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HomeMy WebLinkAboutMansfield Gas/Wahlid Samrout 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Snack 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:. WALID SAMROUT, PRESIDENT BOARD OF HEALTH Whose place of business is: WALID SAMROUT CORP., INC. 54 CHAUNCY STREET License Number: S-12 Permit Expires: December31,2018 Food Fee: $25.00 Milk & Cream - . MichaeINcCCean, 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: BOARD OF HEALTH WALID SAMROUT CORP., INC. 54 CHAUNCY STREET License Number: S-12 Permit Expires: December 31, 2018 MichaefMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit #Issued S 12 �- — FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name WALID SAMROUT CORP., INC. 2) Establishment Address 54 CHAUNCY STREET 3) Establishment Mailing Address (if different) 54 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-3179 5) Applicant Name & Title: WALID SAMROUT 6) Applicant Address 54 CHAUNCY STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508)498-6401 24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 508-838-5100 508-369-1924 508-226-8818 WALID SAMROUT, PRESIDENT 46 HILLCREST AVENUE, ATTLEBORO, MA 02702 5083393179 10) Establishment Owned By 11) If a corporation or partnership, give name, title, and home address of officers I i An Association or partner. A Corporation Name Title Address An Individual F A Partnership - C Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: WISSAM SAMROUT, MANAGER Address: 46 HILLCREST AVENUE, ATTLEBORO, MA 02702 lTelephone No: ',(508) 498-6401 24 Hour Emergency No: 508-838.5100 508-369-1924 508-226.8818 FAX: (508) 339-1940 E-mail: WISSO18PHOTMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: 16) No. of Food Employee 17) DAYS/HOURS: 24 HRS. - 7 DAYS PER WEEK 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 119) Person Trained in Anti -Choking Procedures (If 25 Seats or more) I 20) Location: IJ1 Permanent Location 22) Establishment Type Mobile Mobile Start Date: �./} Retail ( Sq. Ft) Moblie End Date: ' Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: Ji Annual 11_-1 Seasonal Seasonal Dates: �_-1 Temporary - Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): - Food Service up to 101 -200 or up to 25' PHF display $150.00 J Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) TOWN E [] Caterer $25.00 ❑ Milk & Cream $10.00 [_ 1 Mobile Food & Consession $75.00 -1 Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 [J Retail Snack Food $25.00 [� Tobacco Products $25.00 Definitions: PHF- Potentially hazardous food (fime/temperature controls required) Non-PHF's - non -potentially hazardous food(no timeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 1-1Sale of Commercially Pre -Packaged Non PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held i - -- ------ �� for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs I Preparation of PHFs For Hot And Cold Holding For Single Meal Service (._1 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs rY ------- - - Susceptible Population Facility - - - Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer i Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours�I -- - ._.--- _ ------ J Use of Process Requiring A Variance i Customer Self -Service of Non PHF and Non Customer Self -Service li and/or HACCP Plan (including bare hand Perishable Foods Only f - - ----- _ Ice Manufactured and Packaged for contact alternative, time as a public health [ Preparation of Non-PHFs Retail Sale _ control) Other Food Operations Juice Manufactured and Packaged for L 1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin --- - _----" I ]Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date •--- --- ---- or Reconditioned Food IFTo be completed by the Board of Health - -- __--- _--- Total Permit Fee: $25.00 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 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 MOIL 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. 