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HomeMy WebLinkAboutThe Paper 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: RETAIL SNACK FOOD 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:. ROBERT ANDERSON, OWNER Whose place of business is: THE PAPER STORE 280 SCHOOL STREET, SUITE F180 PERSON(S) IN CHARGE: WENDY WHITE, MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-17 BOARD OF HEALTH Michael 9McCtean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued s 17 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name THE PAPER STORE' 2) Establishment Address 280 SCHOOL STREET, SUITE F180NOV z 3) Establishment Mailing Address (if different) 20 MAIN STREET ACTON, MA 01720 4) Establishment Telephone No (978) 263-2198 5) Applicant Name & Title: SHANNON KELLEY, CFO 6) Applicant Address 20 MAIN STREET, ACTON, MA 01720 7) Applicant Telephone NO.: (978) 263-2198 24 Hour Emergency No.: (978) 8154734 JOHN ANDERSON 8) Owners Name & Title ROBERT ANDERSON, OWNER 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 i- An Association or partner. A Corporation Name Title Address C An Individual I A Partnership i Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'WENDY WHITE, MANAGER Address: 280 SCHOOL STREET, SUITE F180, MANSFIELD, MA 02048 Telephone No (508) 618-7299 24 Hour Emergency No: (978) 815.4734 JOHN ANDERSON FAX: _ - - E-mail: AP(cDTHEPAPERSTORE.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title-LYNN-DRTUN, REGIONAL MANAGER 50-2—<x vN Y, e— 1,44y i�� _ Address: 20 MAIN STREET, ACTON, MA 01720 i Telephone No: (978) 263-2198 24 Hour Emergency No: - FAX: E-mail: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: /V 17) DAYS/HOURS: MON-SAT 10:00 AM - 9:00 PM G 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: Permanent Location 22) Establishment Type [; Moblie Moblie Start Date: -'. Retail ( Sq. Ft) Moblie End Date: _. Food Service up to 100 or Moblie Comments:. up to 10' PHF display $125.00 21) Length of Permit Food Service up to 101 -200 Lsr Annual or up to 25' PHF display $150.00 ['', Seasonal Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: Temporary f.. Food Service - Institution Temporary Start Date: ( Meals/Day) ❑ Caterer $25.00 ❑ Milk & Cream $10.00 I.. ] Mobile Food & Consession $75.00 C_ -i Manufacture Frozen Desserts/Ice Cream $25.00/freezer [_ I Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 0 Retail Snack Food $25.00 Tobacco Products $25.00 Temporary End Date: Temporary Time:�' Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous food(timeRemperature controls required) Non-PHF's - non -potentially hazardous food(no timeRemperature controls required) Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ✓Sale of Commercially yPre-Packaged Non PHFs �� � PHFCooked To Order � � Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service — Cold Holding For Single Meal Service [_] PHF and RTE Foods Prepared For Highly j Delivery of Packaged PHFs -- --— i Susceptible Population Facility Reheating of Commercially Sale of Raw Animal Foods Intended _i 9 Y to be Prepared by Consumer �J Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours V - - -- - --- - - ------ �J Use of Process Requiring A Variance -'� Customer Self -Service of Non PHF and Non Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only IMF , ------ -- "i, contact alternative, time as a public health Ice Manufactured and Packaged for ] Preparation of Non-PHFs Retail Sale control) Other Food Operations Juice Manufactured and Packaged for �] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage Out -Of -Date -- - - --- ---- or Reconditioned Food I To be completed by the Board of Health - -__-- "--"_-- Total Permit Fee: $25.00 Payment is due with application Ll 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: "--.