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HomeMy WebLinkAboutSubway 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:. CHARLES SMITH Whose place of business is: SUBWAY 84 COPELAND DRIVE PERSON(S) IN CHARGE: CHARLES SMITH, PRESIDENT Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-84 BOARD OF HEALTH MichaermcCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: CHARLES SMITH having a place of business at: SUBWAY 84 COPELAND DRIVE 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-84 Board of Health MichaeCNcCCean, 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 84 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name SUBWAY 117 NOV 27 AM:It 2) Establishment Address 84 COPELAND DRIVE t u , 3) Establishment Mailing Address (if different) 84 COPELAND DRIVE + NOV 2 y 2017 MANSFIELD, MA 02048 P 4) Establishment Telephone No (508) 339-0600_-__- 5) Applicant Name & Title: CHARLES SMITH, PRESIDENT 6) Applicant Address 7) Applicant Telephone No. 20 JAKES JUNCTION, ATTLEBORO, MA 02703 (774) 254-3461 24 Hour Emergency No. (508)639-5169 8) Owners Name & Title CHARLES SMITH 9) Owner Address (If different from applicant) 20 JAKES JUNCTION, ATTLEBORO, MA 02703 Owner's telephone number (774) 254-3461 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 C r(if Six !� DurA/rr ZO--✓u/«-<ow. i�D yD1 2 L A Partnership _f__, Other legal Entity- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CHARLES SMITH, PRESIDENT Address: 20 JAKES JUNCTION, ATTLEBORO, MA 02703 Telephone No: ';(774) 254-3461 24 Hour Emergency No: (503) 539-5189 - - FAX: (508) 339-0040 E-mail: CHUCKSMITH33@GMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: - Address: Telephone No: FAX: 24 Hour Emergency No: E-mail: i Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SUN 7 AM 9:30 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 10 18) Name of Person In Charge Certified in Food Protection Management: CHARLES D. SMITH REBECCA L. If more than 3 individuals are certified, complete list is on file. TOBIAS Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of HERMANN KONATE certificate WINTER ATCHISON 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) El 20) Location:; Permanent Location 1 22) Establishment Type Moblie Moblie Start Date: 1 -1 Retail ( Sq. Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: [] Annual [; Seasonal - -� Seasonal Dates: [_, Temporary Temporary Start Date: Temporary End Date: Temporary Time: LV Food Service up to 100 or up to 10' PHF display $125.00 [ I Food Service up to 101 -200 or up to 25' PHF display $150.00 [_1 Food Service up to 201 + or 25'+ PHF display $275.00 Li Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 [I 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 ❑ Retail Food $100.00 �] Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions.: PHF- Potentially hazardous food (time temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) .Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) [-�'i Sale of Commercially Pre -Packaged Non-PHFs [[ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs [) Reheating -of Commercially Processed Foods for Service Within 4 Hours ij Customer Self-Serviceof Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations [_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 ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum -- - -- ---- —d L._I Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand - Ice Manufactured and P- ackaged --- _ for - { contact alternative, time as a public health i Retail Sale control) Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities � 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 ❑ 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 CMAR z590.000 and the federal Food Code. 24) Signature of Applicant: Ir Vl_ L 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: 2 26) Signature of Individual or Corporate Name:e: i1 �/ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Applieation 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: SUBWAY ADDRESS: 84 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-0600 FAX NUMBER: (508) 339-0040 OWNER OF BUSINESS: CHARLES SMITH TELEPHONE OF OWNER: (774) 254-3461 FEDERAL ID/SS NUMBER: 27-1418387 FEE: $10.00 PERMIT NUMBER: FS-84 SIGNATURE: DATE: 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: Hm1th\Jme's Doe mentsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc 11 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street; Suite 100 Boston, MA 02114-2017 U1V I www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organni`zationName: �GJS 5wbS ze, caa Address: $7 eppele �I ttV P City/State/Zip: Phone#:�%� Are you an employer? Check the appropriate box: Business Type (required): 5. [1 Retail I, u I am a employer with A_ employees (full and/ or part-time).