25) Social Security Number or Federal ID: 04-2805171 26) 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 andpaid all state taxes required under law. u I t c(MP Signa e of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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:\HealthU=e's Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc Town of Mansfield Town of'Mansfield - Board ofHealth 5 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: WALID SAMROUT CORP., INC. LOCATION OF SALE OF TOBACCO PRODUCTS: 54 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-3179 OWNER OF BUSINESS: WALID SAMROUT ADDRESS OF OWNER: 46 HILLCREST AVENUE, ATTLEBORO, MA 02702 TELEPHONE OF OWNER: (508) 339-3179 FAX NUMBER: (508) 339-1940 If a corporation or partnership, give name, title, and home address of officers or partner. * Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 871288832 FEDERAL ID/SS NUMBER: 04-2805171 SIGNATUR DATE: 0 w fl N mw° ab Ax O N � rn m �z a O � q N P U� U �• o F � 0 p�Oy U Q ccl � ® LZi LL ti O a% N ti U w w W sA us MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L0667436032 s PO BOX 7044 Notice Date: August 9, 2016 CONTACT CENNTERTER OTCA-7044 Case ID:0-000-095-574 C (617) 887-6367 CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE �I�I��IIIIIII�I�III�11�1�111111��I�I��I�II�II�11'��"I��'I�'�'�'� WALID SAMROUT CORPORATION INC 54 CHAUNCY ST MANSFIELD MA 02048-1902 YWIA?!_YCC The Commissioner of Revenue certifies that, as of the date of this certificate, WALID SAMROUT CORPORATION INC is in compliance with its tax obligations under Chapter 62C of the Massachusetts General Laws. This certificate doesn't certify that the taxpayer is compliant in taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. This is not a waiver of lien issued under Chapter 62C, section 52 of the Massachusetts General Laws. >g?lere ctFri yv�zt7:rldztzviizl,znfvrrx¢(rvu? . Visit our website at mass.gov/dor for one -stop access to taxpayer information. You can learn more about state tax laws and DOR policies and procedures, including your Taxpayer Bill of Rights and the appeals process. You can file most business tax returns, make payments and manage your account at mass.gov/masstaxconnect. You may also contact us by phone at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 9:00 a.m. to 5:00 p.m. Charlene Hannaford Acting Deputy Commissioner FP-005 (Rev. 1.1.2015) c�7�e �no�nvrno�caQa.�i �C�/�aaaac>Lu�elta tOr/L/suan, a/. MANSFIELD Certificate of Registration Massachusetts General Law, Chapter 148 § 13 GIS Coordinates License Number In accordance with the provisions of Massachusetts General Law, Chapter 148 § 13, the undersigned hereby certifies that: Person, partnership, corporation or other entity: Walid Samrout Corp, Inc. _ Name of L¢ense Holder 54 Chauncy Street- auvincss Address of LUcense Holder Is the holder of license granted on 5/8/1957 6/27/1973 & 12/20/1984 , and subsequently amended on For the lawful use of buildings and structures located or to be located at: 54 Chatuacy Street Number, So-eet an Assessor's Map antl Parcel ID As or sale of flammables, combustibles, or explosives. REGISTRATION This is to certify that the within named license holder has in accordance with the provisions of Massachusetts General Law, Chapter 148 § 13 filed with me, a certificate of registration setting=forth that the above named entity is the holder of license as relates to the keeping, storage, manufacture, or sale of flammables, combustibles, or explosives at phi above described location. fJ THIS REGISTRATION AND THE LICENSE MUST BE CONSPICUOUSLY POSTED ON THE LAND FOR WHICH IT IS GRANTED, The Commonwealth of Massachusetts Department oflndusbialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIIT'TIN'G AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:�U.4 e 5 6n a Y( / n -k 0 4- City/State/Zip: 2?'hone#: �%� ��C�' 3 Are you an employer? Check the appropriate box: Business Type (required): 1. [el am a employer with �_ employees (full and/ 5. ❑ Retail orpart-time).* 6. Restaurant/Bar/CatingEstablishment 2:0 1 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, 9a4j"a7 with no employees. [No workers' comp. insuran tAny applicant that checks box #I must also fill out the section below showing their workers' compensation policy ioformadon. **If the corporate officers have exempted themsclves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 1l1. I am an employer that is providing workers' coUtensation ingrance,farmy employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: L' POliey # or Self -ins. Lic. # T" (`') '.'