- r Pursuant to MGL Ch.62C, sec. 49A, I certify tmde� th penalh'es` d �perjUry�`at 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: 47-1892442 ''`�"-- 26) Signature of Individual or Corporate Name: I 1 �-��� i 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 Ind vidual or Corporate Name By: Corporate Officer (Mandatory, if Wplicable) Z-/7-(9� �`/V D-- "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:\FImIthUan&s Doc=cnts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street; Suite 100 Boston, MA 02II4-20I7 r ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Business/Organization Name: I ka Ira .P_� ,C 7Yl rd C J ,( Address: . i ( VVV66 A S+ City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): I. [2 I am a employerwith�AA_ employees (full and/ 5. E�-Rctail or part -tune).* 6. ❑Restaurant/Bar/Eating Establishment 2; 0 I am a sole proprietor or partnership and have no y, 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 I0. ElManufacturing no employees. [No workers' comp. insurance required]* 11 ❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12,❑ Other with no employees. [No workers' comp. insuranceeq.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. **if the corporate officers have exempttd tlaemselves, but the corporation has other employees, a worktos' compensation policy is required and such an organization should check hox fi L I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:/Vj./4-- �U 41n j tN -PQ_..k/in j-5 iA) C_,. (OU j? X­De , Insurer's Address: 0j 0X 5(139 t3`t>' 7 - ( I t 1' C2` City/State/Zip: g) ai i Y1'l`� -e '(3 jM /,Or C7 a: 1,95 Policy # or Self -ins, Lie. #- 0141 a a ti C) 3 0 j 7 S/ I I �f 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 the pains and penalties 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 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 AGQRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD(YYYY) 11/16/2017 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 poltcy(les) 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 Cross Insurance -Wakefield 401 Edgewater Place Suite 220 Wakefield MA 01800 CONTACT Ruth be8ant18 PHO E E.D. (783)914-1000 (761)229-5979 Ob IEB•rdesantie®crocisagency. corn INSURERS AFFORDING COVERAGE NAIC0 INSURER A:Phoenix Insurance Company INSURED The-PaperStore, -LLC -. 20 Main Street Acton MA 03.72D INSURER B:Travelers Indemnity Cc 25658 INSURER C:Travelers Property Casualty Company 25674 INSUREROMA Retail Merchants WC Group Inc INSURER E:AHHOC18tiona Members WCT INSURER F:Me'MIC Indemnit Com an COVERAGES CERTIFICATE NUMBER:17-18 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 REOU CED BY PAID CLAIMS. INSL R TYPE OF INSURANCE POLICY NUMBER POLIC EFF PO IC EXP LIMITS X COMMERCIALGENERAL DABRRY CLAIMS -MADE �X.. OCCUft 6305087965A 7/1/2017 7/1/2010 EACH OCCURRENCE $ 1,000,000 DAMA EM ES EaGE 10l�cl ul�e e_ $ 11000,000 MEDEXP(Anyona Peoon) $ 5,000 GERI PERSONAL$ADVINJURY $ 11000,000 AGGREGATE LIMIT aIIT APPLIES POP: POLICY❑jFCT OLOC O HER: GENERAL AGGREGATE $ 10,000,000 PRODUCTS-COMPWP AGO $ 2,000,000 $ E AUTOMOBILE LIABILITY X ANYAUTO AD.OWNEO SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOS BXSJ879974 7/1/2017 7/1/2a18 (1 B EOS (12a.celdium $ 1, 000, D00 BODILY INJURY (Par Person) $ BODILY INJURY (Per accidea0 $ OPERTY DAMAGE $ C X UMBRELLA Line EXCESS LIAB OCCUR CLAIMS -MADE OUp6J095004 7/1/2017 7/1/2018 EACH OCCURRENCE $ 15,000,000 AGGREGATE $ 15,000,000 CEO I X I RETENTION$ 10,000 $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECmNE V/❑N OFFIGENME (Mandatory In NHER ) (Mandatory M NH) Y yyooss OF dastdba OF O OESCRIPTION OPERATIONS b01ax NfA 01:005030195117 " KA 030009100119117 - an 1/1/2017 1/1/2017 1/S/2019 F 1/1/2018 X PERlTUTE OT EL. EACH ACCIDENT $ 5001000 E.L. DISEASE -EA EMPLOYE $ 500 000 _ E.L. DISEASE-POLN:V LIMIT _,-_.,_ 500,000 P Workers Compenoei"on 310 2803201 - CT,HH,NJ,ln 1/1/2017 1/1/2010 1,co0,000M000,000It0o0,CW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Ramedw Schedule, may be aftached If more spat¢ Is required) Ref The Paper Store, 280 School Street Suite PIED, Mansfield Mass 0204E 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 6 Prk Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 — AUTHORIZED REPRESENTATIVE Vincent Thorne/MH6 ACORD 25 (2014101) INS026170140u ©1988.2014 ACORO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD