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Home My WebLink AboutD'Angelo's Sandwich Shop 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:. BRIAN J. MCLAUGHLIN, PRESIDENT Whose place of business is: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY STREET PERSON(S) IN CHARGE: BETH MASTROIANNI, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-18 BOARD OF HEALTH MlchaeCMCCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: BRIAN J. MCLAUGHLIN, PRESIDENT having a place of business at: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY 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-18 Board of Health MichaeCMCCCean, 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 FSFS18 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the plannecope 1) Establishment Name 2) Establishment Address D'ANGELO'S SANDWICH SHOP 260 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 279 WEST BRIDGEWATER, MA 02379 4) Establishment Telephone No (508) 339-8603 5) Applicant Name & Title: MARIVA, INCORPORATED 6) Applicant Address PO BOX 279, WEST BRIDGEWATER, MA 02379 7) Applicant Telephone No,: (508) 586-8456 24 Hour Emergency No 8) Owners Name & Title BRIAN J. MCLAUGHLIN, PRESIDENT 9) Owner Address (If different from applicant) P.O. BOX 337, WEST BRIDGEWATER, MA 02379 Owner's telephone number (508) 586-8456 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: FETH MASTROIANNI, GENERAL MANAGER Address: PURCHASE STREET, MILFORD, MA 01757 Telephone No: 1(508) 478-5732 -- -- - FAX: �(508) 580-0644 E-mail: Alt E-MaiC — 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No. FAX: E-mail: 24 Hour Emergency No: ( q 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 20 17) DAYS/HOURS: MON-SUN 10 AM-10 PM 18) Name of Person In Charge Certified in Food Protection Management: BETH MASTROIANNI 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): n j20) Location: jf Permanent Location j 22) Establishment Type ❑, Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: �y! Annual [] Seasonal Seasonal Dates: ❑ Retail ( 800 Sq. Ft) F/-j 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 -j Food Service up to 201 + or 25'+ PHF display $275.00 _ 1 Temporary ❑ Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: ❑ Caterer $25.00 1j Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer J Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100,00 [_J Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous rood (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) _. 1 Sale of Commercially Pre Packaged Non-PHFs I _ Sale of Commercially Pre -Packaged PHFs _l Delivery of Packaged PHFs !..l Reheating of Commercially Processed Foods for Service Within 4 Hours I Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations l_./I 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 ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service L-! PHF and RTE Foods Prepared For Highly Susceptible Population Facility ------ —--------- I [ Use of Process Requiring A Variance ❑ Customer Self -Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale _ control) ❑ Juice Manufactured and Packaged for ❑ 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 or Reconditioned Food To be completed by the Board of Health --- - - - - -___-- -� Total Permit Fee $125 00 Payment is due with application i waived J I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply wi(h-105 CMR 590.0�(f and all other applicable law. I have been instructed by the board of health on how to obtain cop es of 105,CMR 590 Q00 acid the federalvFood Code. 24) Signature of Applicant: 1, L�— Pursuant to MGL Ch.62C, sec. 49A, I certify and r the p and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2522583 26) Signature of Individual or Corporate Name: of perjury that I, to my best knowledge and belief, have filed all state tax returns 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: D'ANGELO'S SANDWICH SHOP ADDRESS: 260 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8603 FAX NUMBER: (508) 580-0644 OWNER OF BUSINESS: BRIAN J. MCLAUGHLIN, PRESIDENT TELEPHONE OF OWNER: (508) 586-8456 FEDERAL ID/SS NUMBER: 04-2522583 FEE: $10.00 PERMIT NUMBER: FS-18 SIGNATU DP 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. L Alllct t Signature of Individual or Corporate Name By: Corporate'O ficer (Mandatory, if Applicable) q- '7??C *"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:IFlealthUane's Documents\PERMIT 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 PERnaTTING AUTHORITY. Applicant Information Please Print LedblV Business/Organization Name: 41 Ck _ C Address: E City/State/Zip:W �%°C JCJC+htkt Vlje Phonet 7� ) - q{ ;4,r. Are syoouuanemployer? Check the appropriatebox: 1. Cv� 1 am a employer with 4 employees (full and/ Business Type (required): 5. ❑ Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2: C1 I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (irel, 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. LNo workers' comp. insurance required]* l l.❑ 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 #1 most also 5]I out the section below showing their Workers' compensation policy information. **If the corporate officers have exempted themselves, but the corpom6on has other employees, a workers' compensation policy is required and such ao ' organization should check box N. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Policy # or Self -ins. Lie. # Expiration Date: Aftach 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceX. ify, under the pai San. tpenalties of perjury 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact PermWLicense 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone AC O DANGINC-Ot C. g7ApLET �..� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/1-1 -----Y) 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((es) must have ADDITIONAL INSURED provisions or he endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement d, this certificate does not. confer rights to the certificate holder in lieu of such endorsement s). PRODUCER License 0' 71 00004 caxrncr INSURED England D'Angelo, Inc. 323 Manley Street West Bridgewater, MA 02379 id.MMcpp; i� a, E:1); (978) 657.5100 INC, No): (978) 988.0038 ADDRESS: INSURERM AFFORDING COVERAGE NAICp INSURER A: Valley Forge Insurance Company 20508 INSURER D:The Continental Insurance Company 35289 INSURERC:National Fire Insurance of Hartford 20478 INSURER 0: INSURER E: COVERAGES-" CERTIFICA TE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE REVIS ON NUMBER: 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 POLICES DESCRIBED HEREIN IS EXCLUSIONS I AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED DY PAID CLAIMS. SUBJECT TO ALL THE TERMS, INBR ADDL SUER TYPE OF INSURANCE POLICY NUMBER POLICY EFF OLICY EXP 14200m, A X COMMERCIAL GENERAL LIABILITY LIMITS CLAIMS -MADE X OCCUR 6023612989 01/0112017 01/01/2018 EACH OCCURRENCE S DAMAGE TO RENTED 1,000,000 300,000 REMIS-M Ea a ante) $ MED EXP(Anyone person) It 15,000 GEN'LAGGREGATE LIMIT APPLIES PER: PERSONAL SADV INJURY S 1,000,000 POLICY %COT LOC GENERAL AGGREGATE It 2,000,000 PRODUCTS-COMNOP AGO $ 2,000,000 OTHER: B AU )BILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 X ANY AUTO 6023612958 01/01/2017 01/01/2018 OWNED SCHEDULED (Ea accident) $ BODILY INJURY Per arson $ person) AUppT��0pp3 ONLY AUUTTOSSW Ep AUTOS ONLY AUTOSONLV BODILY INJURY Per accident) $ p PeOPE.RTnl AMAGE S B X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE 8023612961 01/01/2017 0110112018 EACH OCCURRENCE $ 20,000,000 DEC X RETENTIONS 10,000 AGGREGATE $ 20,000,000 C WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY X SER ERH OFNpCERR/IMEIMBO�gw"CLUDE0T ECUTIVE YIN NlA C6023612975 12/31/2016 12/3112017z:;EL E 500,000 (C.'5 ory In NH) ' EACH ACCIDENT $ If describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE-POLICYI IMM 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional RemarksSchedule, may be attached if more space is required) CERTIFICATE HOLOFIR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) ....-� ..r..,rwlY. nn regms reserved. The ACORD name and logo are registered marks of ACORD w s s 0 c 0 c � �x u v W c e V d O a` V a � LL c w � v c d }O� b w O sV W a� � QM "y o r � k d � H W 9 a! C t A w N A v�i o 9 Z C C N � W rQ M Qa a N E v 0 w o "� W _ N T wu � W N N W J a � 1 l