANOE RIVER CAMPGROUND g 't
2) Establishment Address 137 MILL STREET
DEC 12 2011
3) Establishment Mailing Address (if different) 137 MILL STREET
MANSFIELD, MA 02048 _._.._
4) Establishment Telephone No (508) 339-6462
5) Applicant Name & Title: MARK BURMEISTER, MANAGER
6) Applicant Address 137 MILL STREET, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 339-6462 24 Hour Emergency No.: (508) 339-8684
8) Owners Name & Title GONSALVES FAMILY
9) Owner Address (If different from applicant) 137 MILL STREET, MANSFIELD, MA 02048
Owner's telephone number (508) 339-8684
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: ,MARK BURMEISTER, MANAGER
Address: '137 MILL STREET, MANSFIELD, MA 02048
Telephone No: (508) 339-6462 24 Hour Emergency No: (508) 339-8684
FAX: (508) 339-5237
E-mail: OPFIL; ECMCANOERIVER.COM
Alt E-Mail:
-
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable)!, 16) No. of
Food Employees: 6
17) DAYS/HOURS: JUNE-SEPTEMBER
18) Name of Person In Charge Certified in Food Protection Management:
MARK A. BURMEISTER
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): !I/'.
20) Location: '!V Permanent Location 22) Establishment Type
''! Caterer $25.00 '..
Mobile Mobile Start Date: -I. Retail ( Sq. Ft)
i Milk & Cream $10.00
Moblie End Date: Ivl Food Service up to 100 or
j L Mobile Food & Consession $75.00
Mobile Comments: up to 10' PHF display $125.00
!.
V Manufacture Frozen Desserts/Ice Cream
21) Length of Permit: - Food Service up to 101 -200
- $25.00/freezer
'V Annual', or up to 25' PHF display $150.00
r-'. Pushcart $25.00 # of Pushcarts: 0
./, Seasonal ,Food Service up to 201 +
Residential Kitchen $100.00
or 25'+ PHF display $275.00
-:
Seasonal Dates: JUNE-SEPTEMBER
Retail Food $100.00 !.
Temporary
Food Service - Institution _', Retail Snack Food $25.00 '.
Temporary Start Date:
( Meals/Day) !I'.V! Tobacco Products $25.00
Temporary End Dale:
Temporary Time:',
Rain Dale:
23) Food Operations Definitions: PHF - Potentially hazardous food time/tem erature controls required)
Non-PHFs
-non-potentially hazardous lood(no timeltemperatu controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
-. Sale of Commercially Pre -Packaged Non-PHFs]
PHFCooked To Order PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs
- - - - - - - I, for More Than a Single Meal Service
Preparation of PHFs For Hot And
Delivery of Packaged PHFs
Cold Holding For Single Meal Service '. PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially
-
to be Prepared by Consumer Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non
Customer Self -Service `.', Use of Process Requiring A Variance
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! I j Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities -._I Prepares Food/Single Meals for !..
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date --- ,- _
or Reconditioned Food, To be completed by the Board of Health,
- - _-- - Total Permit Fee: $125.00
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 cop es of 105 RR $"0
and the federal 50od Code.
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: 04-2375571
26) Signature of Individual or Corporate Name:
S TA-./z (-/'U /,J C.
Town of
Town of Mansfield - Board of Health 6 Pak Rowansfield
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: CANOE RIVER CAMPGROUND
ADDRESS: 137 MILL STREET
TELEPHONE AT LOCATION: (508) 339-6462
FAX NUMBER: (508) 339-5237
OWNER OF BUSINESS: GONSALVES FAMILY
TELEPHONE OF OWNER: (508) 339-8684
FEDERAL IDISS NUMBER: 04-2375571
FEE: $10.00
PERMIT NUMBER: FS-7
SIGNATURE: / � ` e't/:��(���e.
DATE: // /i A 7
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix
To the Board gfllealth cut the Town of Mansfield:
hi, accordance with the provisions gfsection 6511 o/C'hapter 94 of the. General Lowy, as most recently amended, and
the reguhnions mode thereunder, the undersigned herehv applie,sfor a licensefor a WHOLESALE/RETAIL
rnanttfaciure offi•a_en desserts and ice cream mix and.subnrits the,fol/owing iglbrnuttion:
/. FUII name of applicant: CANOE RIVER CAMPGROUND
2. Business address 137 MILL STREET
MANSFIELD, MA 02048
3. Ifapplic ant i.r ar irndividvcr/: FUII name: MARK BURMEISTER. MANAGER
Residence: 137 MILL STREET, MANSFIELD, MA 02048
3a, If applicant is a partnership, fidl name and residence of all pa liners:
3b, If applicant is a corporation: State of incorporation: /1j/}SS/¢C/fu,Sc-77" S _
Date of incorporation:_ C IACA _/9(.0 __- AS 574A-7C/,U
Full name and address of: Principal office: 137 MILL STREET
President /✓A/ LI K 13u/�M� 15 2�t _ l `ll M rt_ [_ S`. _NIA.- o.zo YP
Treasnrw% S-1E7✓E- &0,t)SA-L.t/E-S 1 35 i"eLL 57. zc/q.v.SFt�Z� 1LtA, cia-v 4$
('jerk: ,F]`/'�Lfc �E CA-IVLA) LC_ of S ec: /+ST 5'T. i�lA;✓SFr�`Z D Mlf. O30 V(?
4, Locution q/ Plants.
5. Names gl'brands and trade or corporation name, if any, under which the products are to be sold
nl /A
u G
6. Number and capacitp of freezers and fees: a Fee: ($25.00 pm• freezer) $ S�
Z Ls the mix purchased? L S Ifso, from whom purchased? NEW C�- C 2 c 7F Nl -
8. is the mix pasteurized:' �1/ 1� (71
9. Number ofgallon.s of fi ocen desserts and/or ice cr emn mix to be sold in Massachusetts during the licensing
period a g-C)
I t/, N'urnber of gallons of fto=en desserts and or ice cream inn sold in Massachusetts during the previous licensing veriod
11. Is the plant foam itcled find equipped as provided in the regulations.' �C S
12, is the water supply public or not:' Pf.,i'131. I C_
13. Have you received a copv of the regulations' f e`er
I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of
the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts
Department of Public Health made thereunder and will he manufactured under sanitary conditions, 1 attest that the information stated
in thyis/ ap ficationn Ir lid accurate irndc?pthe pains and penalties ofpelyrry.
(Company owner/officer's signature) (DATE)
Ge7A/ev�,+ (_ M 4N 4(c MAA)StZ 0 /1144 vac, y8
(Title) (City or Town)
Town of
Town of Mansfield - Board of Health 6 Pak Rowansfield
Mansfield, MA 02048
PERMIT NUMBER: FS-7
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: CANOE RIVER CAMPGROUND
LOCATION OF SALE OF TOBACCO PRODUCTS: 137 MILL STREET, MANSFIELD, MA 02048
TELEPHONE AT LOCATION: (508) 339-6462
OWNER OF BUSINESS: GONSALVES FAMILY
ADDRESS OF OWNER: 137 MILL STREET, MANSFIELD, MA 02048
TELEPHONE OF OWNER: (508) 339-8684
FAX NUMBER: (508) 339-5237
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: 25743360
FEDERAL ID/SS NUMBER: 04-2375571
SIGNATURE: o / ` I "
DATE: I I /I 17 _ __
T S:;
MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigarettes
This license must be posted and visible at all times. The sale of tobacco
products to anyone under IS years of age is prohibited.
STARLIN INC
Account ID: CGL-11353826-007
CANOE RIVER CAMPGROUND GENERAL STORE License Number: 25743360
137 MILL ST
MANSFIELD MA 02048-3268
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: November 15, 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.
57 -7-7-WL� L 1.1U 1,A) C /�Vz,,,- A
Signature of Individual or Corporate Name
**Social Security No. (Voluntary) or Federal
ldent�acation 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.
'FZ � The Commonwealth of Massachusetts
Department of IndustrzalAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
V . www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leyibly
Business/OrganizationName: .9TA✓'c -1AO /,Jc A-1 CA.,uor- Avcc
137 MILL 57-
City/State/Zip: MA, van VP phonet go s' _ 3'= % ` 6 `/6 a
Are ttlyou an employer? Check the/ appropriate box:
l.yy I am a employer with employees (full and/
or part-time).*
2: 0 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.l
Business Type (required):
5. ❑Retail
6. E]ReetaurantfBar/Ea6ngEstablishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10,❑ Manufacturing
1111 Health Care
Other 64M1o0/-1u.VZVr-e V
*Any applicant that checks box #1 must also fill out the section below, showing their workers' compensation policy information.
**If the corporate officers have cxempted themsclyn, bat the corporation has other employees, a workers' compensation policy is required and such an
organization should check box N.
I am an employer that is providing workers' compensation insurance far my employees. Below is the policy information,
Insurance Company Name: -Z Irf 7 C 14 A M b--/e I (f/f •A)
insurer's Address: a t/,� a L /" K E M o V 7— V e
0(e( 4,1-)D0 rL. 3< Iy/2i
Policy#or Self-ins.Lic.#.(„Zzo(�;�_("M-S N7S--G -- i% Expiration Data:
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,
f do hereby certify, under thgpainsgnd penaldes ofpgrjury that the information provided above is true ancorrect,
s09-339--6`/6,1
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 Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
Phone
VDAC
ZURICH
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6ZZUB-0495N75-0-17)
RENEWAL OF (6ZZUB-0495N75-0-16)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
1.
INSURED:
STARLIN, INC. DBA CANOE RIVER
CAMPGROUNDS'
137 MILL ST
MANSFIELD MA 02048
NCCI CO CODE: 17965
PRODUCER:
C Pt S INSURANCE AGENCY
316 N MAIN ST #6
MANSFIELD MA 02048
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period Is from 05-13-17 to 05-13-18 '12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT'WC 20 03 0613
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-17-17 WC
OFFICE: ZURICH-ORLAN 809
PRODUCER: C & S INSURANCE AGENCY
011112
75W2J
ST ASSIGN: MA
The Commonwealth of Massachusetts
Department of Industria[Accidents
I Congress Street, Suite 100
Boston, MA 021I4-20I7
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses,
TO BE FILED WITH THE PERIVHTTING AUTHORITY.
Applicant Information Please Print LedbIy
Business/Organization Name: �5'7r,"E2L/ .0 yam <l6� GqN�'.= ,R l ✓G � C �t/'�2o r, l;�
3 7
O;kv
Phone #: _ .3 - 1 - G 1,-6 a
Are y�p an employer? Check the appropriate box:
Business Type (required):
1 I am a employer with 1 employees (full and/
5. ❑ Retail
a' part-time).*
6. Restaurant/Bar/EalingEstablishment
211 1 am a sole proprietor or partnership and have no
7, Q 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]*
i 1. ❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
121P7Other C.AMP6-2yrA..Uk> /,, fir V ,✓,i4 /G
*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 otheremployees, aworkers' compensation policy is required and such an
organization should check box#1.
lain an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: :0 L411L 1 Gt-f Ate cle-I c-,4, i
Insurer's Address: :Z Ya U t- /`1 K CAI tlN T- V
City/State/Zip: e�/&L,-4,1170/ / L
Policy #orSelf-ins.Lie. #-L4 CY`1JN-7S-- O- /'7 Expiration Date: /l3 //8
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 e. 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 DLA for insurance coverage verification.
I do hereby certify, under thtglpain�nd penalties of pegjury that the information provided above is true and correct.
Phone #: � C-1--g - 3 `j - 6 V6
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
//// / /7
Issuing Authority (circle one):
1. Board of Health Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
www.mass,gowma
Phone
VDAC
ZURICH
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6ZZUB-0495N75-0-17)
RENEWAL OF (6ZZUB-0495N75-0-16)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
1. NCCI CO CODE: 17965
INSURED: PRODUCER:
STARLIN, INC. DBA CANOE RIVER C & S INSURANCE AGENCY
CAMPGROUNDS WO N MAIN ST #6
137 MILL ST MANSFIELD MA 02048
MANSFIELD MA 02048
Insured is A CORPORATION
Other work places and Identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-13-17 to 05-13-18 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed In
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
o Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB
o=
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-17-17 WC ST ASSIGN: MA
OFFICE: ZURICH-ORLAN 809
PRODUCER: C & S INSURANCE AGENCY 75W2J
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