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HomeMy WebLinkAboutSimple Amenities 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Retail 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:. MOHAMMAD ARIF KHAN Whose place of business is: SHAHMIR, INC DBA SIMPLE AMENITIES 214 RUMFORD AVENUE, UNIT 103 Permit Expires: December31,2018 License Number: RF-33 Food Fee: $100.00 Milk & Cream V 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. Whose place of business is: SHAHMIR, INC DBA SIMPLE AMENITIES 214 RUMFORD AVENUE, UNIT 103 License Number: RF-33 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, Chairman 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: MOHAMMAD ARIF KHAN having a place of business at. SHAHMIR, INC DBA SIMPLE AMENITIES 214 RUMFORD AVENUE, UNIT 103 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.: RF-33 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must a sbUrr ffite a eas_ ays e ore e p anne Tn�}— /J� 1)Establishment Name � 1 NC d1bla J (lYi'✓,, � ,& %Y_lG_ 2) Establishment Address p q 3) Establishment Mailing Address (if different) (a 3 4) Establishment Telephone No 5) Applicant Name & Title: A" . f �rnmod II ✓pV 6) Applicant Address ' ///,' _5 /' rA_c� v A?A 0, O 7) Applicant Telephone No.: 5©8 6LiT P�) _W4 Hour Emergency No.: 50S 6 4 P �?a(40 8) Owners Name & Title p 10vrn» r__1Q"n q 9) Owner Address (If different from applicant) Owner's telephone number 508 6 L-( 7 S'a (.t I ., 502 G Cf T g�CfQ 10) Establishment Owned By: i 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. P A Corporation ❑ An Individual Name T�e Address / "- ❑ A Partnership y�("b f ❑ Other legal Entity 12) Person Directiv Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) J A Name & Title: Address: Telephone No: 24 Hour Emerg cy No: 50B 6 r(P 8a f{O ©g_64 Batil FAX: E-mail: — ----- Alt E-Mail: - Q . K id 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: 16) No. of Food Employees: DEP Public Water Supply No: (If applicable) 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 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: Permanent Location 22) Establishment Type Caterer $25.00 Mobile Mobile Start Date: [VrRetail (altib Sq. Ft) ,❑ u Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream -$25.00/freezer 21) Length of Permit: P?rAnnual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Pushcart $25.00 # of Pushcarts: ❑ Residential Kitchen $100.00 Food $100.00 . ❑ Seasonal Seasonal Dales: [] Food Service -Institution ( Meals/Day) , �,/Re'ta'il l,_,','f�-rreeini nah5"�'ti"Fc °ad$25-88 u Tobacco Products $25.00 ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: — - Potentially hazardous food (h'meRemperafne controls required) - non potentially hazardous lood(no time/temperature controls required) foods (Ex. sandwiches, salads, muffins which need no further processing) 23) Food Operations (Check all that apply): Definitions PHF- Non-PHFs RTE -ready-to-eat F ❑ 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 PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs — ------ ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours [] 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) elf- ❑ Customer SService of Non PHF and Non- Perishable Foods Only Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale __ ❑ 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 ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 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 590.0 0 and all other applicable law. I have been instructed by the {, board of health on how to obtain copies of 105 CMR § 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 fled all state tax returns and paid state taxes required under law. 25) Social-Seeudty-Numbe or Federal ID: _ 26) Signature of Individual or Corporate Name: JYICA.i' I YYLI,i �N C . 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: �%" IV(- , Clblo_ �J✓V mR/mtLu ADDRESS: 2 14 /Pwmpo Ave I UTik * 103 / AIA TELEPHONE AT LOCATION: 50? 64g g��{I , 508 611L' RAgo FAX NUMBER: OWNER OF BUSINESS: J&,2/Y-" ,Iy �I/ a' TELEPHONE OF OWNER: 509 6 ((k SA g I � (J 50�? 6 c ? Rayc) FEDERAL ID/S1S-NbM MR: 2 6 3 �0 5 T� FEE: $10.00 PERMIT NUMBER: SIGNATURE: DATE: Town of Mansfield Town of Mansfield - Board ofHealth 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: C. LOCATION OF SALE OF TOBACCO PRODUCTS: TELEPHONE AT LOCATION: -- 5©8 65g, (Ra4i , -097 6� 9 patio OWNER OF ADDRESS OF TELEPHONE OF 001i, FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. ' ,0,. * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: FEDERAL ID/SS NUMBER: _263 7C05- 7S SIGNATURE: DATE: MG,ir. zscF'Uss Commonwealth of Massachusetts Department of Revenue Christopher C. Harding, Commissioner mass.gov/dor MAE Letter ID: L 1255411456 Notice Date: February 28, 2018 Account to: CGL-10719457-007 RETAILER LICENSE FOR SALE OF CIGARETTES 1111161JI'I 1111'l'1"'I'll 113I111111111111111111111111111 SHAHMIR INC o SIMPLE AMENITIES 14 SKIPJACK LN HYANNIS MA 02601-2195 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE SP SEA MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes ��>F F� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SHAHMIR INC Account ID: CGL-10719457-007 SIMPLE AMENITIES 214 RUMFORD AVE STE 103 MANSFIELD MA 02048-2176 Location ID: 10719457-0001 License Number: 128755712 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: February 28, 2018 Expiration Date: September 30, 2018 p IN �5sscxt� Commonwealth of Massachusetts Letter ID: L1405849344 '' ` �✓ Department of Revenue Notice Date: February 27, 2018 Christopher C. Harding, Commissioner Account ID: CRL-10719457-010 rFNr pc�' mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I"IIl'llydl � MOHAMMAD ARIF KHAN SHAHMIR INC w SIMPLE AMENITIES 14 SKIPJACK LN I-IYANNIS MA 02601-2195 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE •---------------------------------------------------------------------------------------------------------------------------------------------- SbcHosF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T b w Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SIIAIIMIR INC Account ID: CRL- 10719457-0 10 SIMPLE AMENITIES Location ID: 10719457-0002 214 RUMFORD AVE STE 103 License Number: 147091456 MANSFIELD MA 02048-2176 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: February 27, 2018 Expiration Date: September 30, 2018 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. /,I',- Signature of Individual or Corporate Name 2- 6374nS75- **—%dM,-Security-No:-(Volxeia mij+srFederal Identification Number By: Corporate Officer (Mandatonj, 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. C:\UsersVsleite\DesktopVScott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: �;�/ 1 r�irji,� //i,�, is Z, g�,,94- Address: ?/G/, 3j-z�-- /D,j City/State/Zip: IkI 0,?0q6 Phone #: -� W ­M/S—JZ-40' �0 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ® Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. a 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. ❑ Entertaimnent their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #I 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 #I. I 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. Lic. # 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 th pains andpenalties ofperjury that fire information: provided above is true and correct. Signature: Z .✓' Dnta• D:�-,-Xglld 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 #: wwwmass.gov/dia �v�� �v '���iC�� �`���2C�J�'1c? S � 5c5 ��`�c� ��� `off. ���� � � GSA , �� c-C�S� "� cQ � �c� ��