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HomeMy WebLinkAboutSt. Mary's School 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:. ST. MARY'S CATHOLIC SCHOOL Whose place of business is: ST, MARY'S SCHOOL 330 PRATT STREET PERSON(S) IN CHARGE: MATTHEW A. BOURQUE, PRINCIPAL Permit Expires: December 31, 2018` Food Fee: License Number: FS-82 BOARD OF HEALTH MichaeCMcClean, Chairman /11 Milk & Cream 1/1 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 ST. MARY'S CATHOLIC SCHOOL having a place of business at: ST. MARY'S SCHOOL 330 PRATT 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-82 Board of Health NichaeCMcCCean, 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 FS82 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name ST. MARY'S SCHOOL 2) Establishment Address 330 PRATT STREET 3) Establishment Mailing Address (if different) 330 PRATT STREET 4) Establishment Telephone No MANSFIELD, MA 02048 (508)339-4800 5) Applicant Name & Title: REV. MICHAEL K. MCMANUS 6) Applicant Address 330 PRATT STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 3394800 24 Hour Emergency No.: 8) Owners Name & Title ST. MARY'S CATHOLIC SCHOOL 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 Cl An Association or partner. A Corporation Name Title Address -'I An Individual A Partnership _I, Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 1MATTHEW A. BOURQUE, PRINCIPAL Address: 330 PRATT STREET, MANSFIELD, MA 02048 Telephone No: 1(508) 339-4800 24 Hour Emergency No: FAX: (508)337-2063 _ - - E-mail: MBOURQUE(cDSTMARYMANSSCHOOL.ORG Alt E-Mail: PDIZON(a)STMARYMANSSCHOOL.ORG 13) District Or Regional Supervisor (if applicable) Name & Title: Address Telephone No I FAX: E-mail: 24 Hour Emergency F+�awvc, n. 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: MON. THURS. FRI. 18) Name of Person In Charge Certified in Food Protection Management: KATHY M. GOSSELIN 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) IJ RU.t50t3 PA W F Ll- � R� 20) Location: V1 Permanent Location 22) Establishment Type 1 J Caterer $25.00 1 Mobile Mobile Start Da I I I Retail ( So Ft) [-1 Milk & Cream $10 00 Moblie End Date: Mobile Comments: 21) Length of Permit: 141 Annual [_t Seasonal Seasonal Dates: _j Temporary Temporary Start Date: Temporary End Date: Temporary Time: 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 [V,/Food Service up to 201 + or 25'+ PHF display $275.00 [l, Food Service - Institution ( Meals/Day) ❑ Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer [ J Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 J Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous food ftimMemperature 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 furtherprocessing) [ �1 Sale of Commercially Pre -Packaged Non-PHFs [� Sale of Commercially Pre Packaged PHFs [j Delivery of Packaged PHFs lei Reheating of Commercially Processed Foods for Service Within 4 Hours L.[ Customer Self -Service of Non PHF and Non - Perishable Foods Only n 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 , Customer Self -Service [. j Ice Manufactured and Packaged for Retail Sale [ ] Juice Manufactured and Packaged for 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 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Offers Raw Or Undercooked Food Of Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service [ I Retail Sale of Salvage Out -Of -Date -� or Reconditioned Food To be completed by the Board of Health i -- __- - — - — — _-"- Total Permit Fee: Payment is due with application F/- _j 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: 04-2106666 r� 26) Signature of Individual or Corporate Name: Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31 st of each year. NAME OF BUSINESS: ST. MARY'S SCHOOL ADDRESS: 330 PRATT STREET TELEPHONE AT LOCATION: (508) 339-4800 FAX NUMBER: (508) 337-2063 OWNER OF BUSINESS: ST. MARY'S CATHOLIC SCHOOL TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 04-2106666 FEE: $10.00 PERMIT NUMBER: FS-82 SIGNATURE: DATE: Il / G ,Pa 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:\Hi IthVan&s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc !L\ The Commonwealth of Massachusetts Department oflndusiria[Acctdents 1 Congress Street; Suite 100 Boston, MA 02114-2017 lug www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERAIITTIN'G AUTHORITY. Applicant Information Please Print Ltgjbly Business/Organization Name: City/State/Zip: �30 @ M+t MtnV4l,tw M¢\ D ) Phone 5'0g, 35,A. �-� ©-D Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail 0rpart-time).* 6, Restaurant/Bar/BatingEstablishment 20 I am a sole proprietor or partnership and have no 1, Q 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]* 1 I. ❑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 must also fill out the section below showing their workers' compensation policy information, **If the corporate officers have exempted themselves, but the corporation has otber employees, a workers compensation policy is required and such an organization should check box #1. t am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. #- 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. [do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct 5`0g. 3�Ot . 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 umw.mass.gov/ma Phone ROMACAT-02 LSOUZA1 1 ,4coRa CERTIFICATE OF LIABILITY INSURANCE DATE 11M512017 10/25/2017 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 endorsements . PRODUCER License # 1780862 k2ALACT Lucia Mantles HUB International New England 222 Milliken Boulevard Fail River, MA 02721 _ ac°°, NP, Suit: (508) 235-2210 FAAX NPI: hubinternational.com Nffiksa. Lucia.Mendes@hubinternational.com INSUREINS1 AFFORDING COVERAGE NAIC4 INSURER A: Associated Industries of Massachusetts Mutual Insurance Compan 33756 INSURED INSURER B : INSURER C: Roman Catholic Bishop of Fall River, Corp. Sole P.O. BOX 2577 INSURER D : INSURER E: Fall River, MA 02722 INSURER F: r:r1VFRArAFS f:FRTIFICATF hl IMRFP- RFVISIDN NIIMRER- 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. INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACH OCCURRENCE DAMAGE TO RENTED PREMISES /Ea occurrence) MED EXP (Any on. Person PERSONAL S ACV INJURY GEN'L AGGREGATE LpIIM IT APPLIES PER: POLICY ❑ 'Pa1:1 LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGO AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY ALLTT SSy� AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ P rr acEcfatle^t AMAGE $ $ UMBRELLA LIAR EXCESS UAB CLAIMS -MADE EACH OCCURRENCE $ HOCCUR AGGREGATE $ DED RETENTIONS A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY AANNFICERO/PMRIIMTORJPARTNOED ECUTIVE Y� (Mandatory In NHI I/yes, describe under DESCRIPTION OF OPERATIONS below NIA MZ80080066832017A 07101/2017 071011201E PER OTH- E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE - EA EMPLOYE 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more apace is required) RE: St. Mary's Catholic School, 330 Pratt Street, Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Commonwealth of Massachusetts Dept. of THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Industrial Accidents 1 Congress St, Suite 100 Boston, MA 02114 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©19UH-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J v x 2 N W� T LL 2 O A N W O W � N ag C 0 J w 0 W U w w U V uz z I W z W P z w lr (40y I"1 W U I `' PCI C .� On 0 8 0 M h ti M s is b�v d v y N a � bO N a Mansfield Board of Health We, fit. y CXVAotdv O01 Food Service Permit Fee for the following reason tjan Thank you, Signature Pr&c� 1-1.( Title Date tI I. °U. UO request a waiver of the