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HomeMy WebLinkAboutOld Country Store 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:. CHRISTOPHER BAKER Whose place of business is: OLD COUNTRY STORE AND EMPORIUM, INC. 26 OTIS STREET PERSON(S) IN CHARGE: LAURYN S. BAKER, VICE PRESIDENT Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-70 BOARD OF HEALTH -%4ic(7ae(McC(ean, Chairman kP' 4e FOR BOARD OF HEALTH USE ONLY Permit #Issued FS-70 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name OLD COUNTRY STORE AND EMPORIUM, INC. 2) Establishment Address 260TISSTREET 3) Establishment Mailing Address (if different) 26 OTIS STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-8128 5) Applicant Name & Title: CHRISTOPHER D. BAKER, PRESIDENT 6) Applicant Address 26 ELMWOOD AVENUE, BRAINTREE, MA 02184 7) Applicant Telephone No.: (781) 534-3424 24 Hour Emergency No.: C (781) 267-4593 8) Owners Name & Title CHRISTOPHER BAKER 9) Owner Address (if different from applicant) 26 ELMWOOD AVENUE, BRAINTREE, MA 02184 Owner's telephone number 7815343424 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers L1 An Association or partner, Iv] A Corporation Name Title Address El An Individual 191q)ldw�- El A Partnership - El Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ILAURYN S. BAKER, VICE PRESIDENT Address: �26 ELMWOOD AVENUE, BRAINTREE, MA 02184 Telephone -4593 24 Hour Emergency No: C (781) 267-4593 FAX: 1(508) 339-8845 E-mail: OLDCOUNTRYSTOREMAOVERIZON.NET Alt E-Mail: CDBAKER13PBELD.NET 13) District Or Regional Supervisor (if applicable) - T Name & Title: I Address: Telephone No: M113 24 Hot4 Food Establishment Information 14) WATER SOURCE TOWN �15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No (If applicable) -.L. 16) No. of Food Employees: 6 17) DAYS/HOURS: MON-SAT 10 AM - 6 PM SUN 11 AM .5 PM 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): ❑ 20) Location: F ] Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: [--I Retail ( Sq. Ft) Mobile End Dale: 0 Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: i Annual I _J Seasonal Seasonal Dates: ❑ Temporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 J Food Service up to 201 + or 254 PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 ❑ 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 1-1 Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature 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 further processing) CI Sale of Commercially Pre -Packaged Non-PHFs I ❑ PHFCooked To Order Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer Ice 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 j Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities 1 ❑Prepares Food/Single Meals for I Catered Events or Institutional Food Service 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 ith 105 CMR 595.000 an all other applicable law. I have been instructed by the board of health on how to obtain co es of 105 CMR 5�0.000 an thetfederal Food Code. 24) Signature of Applicant: 4 / Pursuant to MGL Ch.62C, sec. 49A, I cer 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: 27-1270212%} //� p /S6Q���^ N iT 28) Signature of Individual or Corporate Name: (1 �� t �tt� t `1 oil � a",I),J r ni// n �ar 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 lilividual or Corporate Name By: Cofficer (Mandatory, if Applicable) 1 0 76J l- **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;\IiealthVane's Doc=mts\PERMrC APPLICATIONS\TAX CERTIFICATION FORM.doc "D—\ The Commonwealth of Massachusetts Department of Industial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 u,p . www. mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Pr Business/Organization Name: ( 1( Address: - 3 Are y/op an employer? Check the appropriate box: Business Type (required): E, 1. I am a employer with _ employees (full and/ 5. aRetail "'part-time).# 6. Restaurant/Bar/HatingEstablishment 2; � I am a sole proprietor or partnership and have no 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]* 1I.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. ❑ Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **lithe corporate officers have exempted tberasdves, but the corporation bay other employees, a workers' compensation policy is required and such an organization should check box #1. am an employer that is providing workers comye>sadon insurance for rry)S employees. Below is the policy informadoh. Insurance Company Insurer's City/State/Zip: (- "r,1Tk,e l_-- I C 6/ t I Policy# or Self -ins, Lie. #- 2 (, �,���> 6 6'SYC F Expiration Date: a 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 cerd,*, under the pairo and pe/ialties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License IssaingAuthority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Phone w unass.gov/dia 68 (Policy Provisions: WC 00 00 00 C) 35 GG INFORMATION PAGE WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 20605 Company Code: G a POLICY NUMBER: 76 WEG GG3568 Previous Policy Number: 176 WEG GG3568 HOUSING CODE: 76 1. Named Insured and Mailing Address: OLD COUNTRY STORE & EMPORIUM, INC. (No., Street, Town, State, Zip Code) N 0 26 OTIS STREET r� FEIN Number: 271270212 MANSFIELD, MA 02048 x State Identification Number(s): UIN: The Named Insured is: UU VUXNfiUN Business of Named Insured: GENERAL STORE Other workplaces not shown above: 26 OTIS STREET MANSFIELD MA 02048 2. Policy Period: From 01/29/17 To 01/29/18 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: HARTFORD FIRE INSURANCE COMPANY PO BOX 33015 SAN ANTONIO, TX 78265 Producer's Code: 250805 Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $1, 694 Deposit Premium: Policv Minimum Premium: $216 MA Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Suffix LARS RENEWAL 03 Countersigned by "f C��"`t� ' 12/10/16 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 12/10/16 Policy Expiration Date: 01/29/18 ORIGINAL 0 a 0 u E 0 O a` k El E 0 0 c a. E 'E 0 0 co cn r� c ♦ Q to E o� N 1 O co a` CO r --o 0 0 c a n o h � c O' N a) z O LO CD w N .= N � m a s � m a (D .� F � O a 'C O U z O c Cl) o � � V ♦ 4_ E 0 o c 'E a o E m LL i : ° c k CV) N0 04 2 E ^�(D\ :£ \ w J »<E«� % ^k ^ Q \ ƒ w E ( R k \}©» ƒ »\ ~ \ \(}( } % I WN