� ?1 Ht� Expiration Data: 17 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify, under the pains and penaldes ofperjury 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 Contact Person wwW.mass.goNdia ^ Q® A (/J/„ CERTIFICATE OF LIABILITY INSURANCE DATE (YYYY) ,,,16120,6,28„ 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 Bianca Dunn NAME: Dowling Insurance Agency, Inc PArc NO Ex1: (781)848-7652 FAX Nco (781)380-8763 AICI44 E-MAIL ADDRESS: bdunn@dowiingins.wm Adams Street INSURERS) AFFORDING COVERAGE NAIC W P.O. BOX 850962 INSURERA: Utica Mutual Insurance Company 25976 Braintree MA 02185-0962 INSURED INSURER 8: INSURER C : ,,. Walld SammutCorporation, Inc. INSURER 0: 54 CHAUNCY ST INSURER E : INSURER F: MANSFIELD MA 02048 COVERAGES CERTIFICATE NUMBER: Mansfield 11/16/17 BD 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 LTR TYPE OF INSURANCE AUDLISUBR INSD MD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY E%P MMIDDNYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 0 OCCUR EACH OCCURRENCE _ $ PREMISES Ea occurrence $ MED EXP (Any one parson) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY ❑ PRO- ❑ L� JECT OTHER: GENERALAGGREGATE If PRODUCTS-COMPIOPAGG It $ AUTOMOBILE LIABILITY - ANYAUTO OWNED F I SCHEDULED AUTOS ONLY AUTO. HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea aaident $ BODILY INJURY (Per person) $ BODILY INJURY (Per acciden0 $ PROPERTY DAMAGE Paraccidenl $ $ UMBRELLA LIAB11 EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED F iRETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETOMPARTNERIEXECUTIVE � OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, descnbe under DESCRIPTION OF OPERATIONS below N/A 4993962 11/17/2017 11/17/2019 X STATUTE ER I X ERH E.L. EACHACCIDENT It 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 600,000 DESCRIPTION OF OPERATION. I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be 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 Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE MA 02048 (Z(W Mansfield ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _A UTICA NATIONAL MISURANCE GROUP 180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP Information Page 1. The Insured and Mailing Address: Walid Samrout Corporation, Inc. DBA Mansfield Gas & Service 54 CHAUNCY ST MANSFIELD MA 02048 Entity of Insured: Corporation Other workplaces not shown above: Insured's I.D. Number: 042805171 Risk I.D. Number: Policy Number: 4993962 Prior Policy Number: Producer: Dowling Ins, Agency,lnc. 44 Adams Street Braintree, MA 02184 Producer Number: 70333 SICM 7538 NCCI Company Number: 15717 WC 000001A 2. The policy period is from 11/1712017 to 11/17/2018 12:01 AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A., ND, OH, WA, WY D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ❑ See Extension of Information Page Classifications Code No. Premium Basis Total est. Annual Remuneration Rate Per $100Estimated of Remuneration Annual Premium Minimum Premium: $ 287 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 3,752 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 3,752 Issuing Office: New Hartford, NY 13413 Date of Issue: 10-03-2017 Countersigned by -,�� 1 ..�(:At✓ 8-D-WC Ed. 08-2008 Copyright 1988 National Council of Compensation Insurance BILLING NO.200842837 WC 000001 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EXTENSION OF INFORMATION PAGE Item 4. Continued Page: 1 NCCI Company Number: 15717 Policy Number: 4993962 Code o Premium Basis Rate Estimated Classifications Total Est. Annual Per $100 of Annual Remuneration Remuneration Premium State: MA Location #:1 Automobile Service Or Repair Center And Dr (8380) 8380 8380 100,77E 3.08 $3,104 Term: ( 11/17/17-11/17/18 ) State: MA Location #:1 Clerical Office Employees Noc (8810) 8810 8810 21,216 0.07 $15 Term: ( 11/17/17-11/17/18 ) State: MA Location #:1 Store: Retail Noc (8017) 8017 8017 21,216 1.07 $227 Term: ( 11 /17117-11/17/18 ) Term: ( 11/17/17-11/17118 ) Manual Premium $3,346 Employers Liability 9807 1% $33 Employers Liability to Minimum 9848 $17 $3,396 Subject Premium Merit Rating 9885 .95 -$170 Standard Premium $3,226 Expense Constant 0900 $338 Certified Acts of Terrorism (CAOT) 9740 .0300 $43 DIA Assessment .0456 $145 otal State Premium $3,752 8-D-WC (Supp) Ed. 08-2008 Copyright 1987 National Council on Compensation Insurance