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HomeMy WebLinkAboutFresh Catch 12/31/2018 (2)F Commonwealth 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:. WILLIAM F. SARRO Whose place of business is: THE FRESH CATCH, INC. 30 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM F. SARRO, MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-90 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream O r 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: WILLIAM F. SARRO having a place of business at: THE FRESH CATCH, INC. 30 CHAUNCY 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-90 Board of Health Michae(NcCCean, 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 FS-90 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name THE FRESH CATCH, INC. 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 34 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5187 5) Applicant Name & Title WILLIAM F. SARRO, PRESIDENT 5) Applicant Address 453 TURNPIKE STREET, UNIT 2, SOUTH EASTON, MA 02375 7) Applicant Telephone No.: (508( 404-6680 24 Hour Emergency No.: (508) 404-6680 (g68)339a427_ (608).339sw4or, geyae°10 8) Owners Name & Title WILLIAM F. SARRO 9) Owner Address (If different from applicant) 453 TURNPIKE STREET, SOUTH EASTON, MA 02376 Owner's telephone number (508) 404-6680 10) Establishment Owned By: j 11) If a corporation or partnership, give name, title, and home address of officers i ' An Association or partner. V! A Corporation Name Title Address An Individual (L,'t/t<'ti t' rrr lie r 9= { } 1 uAlp'!J_+ a', _ f Z A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IWILLIAM F. SARRO, MANAGER Address: 453 TURNPIKE STREET, UNIT 2 S. EASTON, MA 02375 Telephone No: '(508) 339-5187 24 Hour Emergency No: (508) 404.6680 (506)aa0-44aa. (608i4"-6204• FAX: (508) 339-3941 —1 E-mail: BILLJR(&FRESHCATACHINC.COM Alt E-Mail: - 13) District Or R - egional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 1 14) WATER SOURCE: TOWN 16) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) '', 16) No. of Food Employees: 50 1 17) DAYS/HOURS: MON-TU-WED 8 AM-8 PM THURS 8 AM-9 PM FRI-SAT 8 AM-9:30 PM SUN 8 AMOPM �- Pyyq 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. ANTONIO BONILLA BRENNA J. AUDETTE Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of JOSEPH MATRULLLO RYAN P. KEITH certificate NICOLE V_ANDERVALK HENRY--ESPINO - — - 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) 20) Location: Permanent Location 1122) Establishment Type �❑ Caterer $25.00 �l J Moblie Moblie Start Date: IV1 Retail ( 5,000 Sq. Ft) JI Milk & Cream $10.00 Moblie End Date: iFood Service up to 100 or P Mobile Food & Consession $75.00 Moblie Comments: p display F-] Manufacture Frozen Desserts/Ice Cream u to 10' PHF dis la $125.00 �$25.00/freezer 21) Length of Permit: lV,, Annual Seasonal Seasonal Dates: L.,i Temporary Temporary Start Date: Temporary End Date: Temporary Time: IJ', 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 Food Service - Institution ( Meals/Day) [_] Pushcart $25.00 # of Pushcarts: 0 j] Residential Kitchen $100.00 ❑ Retail Food $100.00 L j Retail Snack Food $25,00 D Tobacco Products $25.00 Rain Date:- 23) Food Operations Definitions: PHF - Potentially hazardous food (timeltemperature controls required) Non-PHF's - 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 rJ, PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held _ y PHFs -- --- --- Preparation of PHFs For Hot And 111 for More Than a Single Meal Service — _ -, Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Dell vef of Packaged PHFsackaged '' Delivery 9 --- - ----- --- — Sale of Raw Animal Foods Intended Susceptible Population Facility L Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours --- . — -- -- - -----: - Use of Process Requiring A Variance [III Customer Self -Service of Non PHF and Non r 'i Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for contact alternative, time as a public health _ [. ] Preparation of Non-PHFs Retail Sale I control) Other Food Operations Juice Manufactured and Packaged for i i Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF inBulk Quantities �] Prepares Food/Single Meals for _ Catered Events or Institutional Food Service i Retail Sale of Salvage Out Of-Dat od e------- — or Reconditioned FoTo be completed by the Board of Health _. -- Total Permit Fee: $150.00 Payment is due with application F] 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 ur and paid state taxes required under law. penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 04-2745150 26) Signature of Individual or Corporate Name: I 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: THE FRESH CATCH, INC. ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-5187 FAX NUMBER: (508) 339-3941 OWNER OF BUSINESS: WILLIAM F. SARRO TELEPHONE OF OWNER: (508) 404-6680 FEDERAL ID/SS NUMBER: 04-2745150 FEE: $10.00 PERMIT NUMBER: FS-90 SIGNATURE: DATE: — --_ 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 prtorporate Name 04")7i5i5,, "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (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:\Hm1thVane's DoemnentsTERMIT APPLICATIONSUAX CERTIFICATION FORM.doe \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street; Suite 100 Boston, MA 021I4-2017 www.mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNII'1'TING AUTHORITY. Applicant Information Please Print Lggjbly Business/Organization Name: / ,, jcT e — L/ , %07 e. Address: Ar�e y an employer? Check the appropriate box: 1, F71 I am a employer with SO employees (full and/ or part-time).* 2rE] I am a sole proprietor or partnership and have no employees working for mein 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.] Phone #: Business Type (required): 5. E31R,tail 6. Restaurant/BadEating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11. ❑ Health Care 12,❑ Other *Any applicant that checks box N must also fill out the section below showing their Workers' compensation policy information. **If the corporals of Been have exempted themselves, but the corporation has other empleyccs, 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 Address:// /- City/State/Zip: 4./GYLfH A�Y. Policy # or Self -ins, Lic. # /ll?�(/ '1`" f '3 5 ,3 7// („ Expiration Date: 0/k ( / / E 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 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 certify, under the paains�aannd peennaldes �ofjoarrj'u"ry that the information provided above is true and correct Date: f/—/5—t jL So _;3- S 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 Phone A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODYYYY) 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 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 C & S Insurance Agency, Inc. CONTACT NAME: Laura Wiesner alcoNN Eat: (508) 339-2951 l Nola (SOB)339_4811 AIL APORESs.laura@candsins.com 190 Chavncy Street/P.0 Box 406 INSURERS) AFFORDING COVERAGE NAICN _ INSURER A:Merchants Preferred Insurance 12901 Mansfield MA 02048 INSURED INSURERB:MA Retail Merchants WC Group Inc The Fresh Catch Inc. & The Fresh Catch V Inc. INSURER C, INSURER D: PO Box 34 INSURER E Mansfield MA 02045 1 INSURER F: COVERAGES CERTIFICATE NUMBER2017-2018 Master 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. IN5R TYPE OF INSURANCE ADOLSUB� POLICY NUMBER MMIDD/Y1'EMI MMIDDYIrEm LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 --� DAMAGE TO RENTED 50,000A CI -AIMS -MADE I X� OCCUR PREMISES�eoccurren� $ CMP9155886 2/28/2017 2/28/2018 MED EXP(My one person) $ 10,000 PERSONAL &ADV INJURY $ 2,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,_000,000_ GEN'L X POLICY JECT LOC PRODUCTS -_COMPIOP AGG $ 4,000,000_ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)_ _ $ ANY AUTO BODILY INJURY (Per person)_ $ 1,000,000 A ALL OWNED 1 SCHEDULED X AUTOS MCA0000159 2/28/2017 2/28/2038 BODILY INJURY (Per accident)$ AUTOS NON -OWNED X PROPERTY DAMAGE $ HIRED AUTOS _X. AUTOS tP.raccW.nt), UMBRELLA LIAR EACH OCCURRENCE $ EXCESS L H1OCCUR I CI -AIMS -MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 014005032537116 1/1/2017 1/1/2018-X p _ STATUTE ER_ AND EMPLOYERS' LIABILITY Y / N ,. _I ANY PROPRIETORIPARTNEWEXECUTIVE E.L. EACH ACCIDENT $ 500,000 8 OFFICERIMEMBER EXCLUDED? `tY ] (Mandatory In NH) NIA 014005031479117 1/1/2017 1/1/2018 E.L. DISEASE EA EMPLOYE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT is 500,000 A Liquor Liability CXP9155886 2/28/2017 2/28/2018 Common Cause Limit $1,000,000 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE Laura Wiesner/LAURA��-- + O^ ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) INS025 (201401) The ACORD name and logo are registered marks of ACORD