HomeMy WebLinkAboutHilliard's Chocolates 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: RETAIL FOOD
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:.
JUDITH MCCARTHY, PRESIDENT
Whose place of business is:
HILLIARD'S CHOCOLATES
333 SCHOOL STREET - B150
PERSON(S) IN CHARGE:
JUDITH MCCARTHY
Permit Expires: December 31, 2018
Food Fee: $100.00
License Number: RF-9
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued RF-9
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name HILLIARD'S CHOCOLATES
2) Establishment Address 333 SCHOOL STREET - B150
3) Establishment Mailing Address (if different) 316 MAIN STREET
NORTH EASTON, MA 02356
4) Establishment Telephone No (508) 238-6231
5) Applicant Name & Title: JUDITH MCCARTHY, PRESIDENT
6) Applicant Address 316 MAIN STREET, NORTH EASTON, MA 02356
7) Applicant Telephone No.: (608) 238-6231 24 Hour Emergency No.: (508)4794902
8) Owners Name & Title JUDITH MCCARTHY, PRESIDENT
9) Owner Address (If different from applicant) 316 MAIN STREET, NORTH EASTON, MA 02356
Owner's telephone number 5082386231
10) Establishment Owned By:
C; An Association
CAI A Corporation
CI An Individual
I l A Partnership
I;.; Other _legal _Entity
__
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
r
Name & Title: 'IJUDITH MCCARTHY
Address: 1316 MAIN STREET, NORTH EASTON, MA 02356
Telephone No: (508) 238-6231 24 Hour Emergency No: (508) 479-4902
FAX: (508)2 38-2389
E-mail: JUDYPHILLIARDSCANDY.COM
Alt E-Mail CHARLIE@HILLIARDSCANDY.COM
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address A/
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No (If applicable) 16 No. of Food Employees: i
_
17)DAYS/HOURS: MONDAYTOSUNDAY
18) Name of Person In Charge Certified in Food Protection Management: TAMRAH COMPRONE
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
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
20) Location: [{I Permanent Location 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: [] Food Service up to 100 or
Moblie Comments: up to 10' PHF display $125.00
21) Length of Permit:
[VI Annual
F 1 Seasonal
Seasonal Dates:
] Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Food Service up to 101 -200
or up to 25' PHF display $150,00
]_i Food Service up to 201 +
or 25'+ PHF display $275.00
[,] Food Service - Institution
( Meals/Day)
❑ Caterer $25.00
❑ Milk & Cream $10.00
❑ Mobile Food & Consession $75.00
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
❑ Pushcart $25.00 # of Pushcarts: 0
❑ Residential Kitchen $100.00
dl Retail Food $100.00
❑ Retail Snack Food $25.00
❑ Tobacco Products $25.00
L_. - Rain Date.
23) Food Operations Definitions PHF- Potentially hazardous food (time4empereture controls required)
Non-PHF s non potentially hazardous tood(no time/temperature controls required)
I(Check all that apply) RTE -ready to -eat foods (Ex sandwiches, salads, muffins which need no further processing)
[;/, Sale of Commercially Pre Packaged Non PHFs
i Sale of Commercially Pre Packaged PHFs
Uelivery, or Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
❑ 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
❑ 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
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Oriqin
Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage Out -Of -Date I---- --- _-.. _—---I
or Reconditioned Food 111 To be completed by the Board of Health
--__---- --- "-"" Total Permit Fee: $10000
Payment is due with application [ I 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:
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: 04-2732716
26) Signature of Individual or Corporate Name: //� //. ,z — -/s
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, iiyRp icdble)
"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:\Hm1(h\Jan&s Documenls\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doe
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
U'r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Business/Organization Name:
City/State/Zip:25a ,-2ir /'Vf1 Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
I. hLl I am a employer with (;Z! ' _ employees (full and/ 5. u Retail
or part-time).* 6. F]Restaurant/Bar/Eating Establishment
2.0 1 am a sole proprietor or partnership and have no 7. Ej Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp, insurance required] $• Non-profit
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.Ej Health Care
4. ❑ We are a non-profit organization, staffed by Vol
with no employees. [No workers' comp. insurance req.J 12. ❑ Other
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employccs, a workers' compensation policy is required and such an
organization should check box#I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon.
Insurance
Insurer's Address:/G/(% Z iI, i i'o1j✓ 1
City/State/Zip: 0%/ 7
Policy # or Self -ins. Lic. # /i / LI/- -'116 6 % Y "2 - U'i!-' 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 thepains and penaldes of perjury that the information provided above is true and correct
Official rise 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.mms.guwwa
NOTICE
TO
EMPLOYEES
WHN9160789 3202338
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will
give you notice that I (we) have provided for payment to our injured employees under the
above -mentioned chapter by insuring with:
THE HANOVER INSURANCE COMPANY
NAME OF INSURANCE COMPANY
440 Lincoln Street, Worcester MA, 01653
ADDRESS OF INSURANCE COMPANY
MORSE INSURANCE AGENCY INC 1286 WASHINGTON ST 508-238-0056
NAME OF INSURANCE AGENT ADDRESS PHONE
HILLIARDS HOUSE OF CANDY INC 316 MAIN STREET
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to
the injured employee. The employee may select his or her own physician. The reasonable cost of the
services provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby
notified that the Insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
U
00215
ACCW?" CERTIFICATE OF LIABILITY INSURANCE
MODNY
DATE(M12/0512017 Y)
/2017
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(les) 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
Morse Insurance Agency, Inc.
285 Washington Street
North Easton MA 02356
CONTACT Karen Forrest
NAME:
NC No ExH t50e)238-0056 ACNot (508)230-8367
ADDRESS: karen(orrest@morselns.com
INSURERS) AFFORDING COVERAGE
NAIG0
INSURERA: Hanover Insurance Company
22292
INSURED
Hilkards House of Candy, Inc..
316 Main Street
North Easton MA 02356
INSURER S: Ailmerica Financial Benefit Insurance CO.
41840
INSURER C, Citizens Insurance Co. of America
31634
INSURER 0:
INSURER E :
INSURER F:
COVERAGES CERTIFICATE NUMBER: 17-18 master REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTEO 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
LiR
TYPE OF INSURANCE
1
POLICY NUMBER
POLICYEP
jqffmomm
POLICY P
MMMDIYYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 2.000,000
CLAIMSMAOEI l OCCUR
PREMISES Ea aCeunelrce
3 30D,000
MEDEXP(AOyonepamen)
3 5,000
pERBONAL....INJFIT,
$ 2.000,000
A
LHND276717
06101/2017
06/01/2018
GEN'LAGGREGATE LIMITAPPUES PER
GENERALAGGREGATE
5 4,000,000
X POLICY ❑ JECT LOC
PRODUCTS-COMPIOPAGG
$ 4.000,000
3
OTHER'
AUTOMOBILE
LIABILITY
EO BINeOsIN LE LIMIT
s 1,000,000
BODILY INJURY (Per Porson)
3
X
ANY AUTO
B
OWNED BCHEOULEO
AUTOS ONLY AUTOS
AWN9160864
06/01/2017
06/01/2018
BODILY INJURY (Per accident)
3
PROPERTY DAMAGE
Pet accident
$
HIRED I NONOWNEO
AUTOSONLY AUTOS ONLY
3
XI
UMBRELLA UAB
X
OCCUR
EACH OCCURRENCE
$ 2,000,000
Cexcess
LlAe
DIAIMSMADE
OBN9180608
O6lOt/2017
06701l2018
AGGREGATE
$ 2,000,000
DEB
I >< RETENTION 3 10,000
$
A
WORKERS COMPENSATION
S' AND EMPLOYERLIABILITY
ANY PROPRIETORMARTNERfEXECUTIVE YIN
OFFICER WRgR EXCI.UDED9 0
(Mandela, In NIH
4 yea, descebe under
DESCRIPTION OF OPERATIONS bel.
NIA
VVHN0160789
06101/2017
aik/p1f2018
PFB OTH'
X STATUTE ER
E.L. EACH ACCIDENT
$ 600,000
E.L. DISEASE - EA EMPLOYEE
3 500,000
ELOISEASE-POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES IAGORD 101, Additional Remarks Schedule, may be attached Ir mom seams is ma urone
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Tom of Mansfield
ACCORDANCE WITH THE POLICY PROVISIONS.
6 Park Row
AUTHORRED REPRESENTATIVE
Mansfield MA 02048
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
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