Loading...
HomeMy WebLinkAboutWines & More 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Retail 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:. KATHLEEN HARONIAN Whose place of business is: WINES & MORE - MANSFIELD 280 SCHOOL STREET Permit Expires: December31,2018 License Number: RF-19 Food Fee: $100.00 Milk & Cream BOARD OF HEALTH MichaeCMcCCean, 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: WINES & MORE - MANSFIELD 280 SCHOOL STREET License Number: RF-19 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, Chairman Iiu FOR BOARD OF HEALTH USE ONLY Permit# Issued RF 19 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name WINES & MORE - MANSFIELD 2) Establishment Address 280 SCHOOL STREET -. V 4 3) Establishment Mailing Address (if different) 1405 DOUGLAS AVENUE t NORTH PROVIDENCE, RI 02904 „ a 4) Establishment Telephone No (508) 339-6900 ; 5) Applicant Name & Title: KATHLEEN HARONIAN, PRESIDENT 6) Applicant Address --- 4-r�-NO-T9-DRd•VE; NGRT-H-PROV"NGC—, 2984 —A(/ !�- 7) Applicant Telephone No.: (401) 353-4400 24 Hour Emergency No.: (401) 466-2627 N . Pro v I Lim p 8) Owners Name & Title KATHLEEN HARONIAN 9) Owner Address (If different from applicant) qS Owner's telephone number 4013534400 - 1�0,�rYidma r 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers62 I An Association or partner. 'V A Corporation Name � Title Address I !An Individual 44 JeZA 4441JAI4t - Y' i in - CL- gam_ A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: KATHLEEN HARONIAN, PRESIDENT Address: NVo.'VO 1 Telephone No: '(401) 353-4400 24 Hour Emergency No i FAX: (401)353-4469 E-mail: SRAO(cDWSRETAILERS.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: CRAIG POWER, VICE PRESIDENT OPERATIONS Address: 40 WHITELOCK STREET, NEW BEDFORD, MA 02745 Telephone No: (401) 465-2527 24 Hour Emergency No: (401) 465.2527 FAX: (401)353-4469 E-mail: SRAO@WSRETAILERS.COM 'Ira( 64 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) Ii 16) No. of Food - 17) DAYS/HOURS: MON-SAT 9 AM - 10 PM SUN 12 PM - 6 PM 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 15 119)_ Person Trained in Anti -Choking Procedures (If 25 Seats or more) _- - 20) Location: ',�/�, Permanent Location 22) Establishment Type ( Caterer $25.00 (- Moblie Moblie Start Date: ' Retail ( Sq Ft) ❑ Milk & Cream $10 00 Moblie End Date: Moblie Comments: 21) Length of Permit: L'.. Annual Seasonal Seasonal Dates: %_j Temporary Temporary Start Date. Temporary End Date: Temporary Time: Food Service up to 100 or (J Mobile Food & Consession $75.00 up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream [� Food Service up to 101 -200 $25.00/freezer or up to 25' PHF display $150.00 Pushcart 25.00 # of Pushcarts: $ 0 Food Service up to 201 + ; Residential Kitchen $100.00 or 25'+ PHF display $275.00 I ] Retail Food $100.00 Food Service - Institution 11 ] Retail Snack Food $25.00 Meals/Day) ii 1-/] Tobacco Products $25.00 Rain Date: - - 23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no time/temperature 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 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 -- ' Delivery of Packaged PHFs ry Cold Holding For Single Meal Service I J PHF and RTE Foods Prepared For Highl) -- -'. Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially :, to be Prepared by Consumer I _Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours t --- ----- - I ❑ Use of Process Requiring A Variance _- [ I Customer Self -Service of Non PHF and Non- _-.I Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for I contact alternative, time as a public health _ E 1 Preparation of Non-PHFs :. Retail Sale control) Other Food Operations Juice Manufactured and Packaged for I Offers Raw Or Undercooked Food Of - Retail Sale Animal Oriqin 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 To be completed by the Board of Health "-- Total Permit Fee: $100.00 Payment is due with application ❑ waived 1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 YMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtgin copi . ell CMR 59 .0 0 a d the federal F od Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certik and 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: 27-2176426 �^ / '"J'' /1 /I /%� r 26) Signature of Individual or Corporate Name: G . 1. CC? i'�,1 71")c' , r "v /nL5 "ore, r d p Town of Mansfield Town of'Han#ield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: Applicationfor 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: WINES & MORE - MANSFIELD LOCATION OF SALE OF TOBACCO PRODUCTS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 339-6900 OWNER OF BUSINESS: KATHLEEN HARONIAN ADDRESS OF OWNER: —46 NGm-G) GH - icvi?m�i ^I'c^v`y'Io^EPco , M* ^, ^^A "1 a NO. Pnvid wa, r-! 02-gdi TELEPHONE OF OWNER: (401) 353-4400 FAX NUMBER: (401) 353-4469 If a corporation or partnership, give name, title, and home address of officers or partner. KAI HLEEN HARONIAN, PRESIDENT Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 2096074752 FEDERAL ID/SS NUMBER: 27-2176426 \¢ SIGNATURE: DATE: ll z - l - - 4sn�!�Uss�� MASSACRUSETTS DEPARTMENT OF REVENUE Letter ID:L0943506432 PO BOX 7044 BOSTON, Notice Date: September 7, 2016 MA 02204-7044 CONTACT CENTER Account ID: CGL-11451273-008 (617) 887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES lPIln11q�11111�gqup�llil�p�ghhlphPh�lhlll���ulll o GT RETAIL INC o= WINES & MORE - MANSFIELD a� 1405 DOUGLAS AVE NORTH PROVIDENCE RI 02904-4052 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re -print a copy of this license. If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE 5y6`"I' Ei� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m,yl Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. GT RETAIL INC Account ID: CGL-1 1451273-008 WINES AND MORE License Number: 2096074752 280 SCHOOL ST MANSFIELD MA 02048-1840 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2016 Expiration Date: September 30, 2018 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-;T��✓LC Signature of Individual or Corporate Name 1 By: Cox orate Officer (Mandatory, if Applicable) dg-�gq& **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:\Hl IthVane's Doou ents\PHRMIT APPLICATIONSWAX CERTIFICATION FORM.doc TheCommctnwealtlt ofMassachusetts Department of lndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p wmv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information IPlease Print Legibly Business/Organization Name: GT Retail Inc. DBA Wines & More - Mansfield Address: 280 School Street, Suite 140 City/State/Zip:Mansfield, MA 02048 Phone #: 508-339-6900 Are you an employer? Check the appropriate box: Business Type (required): 1. © I am a employer with 14 employees (full and/ 5. ® Retail orpart-time).* 6. ❑Restaurant/Bar/Eating Establishment 2. ❑ 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, §I(4), and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We by 11.❑ Health Care are a non-profit organization, staffed volunteers, 120 Other with no employees. [No workers' comp. insurance req.] *Any applicant that cheeks box#1 must also till out the section below showing their workers' compensation policy information. **If are corporate officers have exempted themselves, butthe corporation has other employees, a workers' compensation policy is required and such an organization should check box ill, I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: MA RETAL MERCHANTS WC GROUP INC. Insurer's Address: P.O. BOX 859222-9222 City/State/Zip: BRAINTREE, MA 02185 Policy # or Self -ins. Lic. # 01400503298211 Date: 1/1/18 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 MOL 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 here rtify, rind tl pains atjjd enalties ofperjury that the information provided above is true and correct. 401-3 Official use only. Do not write in this area, to he conapieted by eity or town official. City or Town: 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 www,mass.gov/dia Phone INFORMATION PAGE RENEWAL AGREEMENT Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: CT Retail Inc Wines And More Mansfield Mailing Address: 1405 Douglas Ave N Providence, RI 02904 Other workplaces not shown above: SEE SCHEDULE OF OPERATIONS PRODUCER: Agent# 5779 Hadley Insurit Group Insurance Age 246 Durfee St Fall River, MA 02720 Carrier Policy #: 014005032982117 Carrier Prior Policy #: 014005032982116 Fein: 272176426 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1/01/2017 to 12:01 a.m. on 1/01/2018' 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 D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000414(07/90) WC000422B(01/15) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 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. Classifications Code Premium Basis No. Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 3,178.00 Minimum Premium $ 266.00 Expense Constant $ Rate Per Estimated $100 of Annual Remuneration Premium 00 Deposit Premium $ .00