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HomeMy WebLinkAboutCat Man Cafe 12/31/2018Commonwealth 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:. STEPHEN J. CERULLO, PRESIDENT Whose place of business is: CAT MAN CAFE 16 OLD COLONY WAY PERSON(S) IN CHARGE: STEPHEN CERULLO Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-8 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: STEPHEN J. CERULLO, PRESIDENT having a place of business at. CAT MAN CAFE 16 OLD COLONY WAY 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-8 Board of Health NichaeCNcCCean, 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-8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address CAT MAN CAFE 16 OLD COLONY WAY 3) Establishment Mailing Address (if different) 16 OLD COLONY WAY MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-0038 5) Applicant Name & Title: STEPHEN CERULLO 6) Applicant Address 19 WAMPUM ROAD, NORTON, MA 7) Applicant Telephone No.: (508) 285-7712 Ito 'J S v 24 Hour Emergency NO.: (508I 734-0634 (508) 380-9133 8) Owners Name & Title STEPHEN J. CERULLO, PRESIDENT 9) Owner Address (If different from applicant) 19 WAMPUM ROAD, NORTON, MA Owner's telephone number (508) 285-7712 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers i I 'An Association or partner. A Corporation Name Title _ Address An IndividualeQht_d1_-- A Partnership-- i Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: STEPHEN CERULLO Address: i19 WAMPUM ROAD, NORTON MA Telephone No I(508) 285-7712 24 Hour Emergency No: (508) 734.0634 (508) 380-9133 'FAX: E-mail: HCERULLO(cDCOMCAST.NET Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees. 4 17) DAYS/HOURS: 5:30 AM - 12 PM 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN J. CERULLO 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): ir'I 20) Location: [J] Permanent Location P2) Establishment Type .� F-_1 Moblie Mobile Start Date: [� Retail ( Sq. Ft) Mobile End Date: lVii Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21 An Length of Permit: Food Service up to 101 -200 - or up to 25' PHF display $150.00 -_ Seasonal I_J Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: i I Temporary - Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: ❑ Caterer $25.00 i41 Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer FF'; Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 Retail Food $100.00 [] Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date - _-- -- -- -- - -- — ' 23) Food Operations Definitions.PHF- Potentially hazardous food(tlmeBempermure controls required) Non-PHFs non -potentially hazardous food(no tlme/temperature 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 Sale of Commercially Pre -Packaged PHFs F_ I Delivery of Packaged PHFs [ ] Reheating of Commercially Processed Foods for Service Within 4 Hours l..' Customer Self -Service of Non PHF and Non - Perishable Foods Only Ji Preparation of Non-PHFs Other Food Operations IV PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service and Packaged for .% Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service i ] PHF and RTE Foods Prepared For Highly Susceptible Population Facility [_] Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Retail Sale conuo0 1 Juice Manufactured and Packaged for i ] Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin Offers RTE PHF in Bulk Quantities 1 F 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 F_ 11 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: I I Pursuant to MGL Ch.62C, sec. 49A, 1 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: 04-3576340 26) Signature of Individual or Corporate Name: __---_-_ 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: CAT MAN CAFE ADDRESS: 16 OLD COLONY WAY TELEPHONE AT LOCATION: (508) 339-0038 FAX NUMBER: OWNER OF BUSINESS: STEPHEN J. CERULLO, PRESIDENT TELEPHONE OF OWNER: (508) 285-7712 FEDERAL ID/SS NUMBER: 04-3576340 FEE: $10.00 PERMIT NUMBER: FS-8 SIGNATURE: DATE: _ _(.-fa 3- a� o 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 By: Corporate Officer (Mandatory, if Applicable) CJ �-i3 .+ U 3L10 "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:\Hm1thVane's Doc=entAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial 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 PERMTTTING AUTHORITY. Applicant Information //'pp ++ � " i� /l Please Print Le:ribly Business/Organization Name: Ir am D�Aaw �3v.A C c 6&JYqCtV\ &�,'- Address: (U QL0 0,'3 \OAn j City/Sta1e/Zip:\M(k05V(ls�.f) AAA()2u `Ijr Phone#:J f9 5�q _ 0039, Are y,o/ryan employer? Check the appropriate box: Business Type (required): 1. l�'l am a e Toyer with _ employees (full and/ 5. ❑Retail or p -ti .