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Home My WebLink AboutRoute 106 Wines/Spirits 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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:. BOARD OF HEALTH JOHN MCINTYRE, PRESIDENT Whose place of business is: ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET License Number: S-14 Permit Expires: December 31, 2018 Food Fee: $25.00 Milk & Cream 1_1 MichaeCMcCCean, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: BOARD OF HEALTH ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET License Number: S-14 Permit Expires: December 31, 2018 MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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:. JOHN MCINTYRE, PRESIDENT Whose place of business is: ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET License Number: S-14 Permit Expires: December 31, 2018 Food Fee: $25.00 Milk & Cream BOARD OF HEALTH MichaeCMcCCean, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. BOARD OF HEALTH Whose place of business is: ROUTE 106 WINES & SPIRITS 377 CHAUNCY STREET License Number: S-14 Permit Expires: December 31, 2018 M1chaeCMcCCean4 Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued S-14 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name ROUTE 106 WINES & SPIRITS 2) Establishment Address 377 CHAUNCY STREET 3) Establishment Mailing Address (if different) 377 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No i 5) Applicant Name & Title: JOHN MCINTYRE 719-2817 6) Applicant Address 421 LANDRY AVENUE, NORTH ATTLEBORO, MA 02760 7) Applicant Telephone No.: (508) 736-8888 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: (508)736-8888 JOHN MCINTYRE, PRESIDENT 5087368888 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 Fr ❑ An Individual �ii [qa . t_ aA,f A Partnership LI Other legal Entity___-__ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IJOHN MCINTYRE I [Address: 1421 LANDRY AVENUE, NORTH ATTLEBORO, MA 02760 Telephone No 1(508)736-8888 24 Hour Emergency No: (808) 736.8988 FAX: E-mail: MCINTYRE549@HOTMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: - - --_ - -- _ ...._..__..------ 24 Hour Emergency No: LFAX: �E mail: Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) _ - _. 16) No. of Food Employees: 17) DAYS/HOURS: 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) 0 20) Location: W Permanent Location ❑ Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: L I Annual [ I Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $125.00 [J Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 (_1 Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 [] Milk & Cream $10.00 Mobile Food & Consession 00- ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 W Retail Snack Food $25.00 [41 Tobacco Products $25.00 Rain Date: - __--_- _-- 23) Food Operations Definitions' PHF - Potentially hazardous food (flme/lemperature controls required) Non-PHF'' non potentially hazardous food(no time4emperature controls required) '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 (] Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF arid -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 Manufa( Retail Sale ❑ 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 Packaging /Cook Chill j ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service L I Retail Sale of Salvage Out -Of -Date I _.,,., --- 1 or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 25.00 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-y590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of�ri)5 CM 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49� rtffy under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required unde w. 25) Social Security Number or Federal ID: 46-0e i 81 029 u!! _ 26) Signature of Individual or Corporate NamU-e- lu Town of Mansfield Town of Alfonsfaeld - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on December 31st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: ROUTE 106 WINES & SPIRITS LOCATION OF SALE OF TOBACCO PRODUCTS: 377 CHAUNCY STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (774) 719-2817 OWNER OF BUSINESS: JOHN MCINTYRE ADDRESS OF OWNER: 421 LANDRY AVENUE, NORTH ATTLEBOROUGH, MA 02760 TELEPHONE OF OWNER: (508) 736-8888 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. JOHN N. MCINTYRE 42 LANDRY AVENUE, NORTH ATTLEBORO, MA 02760 x provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 1511419904 269103104 FEDERAL ID/SS NUMBER: 46-0819029 SIGNATURE: < r DATE: I l f M /!7 DETACH HERE NTA.SSACHUSETTS DEPARTMENT OF REVENUE ' Retailer License for Sale of Cigars and Smoking Tobacco NZt r - p#: e sl ne st:d and fsible at all times. The sale of tobacco z rr�_- aanNo e under IS years of age is prohibited. s Form CT-3T Account ID: CRL-12241468-010 License Number: 269103104 at cne taxpayer named above is licensed under C1-_:er 64C of the Massachusetts General Laws to address shown above. Thus license is non-rran; — rabie and may be suspended or revoked for _ i'h state laws and regulations. E ff:'k - ts�--re yr 11. 