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Home My WebLink AboutHangar #12 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:. MICHAEL LEVINSON Whose place of business is: HANGAR #12 RESTAURANT, LLC 265 FRUIT STREET PERSON(S) IN CHARGE: MICHAEL LEVINSON Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-2 BOARD OF HEALTH Aichae(McC(ean, Chairman Milk & Cream ❑O 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: MICHAEL LEVINSON having a place of business at HANGAR #12 RESTAURANT, LLC 265 FRUIT 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-2 Board of Health .Michae(MCCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred I FORWARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FQOD ESTABLISHMENT PERMIT APPLICA t IUN pp rca on mus a su mr e a eas ays e ore e p anne opening a e 1) Establishment Name J 2) Establishment Address 3) Establishment Mailing Address (if different) Establishment Telephone No - 3 5) Applicant Name & Title: 6) Applicant Address1a- 7) Applicant Telephone No.: 24 Hour Emergency No.: to 8) Owners Name & Title t = /) 8N w _� �2 I 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 O'y AyAssociation or partner. i A Corporation Ntame Title Address [Ed An Individual U�1 — ) �Le 11 A Partnership M Other legal Entity 121 Person Directiv Resoonsible For Dailv Operations (owner, person in charge, supervisor, manager etc.) nllr7-0y 9 Name & Title: -VA (--LA c-+ r =J o / Address: l� r F�iTti �r-bJ°Il1ptLs7Ji.t Telephone No: 24 Emergency No: FAX: E-mail: levb®r) L) . Alt E-Mail: C A11Z 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No. FAX: E-mail: ,j,rS NN, OF" MAN PAIL) APR 3 0 20M Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17)DAYS/HOURS: L a 7 riyS ( SSrdf rr7 �rz� �� zt 18) Name of Person In Charge Certified in Food Protection Management:r�q 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): 20) Location: 0 Permanent Location 22) Establishment Type D Caterer $25.00 0 Mobile Mobile Start Date: I] Retail ( Sq. Ft) H Milk & Cream $10.00 Mobile End Date: Ni400d Service up to 100 or 0 Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ® Food Service up to 101 -200 O Manufacture Frozen Desserts/Ice Cream $25.00(freezer 21) pngth of Permit: Annual or up to 25' PHF display $150.00 ."❑-7 Food Service up to 201 + or 25'+ PHF display $275.00 Pushcart $25.00 # of Pushcarts: Residential Kitchen $100.00 Retail Food $100.00 0 Seasonal Seasonal Dates: 0 Food Service- Institution 0 Retail Snack Food $25.00 H Temporary Temporary Start Date: ( Meals/Day) E0 Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF -Potentrrally hazardous food(timelfemperature controls required) Non-PHFs - non -potentially hazardous food(no Ilme/tempereture controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ,,: Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service :'. Sale of Commercially Pre -Packaged PHFs .' Preparation of PH For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs I❑'t Sale of Raw Animal Foods Intended to be Prepared by Consumer reheating of Commercially Processed Foods for Service Within 4 Hours ❑3 Vacuum Packaging / Cook Chill ❑�, Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) F7 Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑"E Customer Self -Service + Ice Manufactured and Packaged for O 9 Retail Sale I07 Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service r N Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application -❑i waived I, the undersigned, attest to the accuracy establishment operation will comply with 1 board of health on how to obtain (;gpies,ol 24) Signature of Applicant: information rowded in this application and affirm that the food MR 590.000 a all other applicable law. I have been instructed by the CMR 990.000 nN the federal Food Code. 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. 4 — r '3! p /t-' 25) Social Security Number or Federal ID: 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: !"�G c�c [ .y_ " ^ I- L ADDRESS: IA'4'�S' i t Uvd o q2 TELEPHONE AT LOCATION: —V FAX NUMBER: OWNER OF BUSINESS:`�� TELEPHONE OF OWNER: c<-/3 FEDERAL IDISS NUMBER: &2 {0 q L, FEE: $10.00 PERMIT NUMBER: SIGNATURE: i f — DATE: (-v5 I2' 1G6 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. 1�i�YiV(�r+2�/�2 6��•��vz�n<r L. � � r9�t� ��'-zee--�rc� Signature of Individual or Corporate Name By: Corporate Officer (Mandatonj, 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. C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of'Industrial Accidents Office of Investigations 600 Washington Street IV Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Business/Organization Name: 6_A+ t ,,7- Address: ,7_ L> t' �.zu, r �r Phone #: Aree yow an employer? Check the appropriate box: Business Type (required): I. `<_j I am a employer with /0 employees (full and/ 5. ❑ Retail or part-time).* 6. �estaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ 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 10.0 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.] 1, 12.❑ Other '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 other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. Expiration 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, finder the pain`s and penalties ofperjury that the information provided of ove is tfue and correct. Phone #• Official use only. Do not ivrite 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: Phone #: www.mass.gov/dia a� �® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIO18 ) 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: John J. Lamb Insurance Agency Inc. HONK E,t; 781.749.6960 FAXA/C No: 781.749.8822 24 North Street Hingham, MA 02043 E-MA L ADDRESS: kariny@jlambinsurance.com INSURER(S) AFFORDING COVERAGE NAICN INSURERA: Scottsdale Insurance INSURED INSURER B: The Hartford INSURER C: HANGER12 RESTAURANT LLC 266 FRUIT STREET MANSFIELD, MA 02048 INSURER D: 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 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. INR LS TYPE OFINSURANCE INSD MD POLICY NUMBER EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS A X COMPOLICY MERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR CPS3032329 03107118 03107/19 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 60,000 MED EXP (Any oneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: %C POLICY ❑JECTT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED F I SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY EOeBBINEDt SINGLE LIMIT rddu $ BODILY INJURY (Per person) $ BODILY INJURY(Pareccldenl) $ PROPERTY DAMAGE Per acddenl $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACHOCCURRENCE $ AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? IMandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 1173321 03108118 03108119. PER OTH- !� STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 EL. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Jeanne R McPhail 01988-2016 ACORD CORPORATION. All rights ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SCOTT TEFFT +Nho ha mnz all tho. M s yofes 1,iia)isquiremtei,Nfoiin food! service saf;:zy tI,icl s-CnRation. 40659 Exam 1821 Recognized By Conference For Food Protection Mr. MA", " Certificate No: 1939250. Ryan MOMllben, Client services Manager _ 'Exam Date: 02/28/17 - Pmmolric 1 7941 Carporale Dnve, Notlin0ham, MD 21236 1 600.6242736 Test Coder 6203041821 ` Expires on: 02/28/22 REI!3 I Bank N PktN De artmeUL: BOARD OF HEALTH �$Chedule: te: JED43010 T Da�4 30 2018 HANGAR 912 AIRPORT 1 01512-445006 i 1 1 $ 125.00 12500 or 5S9DE'd1➢R7 To The Officer Making the Payments: The above Is a detailed list of moneys collected ,by me amounting in the aggregate to: $126.0 for the period ending �30-Ml1 _ which I have paid to the Town Treasurer whose receiot I hold therefor. �1 CHEC4Cit ,�T�Y