* 6.estaurant/Bar/Sating Establishment 2.0 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. 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]* 11.❑ Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.l I 12, ❑ Other °Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate oOcers have exempted themselves, but the corporation has other emplayees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company insurer's Address(:` �D © S ANGCj V-QSS D� City/State/Zip; (" \0 G)\eS( 0,,tf" ,Ili) p�.�t ZL �1 Policy # or Self -ins, Lic. #- V) 6 ((d 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 certify, under the pains and pa"It es of perjury that the information provided above is true and correct Phone #' ts—W V i3 w C) G J y 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 Ph CERTIFICATE OF LIABILITY INSURANCE 1 11/0812/00/YYVV) 1/os/zon 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 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 endorsemands). PAYCHEX INSURANCE AGENCY INC 150 SAWGRASS DR ROCHESTER, NY 14620 (877) 362-6785 CHAMBERLAIN AVENUE ENTERPRISES INC DBA CATMAN CAFE 16 OLD COLONY RD MANSFIELD, MA 02048 INSURERS) AFFORDING COVERAGE INSURER A :THE TRAVELERS INDEMNITY COMPANY OF NSURER B NSURER C INSURER D INSURER E: INFAIMl INSURER F: II nrnroonrero 000. won cano�o RFVISIf1N NIIMRFR. 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUER WVD POLICY NUMBER POLICY EFF MMIDDIYYYY) POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE DOCCUR EACH OCCURRENCE $ DAMAGE RENTED REMISES Ea occurrence $ GEN'L MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- PRO- ❑LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMPOP AGG $ AUTOMOBILE LIABILITY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON OWNED AUTOS CO BINEDISINGLE LIMIT P.ANY $ BODILY INJURY (Per parson) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per ac.id.ct) $ UMBRELLA LIAB EXCESS HAS OCCUR CLAIMS -MADE - EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WN. ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mendamry in NM It yes, describe under DESCRIPTION OF OPERATIONS below N/A UB-BG617342-17 02/08/2017 02/08/2018'.: T X STATUTE El E.L. EACH ACCIDENT $ 100,000 E.C. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES IACORD 101, Additional Remarks Schedule, may be ettached if more space is required) .,,. Ina DEPARTMENT OF PUBLIC HEALTH 250 WASHINGTON STREET BOSTON, MA 02108 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 4L 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) - The ACORD name and logo are registered marks of ACORD A�Rbr CERTIFICATE OF LIABILITY INSURANCE IDDIY DA11/07/17YYY) 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 have ADDITIONAL INSURED provisions or 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 CONTACT NAME: Muriel Studley Barrows Insurance Agency, Inc. 215 North Main Street Mansfield, MA 02048 AHC NE. E,1: 608-339-7260 FA/G, No; 608-339-9624 EE MA L ADDREss: into@barrowsins.com INSURERS) AFFORDING COVERAGE NAIC# INSURER A: Hospitality Mutual Ins Co INSURED INSURER B: INSURER C: Chamberlain Avenue Enterprises Inc dba Catman Cafe 19 Wampum Road INSURER D: Norton, MA 02766 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR LTR I TYPE OF INSURANCE ADDL3UtcK INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one pereanI $ 6,000 PERSONAL BADV INJURY $ 1,000,000 A 00101170GL 04/16/17 04/16/18 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY❑JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Es accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ $ EXCESS LIAB CLAIMSMADEAGGREGATE DED I I RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE❑ OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE-POLICYLIMIT $ A Liquor Liability 00101171LL 04/16/17 04/16/18 Per Occurrence Aggregate $600,000 $600,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 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. cnRPn1PAT1nld All rinhf .... -A ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD O N O N Ln 14 N Ln N N N ri C a 1. I I � . � / . U/ ± . ./, ± sz! § ?/ ' \tiQ R. +� \ §{]» ƒ ~ t/ 5 \ my\ \ m