2016 ;1Z -0£ .taqutaldaS :apeQ uoijwidx:,j Expiration Date: September 30, 2018 910Z'ZI aagoloO :aaeQanpaa333 suotlulnnw puu smeI apels glim f1dmoo of aznlTe3 io papuadsns oq tfem pue olgeza3suwj-uou st osuooil stg1 a.wge mmotls ssoappe aql In hula pe pas == a9 suasngoesseyg agp3o Dtig .ialdegD .tapun posuaatl st ancge paaunt .ia,(udxq aqp lutlp sat31lzao stgy r =661 f l t c I :aagmnN asuaat7 _ 89 Ihlli IJD:QIxunoaaV 6911-8bOZO VW O'JHlASXVW .LS AONf1VHD LL£ SIDIIdS ?8 SHI IIM 90I 3.111Od Ds.'II S MMS SIII IIM 901 RLf1O2I -paplgtgoad si afle}o s.tuari ST aapun auo.{uu of slanpoad oaaegot 3o ales aq•T, -same llu in alglsiA puu palsod aq;sntu asuaoll siq.L sapla.1010 3o aluS aq3 asua317 aallepag 3f1NJA3[H 30 ,LIs aWJHVd:4Q S,L,L3Sf1HDVSSVW 3'd3H HDV13Q 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 Corporates e Name "*Social Security No. (Voluntary) or Federal Identification Number By: Cor a e fficer (Mandatory, if Applicable) *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:\HI IthUanes Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndusttialAccidents 1 Congress Stree4 Suite 100 Boston, MA 02114-2017 r www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PER.NHTTING AUTHORITY. Applicant Information PIE Business/Organization Name: %4,1-e- to b r ll ) j7j j (., Address: 3 ?) Are you an employer? Check the appropriate box: I. q I am a employer with ji: employees (full and/ or part-time).* 2: 0 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 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 j Phone#: �7Cii _tij�j} Business Type (required): 5. E3�etail 6. []Rcstaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. Q Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11. [1 Health Care 12,[] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate of5cers have cxempicd themselves, but the corporation has other employees, a workers` compensation policy is required and such an organization should check box #1. lam an employer that is providing wor,(cers' compensadou insurance for my employees. Below is the policy information. Insurance Insurer's Address: M City/State/Zip: I:�Q 1 �� / � 1 �r 611 f T Policy # or Self -ins. Lie. [� l `C� > �i O Ly �7 (f �" Expiration Date: t Attach a copy of the workers' compensation policy declaration page (showing the policy number nd 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 $1,5D0.00 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. f do hereby certify, uyder-tiye pains anal penalties of perjury that the information provided above is true and correct Phone # �& 9 1 �) k` L i Of 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 Healtb 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mass.govld,a Phone KUU IE-3 OF ID: M A��Ro CERTIFICATE OF LIABILITY INSURANCE DATE 112017V) 10/31/2017 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(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 508-528-3310 Keefe Insurance Agency 51 West Central Street Franklin, MA 02038 Matthew Keras c NTAcr Matthew Keras PHONE 508-528-3310 FAX lac, Ma, Eat): FAX NP).508-528-3887 EMAIL ADDRESS' INSURERIS) AFFORDING COVERAGE NAICN _ _ INSURER A: Liberty Mutual Insurance INSURED Route 106 Wines & Spirits Jack McIntyre INSURER B:MA Retail Merchants Assoc. INSURER C 377 Chauncy St 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 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. INTo SR rypE OF INSURANCE DDL NSDPOLICY UBR NUMBER POLICY EFFIYYYY, POLICY EXP _ LIMITS A X COMMERCIAL GENERAL LIABILITY LIABILITY CLAIMS -MADE u OCCUR Liquor Liab BZS57406077 06/10/2017 06110/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE SESOERRENTED $ 300,000 X MED E%P [Anyone person)$ 15,000 PERSONAL- B ADV INJURY $ 1,000,000 GEHL X AGGREGATE LIMIT APPLIES PER: POLICY D PRO- JECT D LOG _ GENERAL AGGREGATE $ 2,0001000 PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER' AUTOMOBILE LIABILITY EOMBINED SINGLE LIMIT BODILY INJURY Per rsan $ _ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUpTOpSWN BODILY INJURY IPer accident - ' PerOawd.ntDAMAGE _ AUTOS ONLY AU BOMB UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ _ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBVEp EXCLUDED? Dyes,RIPTI Nunder Ityes,doryin and DESCRIPTION OF OPERATIONS below N /A 014005030069116 01/01/2017 01/0112018,.,EL.EacH_AccmENT PER OTH- ST ER $ 100,000 E.L. DISEASE - EA EMPLOYE $ 100,000 E.I. DISEASE - POLICY LIMIT - 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Liquor Store MANSF-3 Town of Mansfield 50 West Street Mansfield, MA 02048 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 Matthew Keras M+ Vmu aO t<vI O/ud/ U 1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD