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HomeMy WebLinkAboutCibo Matto 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 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:. PETER KUPLAST Whose place of business is: CIBO MATTO 254 CHAUNCY STREET PERSON(S) IN CHARGE: PETER KUPLAST Permit Expires: December31,2018 Food Fee: $125.00 License Number: FS-10 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W1 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: PETER KUPLAST having a place of business at: CIBO MATTO 254 CHAUNCY STREET 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-10 Board of Health Michae(McCCean, 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 FSFS10 r, FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address CIBO MATTO 254 CHAUNCY STREET 3) Establishment Mailing Address (if different) 254 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-9800 5) Applicant Name & Title PETER KUPLAST 6) Applicant Address 61 CAMPBELL STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (774) 219-6060 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 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 V Other -legal Entity- _I 24 Hour Emergency No.: (774) 219-6060 PETER KUPLAST 61 CAMPBELL STREET, MANSFIELD, MA 02048 (774) 219-6060 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) - Name & Title: PETER KUPLAST Address: 61 CAMPBELL STREET, MANSFIELD, MA 02048 Telephone No: I(774) 219-6060 24 Hour Emergency No: (774) 219.6060 FAX: (508) 339-9806 E-mail: 'PETER(c@CIBOMATTOCAFFE.CO Alt E-Mail: iPETERKUPLAST(cDGMAIL.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No 24 Hour Emergency W FAX: E-mail. 4,,1IdeP11 W Food Establishmbnt Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 30 17) DAYS/HOURS: 7 DAYS PER WEEK 11 AM - 11 PM 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) IV] 20) Location: I] Permanent Location 1,22) Establishment Type 1 [ 1 Mobile Moblie Start Date: L] Retail ( Sq Ft) Moblie End Date: Mobile Comments: 21) Length of Permit: 'V Annual Seasonal Seasonal Dates: [ _ ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: [J Food Service up to 100 or up to 10' PHF display $126.00 "1 Food Service up to 101 -200 or up to 25' PHF display $150.00 _l Food Service up to 201 + or 25'+ PHF display $275.00 ] Food Service - Institution ( Meals/Day) BRENDON BROPHY I I Caterer $25.00 J] Milk & Cream $10.00 [ ] Mobile Food & Consession $75.00 ] Manufacture Frozen Desserts/Ice Cream Cf $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 i.] 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 (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ;Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) �. Sale of Commercially P yPre-Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours I 1 Customer Self -Service of Non PHF and Non - Perishable Foods Only V; Preparation of Non-PHFs Other Food Operations V 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 Ice Manufactured and Packaged for Retail Sale lyl 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 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health L] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin Offers RTE PHF in Bulk Quantities 1 ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service I J Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health 1 -- 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 copies of 105 CMR 590.000 pocLtke federa Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 44A, 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: 27-0868462 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: CIBO MATTO ADDRESS: 254 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-9800 FAX NUMBER: (508) 339-9806 OWNER OF BUSINESS: PETER KUPLAST TELEPHONE OF OWNER: (774) 219-6060 FEDERAL ID/SS NUMBER: 27-0868462 FEE: $10.00 PERMIT NUMBER: FS-10 SIGNATURE: DATE: 1 - __f I L 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) **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:\Hn1thUane's Documents\PERMIT APPLICATIONSWAX CERTIFICATION FORM,doc The Commettwealth of Massachusetts Deparllneut of Industrial Accidents a 1 eongress Street, Suite 100 Boston, MA 02114-2017 Y www.massgov/aria Workers' Compensation Insurance Affidavit, General Businesses, TO BF. FILED wITH THE PERMITTING AuTuORITI', Apmicant Information Please Print Legibly Business/OrganizationName:rv\byNn tic Address: 5 l Ctnuw c� SV t _ MA o��t Are yoop an employer? Check the appropriate box: L M I am a employer with_ 50 employees (full and/ or part-time),* 2.0 1 am a sole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp, insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption per e, 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.; Phone#: �30'6-- It »o 0 Business Type (required): 5, ❑ Retail 6. estaumnt/Bar/Eating Establishment 7, Office and/or Sales Cincl, real estate, auto, etc,) 8, Non-profit 9, 0 Entertainment 10:❑ Manufacturing I Ln Health Care l2.© Other pmployess, and Such nn I atro an employer that'is prouitfing workers' con(pensatiott tusarancefor my employees, Below is the policy Information. Insurance Company Name:_'VhP,1A-0,C F fw t1 Insurer's Address; \OU (Livo/ (L\o,(?, \0�1IVt o'r wodb a a- U 'a - Policy It or Self -ins. Lie. P () b — W e z- - C F 3 �-P lb H' Rxpiration Date: 1'5 I I Attacha 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 herebj, certify, talder the that Official use only. Do not write In this area, to be completed by city or town offtclat, City or Town: Permit/License above is trite l Issuing Authority (circle one): t. Board of Health 2. Building Department'3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office- 6.Other _-- — _-- Contact Phone#: HEYMLLC-01 CERTIFICATE & LIABILITY INSURANCE OWITZ DA11/07/2017Y) 1 vo7/eon 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(fes) 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 endorsements . PRODUCER R. S. Gilmore Insurance 27 Elm St North Attleboro, MA 02760 C2gjACT PHONE FAX (A/rytc, Nu, Ext : (508) 699.7511 (mc, no :(508) 699-7511 EopA LS INSURERS) AFFORDING COVERAGE NAIC C INSURER A: Hartford Insurance Company of the Midwest 37478 INSURED Heymohn, LLC 254 Chauncy St Mansfield, MA 02048 INSURER B : INSURERC: INSURER D: INSURER E : INSURER F : COVERAGES CFRTIFICATF NIIMRFR• RFVISInN NnnnROR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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. INSfl Tq TYPE OF INSURANCE ADDL gp SUBR p POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED Ea occurte ce S MED EXP An one rsan PERSONAL &ADV INJURY _ $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOG OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OPAGG _$ AUTOMOBILE LIABILITY ANY AUTO AUTOS IDONLY SCHEDULED SSWULNEEDD AUT OS ONLY BOB COMBINED SINGLE LIMIT BODILY INJURY Per arson $ BODILY INJURY Pereccidenl S PPerGPERdenl AMAGE $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED I I RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE gqF�FICER/MEM9ER EXCLUDED'! (Mantletory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 08WECCF3682 05/15/2017 05/16/2018 PER OTH- S TUTE E.L.EACH ACCIDENT $ 110001000 E.L. DISEASE - EA EMPLOYE $ 11000,000 E.L. DISEASE -POLICY LIMIT 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Heymohn LLC Mansfield MA 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 ACORD 25 (2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I F k W 0 U 7 i I I Cti 0 u 0 vi 0 0 0 a E LU 0 Ln m 00 mwE o o v� ocb rL N If � U ¢_ fV H D � C N 2 m V B W N N N mo O v U -2 N LO C - N b0 Ln.0 4� zUrocl� wl� 0 W-4 � � u OMM4 W-4 � I Q) z �—O z -4■ (A � � z 94 � � � z � � � r �-4 � �jy$�©���� � cu U 0»dd Q «0 � ) awƒa ƒ \\\\ } \~®° \ \ \ [) \ ƒ)]7 ) |}\§ a }\\) ) a §{\u � /