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Home My WebLink AboutWhite's Pastry Shop 12/31/2018Commonwealth 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;. DAVID WHITE, PRESIDENT Whose place of business is: WHITE'S PASTRY SHOP 321 SCHOOL STREET PERSON(S) IN CHARGE: DAVID WHITE Permit Expires: December 31, 2018 Food Fee: $125.00 License Number; FS-97 BOARD OF HEALTH MichaeLA&CCean, Chairman Milk & Cream W 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: DAVID WHITE, PRESIDENT having a place of business at: PTff APUTRITANAPT.e. 321 SCHOOL 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-97 Board of Health MichaeCMcCCean, 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 FSFS97 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned oemng date) 1) Establishment Name WHITE'S PASTRY SHOP 2) Establishment Address 321 SCHOOL STREET NOV , ! nj7 3) Establishment Mailing Address (if different) 1041 PEARL STREET BROCKTON, MA 02301 4) Establishment Telephone No (508) 339-8230 5) Applicant Name & Title: DAVID WHITE, OWNER 6) Applicant Address 90 BARNABAS ROAD, FALMOUTH, MA 02574 7) Applicant Telephone No.: (508) 269-5809 24 Hour Emergency No.: 8) Owners Name & Title DAVID WHITE, PRESIDENT 9) Owner Address (If different from applicant) Owner's telephone number (508) 269-5809 10) Establishment Owned By. 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. hh// A Corporation Name f n Title , ^ �Address An Individual �Gl /1 (� vv�1 I �C I Q I GW 016 (RA (�-�i2L(' A Partnership QLWIUV" rAM _,.__ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: DAVID WHITE Address: 90 BARNABAS ROAD, FALMOUTH, MA 02574 Telephone No: (508) 269-5809 ((508) 584-5100 BR 24 Hour Emergency No: FAX: (508) 894-8590 E-mail: DAWHITE24(a)HOTMAIL.COM Alt E-Mail: JAMIE@WHITESBAKERYANDCAFE.COM 13) District Or Regional Supervisor (if applicable) Name & Title: MELISSA ROBBINS, MANAGER Address: 19 RUFUS JOHNES LANE, NORTH EASTON, MA 02356 Telephone No: (508) 339-8230 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-FRI 7:00 AM -7:00 PM SAT 7:30 AM I 15) SEWAGE DISPOSAL: 16) No. of Food Employees: 7:00 PM SUN 7:30 AM-6:00 PM TOWN 18) Name of Person In Charge Certified in Food Protection Management: MELISSA A ROBBINS If more than 3 individuals are certified, complete list is on file. LRequired as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of LC 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): I f20) Location: V Permanent Location 22) Establishment Type Mobile Mobile Start Date: Mobile End Date: Moblie Comments: Retail ( Sq. Ft) d Food Service up to 100 or up to 10' PHF display $125.00 21) Length Of Permit: Food Service up to 101 -200 /', Annual or up to 25' PHF display $150.00 'i Seasonal Food Service up to 201 + '_- or 25'+ PHF display $275.00 Seasonal Dates: (._?Temporary L_--.. Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ Caterer $25.00 j ] Milk & Cream $10.00 -, Mobile Food & Consession $75.00 ;.i Manufacture Frozen Desserts/Ice Cream $25.00/freezer [j Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 [_] Retail Food $100.00 ❑ Retail Snack Food $25.00 [,] Tobacco Products $25.00 Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) L I Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs ] - 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 PHFCooked To Order i Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer (] 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 �'L_I , Customer Self -Service and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative time as a public health Retail Sale _ control) Juice Manufactured and Packaged for 1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities li I Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage Out -Of -Date --- ------ llI ...._-- -- .....-..-.I or Reconditioned Food � i To be completed by the Board of Health - -- -- _---- - J 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 with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to optafn) copies of 106 CMR 590.000 and the federal Food Code. 24) Signature of Pursuant to MGL Ch.62C, seta 9A, I certify under the and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-305-68 26) Signature of Individual or Corporate Name: perjury that I, to my best knowledge and belief, have filed all state tax returns 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: WHITE'S PASTRY SHOP ADDRESS: 321 SCHOOL STREET TELEPHONE AT LOCATION: (508) 339-8230 FAX NUMBER: (508) 894-8590 OWNER OF BUSINESS: DAVID WHITE, PRESIDENT TELEPHONE OF OWNER: (508) 269-5809 FEDERAL ID/SS NUMBER: 04-305-6801 FEE$10.00 PERMIT NUMBER: FS-97 SIGNATURE: + DATE: __ I -III "I' jr%- 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. &C+-y" .SFw ZiAll Signature of Individual or Corporate ame By: Corporate Officer Wandrt if Applicable) 01�1-305��( **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:\Health\Jme's DoG ments\PERMIT APPLICATIONWAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress ,Sheet, Suite 100 Boston, MA 02114-2017 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: Address: IO�II,,nn Pelt(l City/State/Zip: .i� O Pik- h n MA 023 0I Phone #: 1j 09- `) '?,,"q _ '�_) 06 Arllae��e you an employer? Check the appropriate box: Business Type (required): I. ly.l I am a employer with employees (full aod/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/BarlEating Establishment 2: ❑ 1 am a sole proprietor or partnership and have no 7. 