* 6. J/ Restaurant/Ba Mating Establishment 2. [:] lam a sole proprietor or partnership and have no ?. 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. insurancereq.] 12.0 Other 'Any applicant that checks box #I must also fill out the section below showing thcir workers' compensation policy information. **If the corpomte of5eers have exempted thenvselves, but the corporation has other empiayms, a workers compensation policy is required and such an organization should check box N. I not an employer that is providing workers' pompensat pn insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: 3 6 e e / 4��^,d. . City/State/Zip: Policy #or Self -ins, tic.# - Goya`%' 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. Ida hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Vr ze-u- 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: Phone [a EMPLOYEES DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 — http://www.state.u-na.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-. HARTFORD INSURANCE COMPANY OP' THE MIDWEST NAME OF INSURANCE COMPANY ONE PARK PLACE, 300 S. STATE ST., 7TH FLOOR ADDRESS OF INSURANCE COMPANY 76 KEG GC0709 12/09/17 POLICY NUMBER EFFECTIVE DATES PO BOX 33015 COMPLETE BENEFIT SOLUTIONS/PAC SAN ANTONIO TX 78265 NAME OF INSURANCE AGENT ADDRESS PHONE CSS SUB INC '74 TAUNTON AVE EMPLOYER ADDRESS S WORKERS COMPENSATION OFFICER (IF ANY) 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 Workers Compensation Act. A copy of the First Report of Injury must he 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 ex a Form WC 88 20 01 D Printed in U.S.A. INFORMA fi 10N PAGE (Continued) Policy Number C1'0709 3. A. Workers Compensation Insurance: Pail one ofthe policy applies to the Workers Compensation Law oft`' states listed here: MA B. Employers !viability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A_ The limits of our liability under Part Two are: Bodily injury by Accident $100, 000 each accident Bodily injury by Disease $500, 000 policy limif Bodily injury by Disease $100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A 4. the premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 9079 RESTAURANT NOC 184,300 1.09 2,009 MA RATE DEVIATION PREMIUM CREDIT (.15) (9037) TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION MA - MERIT' RATING CREDIT (9885) PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION TOTAL ESTIMATED ANNUAL STANDARD PREMIUM EXPENSE CONSTANT (0900) MASSACHUSETTS DIA ASSESSMENT 4.560 PERCENT TERRORISM (9740) 184,300 .030 TOTAL ESTIMATED ANNUAL PREMIUM Total Estimated Annual Premium: $2, 103 Deposit Premium: Policy Minimum Premium: $27.7 MA Interstate/Intrastate Identification Number: Labor Contractors Policy Number: / 00099211B -301 1,708 .950 1,623 1,623 338 87 55 2,103 NAICS: SIC: 5812 DIN: NO. OF EMP: 000006 Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 10/21/17 Page 2 Policy Expiration Date: 12/09;/18 WC 00 00 00 C) IMFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY URER: HARTFORD INSURANCE COMPANY OF THE MIDWEST ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 20605 Company Code: G POLICY NUMBER: 76 WEG GC0709 Previous Policy Number: 176 WEG GC0709 El HOUSING CODE: 76 1. Named Insured and Mailing Address: CSS SUB INC (No., Street, Town, State, Zip Code) 74 TAUNTON AVE FEIN Number: 271418387 SEEKONK, MA 02771 State Identification Number(s): DIN: The Named Insured is: CORPORATION Business of Named Insured: RESTAURANT - FULL SERVICE Other workplaces not shown above: 74 TAUNTON AVE SEEKONK MA 02771 2. Policy Period: From 12/09/16 To 12/09/17 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: COMPLETE BENEFIT SOLUTIONS/PAC PO BOX 33015 SAN ANTONIO, TX 78265 Producer's Code: 250837 Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $2, 046 Deposit Premium: Policy Minimum Premium: $217 MA Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. THE ic HARTFORD Suffix LARS RENEWAL 03 Countersigned by u�RnZ� 10/22/16 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 10 /22 / 16 Policy Expiration Date: 12 / 09 / 17 ORIGINAL wa%\ \\\\ \ (\ ©\ \ ���9m itsr y�sa�. wrnx ��x„ �� �s�e. 9 � �v�m�. • � �I HERMANN KONATE (or success(ully<o ipl hnyd t nd_ dsre!fodh6 Se,Sa'["; b--IP-!. ion �.la -� �:I,(�«�!i min�nior� v.hch s aco-ad!ed 6y SIlndclyds !ondu!e for fux_I {rFpl. 87 10440 C >'.r, FORM IJUMBFH 0NUr1GL 4-' N' 9/20/2020 DATE OFDATI OF /FIKAiIOht lif ,..._ 1, ,. 1'. less I_.v I I 1-1 -,—,, .. , 00 00 M w I a