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Home My WebLink AboutPushkart Cafe 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 Serviee Establishment Type: FOOD ESTABILISHMENT 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:. KATEENA ALMEIDA Whose place of business is: PUSHKART CAFE 219 NORTH MAIN STREET PERSON(S) IN CHARGE: KATEENA ALMEIDA Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-26 BOARD OF HEALTH gblichaeCMcCCean, Chairman Milk & Cream Commonwealth of Massachusetts Town of Mansfield Town of'Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify than KATEENA ALMEIDA having a place of business at: PUSHKART CAFE 219 NORTH MAIN STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expire 1213112018 License No.: FS-26 Board of Health MichaeCNcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH U$E bNLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Establishment Name Establishment Address � (t 0J Md J hil ; f Establishment Mailing �Address (if different) t � y 4 i VuCC t s+ �' Z_ fts4''jLt-i rfd0 n04 Establishment Telephone No Applicant Name & Title: Applicant Address t � WA r Q- - --�-li Applicant Telephone No.:(}. �� a .� C� 24 Hour Emergency No.: S(7Y Applicant Email p( ,J o, EL�{ 6 r f�t-e4 LLo Owner Name & Title (If different from applicant) Owner Address Owner telephone number Vm Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association I partner. I A Corporation ame itlep� Address Cl An Individual (�k )�E1 i �} tl C t� (QZ ��l�tl f� i'V� 71tA4 {'Z_yk_ I o APartnership �� G (i{ � (f ( C tlt i I�_�cLfe 44 g �'-a�i211 Other legal Entity i , )� WN ST �f 2 (W5 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IW IL�_ kwdou Address: rj � UJo�� L Mavis 1�(d Ala CIO °� Telephone No: G o - d --i - c t q. 4 S 24 Hour Emergency No: FAX: E-mail: Alt E Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: i tj10 24 Hour Emergency No: 11 T® WATER SOURCE: p_A '.. DEP Public Water Supply No: (If applicable) DAYS/HOURS:( j Food Establishment Information SEWAGE DISPOSAL: No. of Food ` C WLO Name of Person In Charge Certified in Food Proltection Management: ( n(� If more than 3 individuals are certified, complete list is on file. 1(akwo y/��`Q _ t�� d Person Trained in Anti Choking Procedures (If 25 Seats or more): Location: VA LA ermanent Location ❑ Moblie Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: !Annual !_j Seasonal Seasonal Dates: I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type: ❑ Retail ( Sq. Ft) ood Service up to 100 INCLUDING FOOD TRUCKS $1755.0-a 1. ] Food Service up to 101 -200 $250.00 I I Food Service up to 201 + $300.00 I] Supermarkets $400 1] Caterer $35.00 Allillk & Cream $10,00 !- I Mobile Food Consession NO PHF PREPARED ON SITE $100.00 �._ Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer ❑ Pushcart $50.00 If of Pushcarts: [_] Residential Kitchen $100.00 ] Retail Food $125.00 Retail Snack Food $50.00 Tobacco Products $150,00 Food Operations Definitions: PHF- Potentially hazardous food (timeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) ,(Check all that apply) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs i Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non Perishable Foods Only Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accuracy of the info establishment operation will{{cgmply with 105 CMR board of health on how to ogt$in copies of 105 CM Signature of Applicant: [_ 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 ] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health _-- -------- ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service El Retail Sale of Salvage, Out -Of -Date — _: _ _:c or Reconditioned Food — To be completed by the Board of Health - _-- J Total Permit Fee: Payment is due with application I I waived tion provided in this application and affirm that the food 000 and all other applicable law. I have been instructed by the 0.000 dndAhe federal Food Code. 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. t� gg 6 2 7 Social Security Number or Federal ID: 00 ' 3� ' g � in U I Signature of Individual or Corporate Name: 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. cat, L ry4f4wla Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) W 3� — �r I "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. C:\Users\sleite\Desktop\Scott's Documents\Eood Establishments- Temp\TAX CERTIFICATION EORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. N Phone#:5(-1 -g0Uj Are yop an employer? Check the appropriate box: Business Type (required): JZ' I am a employer with 4_ employees (full and/ 5. ❑ Retail or part-time).* 6JN�Restaurant[Bar/Bating Establishment 2: ❑ 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. 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. insurance req.] 12.❑ Other -Anv aoolicant that checks box #1 must also fill out mm ..cation nnlicv information. xxlf 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 C. lam an employer that is prok(di Q wo kern' nsation Insurance for my employees. Below is the policy information. Insurance Company Name:--, /U 1i'(1- JLtU Insurer's Address: City/State/Zip:t Q�/t�jq�( / j]�j�: ` �\� U 1(} Policy # or Self -ins. Lie. #- u 7� t "�V Ab I 7 Expiration Date: C1UI Attach a copy of the workers compensation policy declaration page (showing the policy number Ad a tpiration date). Failure to secure coverage as required under Section 25A of MGL e. 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, ji�-tify, under the pe s ndpen es ofperjury that the information provided abov is true and correct. Signue•/,/)jUn Date: k9ti(i Phone #: 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#: AII o® CERTIFICATE OF LIABILITY INSURANCE DgT10112/201'1'YY) 10/2/18 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 CONTACT II ssa NAME: y Riley Encharter-MA gNCONNo Extt: (800)675-6695 �jq/c, No): (800)754-1602 Encharter Insurance LLC E-MAIL — iriley@encharter.com ADDRESS: y� _ INSURER(S) AFFORDING COVERAGE _ NAIC 11 25 University Drive Amherst MA 01002 INSURERA: The Hartford 00914 INSURED INSURER B: INSURER C : PUshkart Cafe INSURER D: 171 Ware St Apt 2 INSURER E: Mansfield MA 02048 INSURER F: COVERAGES CERTIFICATE NUMBER: 2018-2019 COIs 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 Lm TYPE OF INSURANCE ADDLSUBR INSD WVD POLICYNUMBER POLICY OFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 CLAIMS -MADE X OCCUR DA AGET RE TED PREMISES Ea occurrence S_ 1,000,000_ MED EXP /Any one person) g 5,000 PERSONAL BADV INJURY S 1,000,000 A 08SBAAB9745 10/10/2018 10/10/2019 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S 2,000,000 X POLICY PRO- JECT❑ LOC PRODUCTS-COMP/OP AGO S 2,000,000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) S ANVAUTO OWNED SCHEDULED AUTOSONLY AUTOS 1 BODILY INJURY (Per accident) $ PROPERTYDAMAGE Peramci $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY H 1 $ UMBRELLA LIAD OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DIED I I RETENTION S $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYCER/MEETORIPAftTUDED?ECUTIVE ❑ OFFICER/MEMBER EXCLUDED? Y (Mandatoryfy..,din NH) NIA 08WEGAClYDK 10/10/2018 10/10/2019" PER OTH - STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 Dyed, IPTIONunder DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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 01988.2016 ACORD CORPORATION. All rights reserved. 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