0 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 arc 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, 12,❑ Other with no employees. [No workers' comp, insurance req.] *Any applicant that checks box #1 must also fill out the section below showing thcirworkers compensation policy information. **If the coryernte of icna have cxcmpled themselves, but the corporation has other employees, a workers' compensation policy is required and such an ' organization should check box M. I am an employer that is providing workers' compensation insurance for my,employees. Below is the policy informadoh. Insurance Company V�/ (._ Insurer's Address: PO Box (RSRD any` City/State/Zip: ?) r6L l,11 +-C e-k Policy 4 or Self -ins, Li,. 4- 0 1 f j 0 0'� O3 I 1/ 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c dfy, under the pains andpenaldes of perjury that the information provided above is true and correct rP•��TA AAAA _19 l A/ it , k- Date" i I I I ")11-7 Official use only. Do not write in this area, to be completed by city or town official, City or Tower: Permit1License 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.gowma Phone A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 11/29/2017 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 tNSURER(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 endomement(s). PRODUCER CONTACT Margaret Viera NAME: Morse Insurance Agency, Inc. PRONE (508)238-0056 FAX (508)230-8367 qIC No Ext :(AID, No): E-MAIL maggieviera@morseins.com ADDRESS: 285 Washington Street INSURERIS) AFFORDING COVERAGE NAIC N INSURER A: Arbella Insurance Group North Easton MA 02356 INSURED INSURER B: Arbella Protection Ins. Co. 41360 White's Pastry Shop Inc. INSURER C: MA Retail Merchants WC Group Inc. 1041 Pearl Street INSURER O: INSURER E : INSURER F: Brockton MA 02301 COVERAGES CERTIFICATE NUMBER: 2017 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. INSR LTR TYPE OF ADDLSUBR INSD MD POLICY NUMBER POLICYEFF MMIDDIYYYY POLICYEXP MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TORENTED PREMISES Ea occurrence $ 100,000 MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000.000 A 8500053720 12/23/2017 12/23/2010 GEN'LAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE $ 2,000,000 X POLICY ❑ jECT LOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Par person) $ ANVAUTO B OWNED X SCHEDULED AUTOS ONLY AUTOS 1020010665 12/23/2017 12/23/2018 BODILY INJURY(Peracciden0 $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PerOPER nDAMAGE ll $ PIP -Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB cIA"MADE 4600053835 12/23/2017 12/23/2018 AGGREGATE $ 5,000,000 DED I X1 RETENTION it 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA 014005031718118 01/01/2018 01/01/2019 X STATUTE ERH E.L. EACHACCIOENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) 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 Mansfield MA 02048 Uw^-. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD INFORMATION PAGE RENEWAL AGREEMENT Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: White's Past Mailing Address: 1041 Pearl S Brockton' MA Other workplaces not shown SEE SCHEDULE OF OPERATI01 2. The policy period is from at the insured's mailing 3. A. Workers Compensation Compensation Law of t] MA B. Employers Liability In state listed in Item 3 Bodily Injury by Bodily Injury by Bodily Injury by C. Other States Insurance D. This policy includes WCOOOOOOC(O1/15) WCOOO WC200302(05/86) WC200 Shop, Inc. 1 PRODUCER: Agent# 2036 Morse Insurance Agency, Inc, 285 Washington St, N. Easton, MA 02356 Carrier Policy #: 014005031718117 Carrier Prior Policy #: 014005031718116 Fein: 043056801 Type of Business: Corporation Risk ID: 01 a.m. on 1/01/2017 to 12:01 a.m, on 1/O1/2078- Part One of the policy applies to the Workers listed here: Part Two of the policy applies to work in each a limits of our liability under Part Two are: $ 500 000 each accident $ 500 000 policy limit 500 000 each employee e endorsements and schedules: 8/841) WC000414(07/90) WC000422B(Ol/15) WC200301(04/84) 07/99) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policylwill be determined by our Manuals of Rules, Classifications, Rates and RatingjPlans. All information required below is subject to verification and change by audit. Classifications Codel ' Premium Basis Rate Per Estimated No., i Total Estimated $100 of Annual Annual Remuneration Remuneration Premium i SEE SCHEDULE OF OPERATIONR Total Estimated Annual Premium $ i 49.162.00 Minimum Premium $ 329.06 Expense Constant $ 00 Deposit Premium $ .00 SCHEDULE OF OPERATIONS $OR: PAGE: White's Pastry Shop, Inc. Carrier Policy #: 014005031718117 1041 Pearl Street Fein: 043056801 Brockton, MA 02301 DIV #: 00000 E/L Number: 0000000001 OTHER WORKPLACES: White's Pastry Shop, Inc. 98 Derby Street, Unit 40!7 State Risk ID#: 000220115 Hingham, MA 02043 Eff date: O1/01/17 NAICS: 311811 DIV #: 00000 E/L Number: 0000000002 White's Pastry Shop, Inc::. 321 School Street State Risk ID#: 000220115 Mansfield, MA 02048 Eff date: 01/01/17 SIC: 5999 DIV #: 00000 E/L Number: 0000000004 WC 00 00 01 B 1 f= LA M `1 U)/QA) �) Y V W 2 O t d A N 1� - Blame of Redpient: Data MOConnor Certificate Number: CWSS047 Date ofCompletion: 01/02/2015 Date ofE*mtion:0 /01/2020 _ 7&aLaore-sa ,ftrmn ittmoy iunedaitafflywie farmmpfmingm allergen amareaetr [mining frograM saagnirid by the Mavarbnre[a Deyar[ment ajPab/icHm/db in rdanmmid loS CMRS90009(Cj(3)(at MiertYF-(e utilbes-Nd,4r'nn(S)y-afm-da(C 4f i4N C[I4N. TmaedB7s r-MPU &S)'"Mo� S%NonhAme ,D4or2 A%Wmfield,111A 01880 A981-2I4-1113 P 781-22a0584 1nW.m0Pmlb.e401