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HomeMy WebLinkAboutWicked Vaped 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:. BOARD OF HEALTH IAN DEVINE Whose place of business is: 266 NORTH MAIN STREET License Number: S_22 Permit Expires: December31,2018 Food Fee: $50.00 Milk & Cream I MlchaeCMCCCean, 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. BOARD OF HEALTH Whose place of business is: WICKED VAPED 266 NORTH MAIN STREET License Number: S_22 Permit Expires: December31,2018 MichaeCMcCCean, Chairman 1) Establishment Name WICKED VAPED 2) Establishment Address 266 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 266 NORTH MAIN STREET 4) Establishment Telephone No 5) Applicant Name & Title: (AN DEVINE MANSFIELD, MA 02048 (774)284-4964 6) Applicant Address 1246 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (74) 219-6297 24 Hour Emergency No.: 8) Owners Name &Title IAN DEVINE 9) Owner Address (If different from applicant) 1246 EAST STREET, MANSFIELD, MA 02048 Owner's telephone number 7742196297 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers !An Association or partner. I ICI A Corporation Name Title Address 1 1 An Individual A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: IAN DEVINE Address: 11246 EAST STREET, MANSFIELD, MA 02048 j Telephone No: 1(774) 219-6297 24 Hour Emergency No: FAX: E-mail: IAN78D@G MAIL.COM Alt E-Mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No. (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 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 l 22) Establishment Type Mobile Mobile Start Date: � - � Retail ( Sal Ft) Mobile End Date: Moblie Comments: 21) Length of Permit: I Annual Seasonal '�. Seasonal Dates: _l Temporary Temporary Start Date: Temporary End Date: Temporary Time: ❑ Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 254 PHF display $275.00 Food Service - Institution ( Meals/Day) [-] Caterer $25.00 [] Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [.] Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 L] Retail Snack Food $25.00 Ill Tobacco Products $25.00 Rain Date: - - ---- - 23) Food Operations Definitions: PHF- Potentially hazardous food (tlmeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) !(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) �',I Sale of Commercially Pre -Packaged Non-PHFs ] Sale of Commercially Pre -Packaged PHFs --- ----- - ---- ---- - 'I Delivery of of Packaged PHFs - Reheating of Commercially Processed Foods for Service Within 4 Hours -I Customer Self Service of Non PHF and Non - Perishable Foods Only 1 Preparation of Non-PHFs Other Food Operations i,] PHFCooked To Order Nfepafation er PFn's t-or Hot Ana 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 --- - - Customer Self Service III i Use of Process Requiring A Variance 1 and/or HACCP Plan (including bare hand [ ] Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) -.-I Juice Manufactured and Packaged for ', -..'; Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ] Offers RTE PHF in Bulk Quantities I I Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food --- I I To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application I. .I 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 ofyfd5 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: l " ^ -� ) 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. \ 25) Social Security Number or Federal to: 82-2598377 ( 1, 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 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: WICKED VAPED LOCATION OF SALE OF TOBACCO PRODUCTS: 266 NORTH MAIN STREET TELEPHONE AT LOCATION: (774) 284-4964 OWNER OF BUSINESS: 266 NORTH MAIN STREET, MANSFIELD. MA 02048 ADDRESS OF OWNER: IAN DEVINE TELEPHONE OF OWNER: (774) 284-4964 FAX NUMBER: 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: FEDERAL ID/SS NUMBER: 82-2598377 SIGNATURE: &"-/ DATE: 11 /1 /2017 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 or Corporate Name 82 - a 55837-7 "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\Plealth\tme's Doom➢ents\PERMrP APPLICATIONS\TAX CERTIFICATION FORM.doo The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 n www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Business/OrganizationName:( CVe k V,CA) lG�j,v . F—IA Pr:je ins, be," Address: ixi(da N. µo,bA s City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1.19 I am a employer with Jr employees (full and/ 5. ❑ Retail orpart-time),# 6. Restaurant/Bar/EafingEstablishment 2: 0 lam a sole proprietor or partnership and have no ?. F1 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, El manufacturing no employees. [No workers' comp, insurance required]* I I. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12. ❑ Other *Any applicant that cbooks box #] must also fill out the section below showing their workers' compensation policy information. **If the enrpoateofficers have cxcmpled themselves, but the corporation has other employees, a workers' compensation policy is required and such au organization should checic box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 44C.'ri C. -ck g Insurer's Address: 3eOex� W, %eyi wpi City/State/Zip: Sa n An-lrS n b ­ r'S4- % S 2,r Policy # or Self -ins, Lic. # 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under-$hc pains and penalties of perjury that the information provided above is true and correct Phone#: %7y-21l (eZ% 7 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#: www.mass.gov/dia THE HARTFORD BUSINESS SERVICE CENTER THE r 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 Mansfield Board of Health 6 PARK ROW MANSFIELD MA 02048-2433 Account Information: Policy Holder Details : Devine Enterprise DIB wicked vap�1 November 1, 2017 vQ Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 467-8730 Fax: (888) 443-6112 Email: agency.servicesag thehartford.com Website: httos://ebc.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WITR005 A �Q° CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDM'YY) 11/01/2017 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(les) 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 endorsements , PRODUCER CONTACT NAME: AUTOMATIC DATA PROCESSING INS AGCY PHONE(877) 467-8730 (888) 443-6112 76250871 71 HANOVER ROD N ,Ezt. jAX No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICN FLORHAM PARK NJ07932 INSURERA: The Hartford Fire Insurance Company 19682 INSURED INSURER B : DEVINE ENTERPRISE DBA WICKED VAPE INSURER C: 266 N MAIN ST UNIT 2 MANSFIELD MA 02048-3331 INSURERD: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 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 INSURANCE ADDL INBR SUB WVD POLICY NUMBER POLICY EFF MMIDD/YIMMIDDIYYYYI POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑OCCUR DAMAGE TO RENTED PREMISES Eaoccunence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PRO JECT ❑LOC PRODUCTS-COMP/OP AGO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee i e $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Peraccident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER $ E.L. EACH ACCIDENT $ 100,000 A YIN ANYPROPRIETOR/PARTNDED? CUTIVE (Mandatory In NH) (Mandatory In NIA 76 WEG AA6WRF 09/01/2017 09/01/2018 E.L. DISEASE -FA EMPLOYEE $ 100,000 If yes, describe under E.L, DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below $ DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace Is required) Those usual to the Insured's Operations CERTIFICATE HOLDER CANCELLATION MANSFIELD BOARD OF HEALTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 6 PARK ROW MANSFIELD MA 02048-2433 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988.2015 ACORD CORPORATION. All rights reserved.