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HomeMy WebLinkAboutMansfield Adult Day Health Care 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:. HEALTHCARE OPTIONS Whose place of business is: MANSFIELD ADULT DAY HEALTH CENTER 300 BRANCH STREET PERSON(S) IN CHARGE: KAREN AMADO, PROGRAM DIRECTOR Permit Expires: December31, 2018 Food Fee: License Number: FS-41 BOARD OF HEALTH MichaeCwlcCCean, Chairman WAIVED 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: HEALTHCARE OPTIONS having a place of business at MANSFIELD ADULT DAY HEALTH CENTER 300 BRANCH 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-41 Board of Health MichaeC-blcCCean, 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 FSFS41 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD ADULT DAY HEALTH CENTER 2) Establishment Address 300 BRANCH STREET 3) Establishment Mailing Address (if different) 300 BRANCH STREET ( � , dsR.G �� 3� 0.5 f,d idJ MANSFIELD, MA 02048 r 4) Establishment Telephone No (508) 339-2119 5) Applicant Name & Title: DAWN SULLIVAN, DIRECTOR OF CLINICAL SERVICESICOO I 6) Applicant Address 10 EMORY STREET, ATTLEBORO, MA 02703 7) Applicant Telephone No.: (508) 222-0118 24 Hour Emergency No.: (508) 595-0369 8) Owners Name & Title HEALTHCARE OPTIONS 9) Owner Address (If different from applicant) 10 EMORY STREET, ATTLEBORO, MA 02703 Owner's telephone number (508) 222-0118 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I An Association or partner. /I A Corporation Name Title Address 'An Individual A Partnership Other legal Entity- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) _- Name & Title: ';KAREN AMADO, PROGRAM DIRECTOR Address: i300 BRANCH STREET, MANSFIELD, MA 02048 Telephone No: j(508) 339-2119 24 Hour Emergency No: (508) 595-0359 FAX: I(508) 339-3820 r E-mail: KAMADO@MANSFIELDADHC.COM Alt E-Mail: - 13) District Or Regional Supervisor (if applicable) Name & Title: (DAWN SULLIVAN, DIRECTOR OF CLINICAL SERVICES/COO Address: 10 EMORY STREET, ATTLEBORO, MA 02703 Telephone No i(508) 222-0118 24 Hour Emergency No: FAX: (508) 226-3573 E-mail: DSULLIVAN@COMMUNITYVNA.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No. (If applicable) _.._ 16) No of. Food Employees: 1 17) DAYS/HOURS: MON - FRI 7:30AM - 4:30 PM 18) Name of Person In Charge Certified in Food Protection Management: PAUL J. ALIOTO 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) w! Permanent Location ? Typeil 25.00 ��J ; Moblieo Moblie Start Date I22)Rettaablishment Sq. Ft) Mlk &Cream $10.00 Mobile End Date: ! V1 Food Service up to 100 or _l Mobile Food & Consession $75.00 !' Mobile Comments: up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream -_ 21) Length : -- - of Permit: Food Service up to 101 -200 " $25.00/freezer IV Annual !� or up to 25' PHF display $150.00 1! Pushcart $25.00 # of Pushcarts: 0 '. Seasonal !i Food Service up to 201 + _'� Residential Kitchen $100.00 Seasonal Dates: or 25'+ PHF display $275.00 ; I. j Retail Food $100.00 ---- L. I Temporary --Food Service - Institution � 1 Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) [ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/femperature controls required). '.(Check all that apply):', RTE- ready -to -eat foods (Ex.sandwiches, salads, muffins which need no further processing) Sale of CommerciallyPre-Packaged Non-PHFs o Cooked an Cooled or Hot Held Sale of Commercially Pre Packaged PHFs f PH For Hot And for MoreSingleMealService CPreparation old Holding r Si H ogle Meal Service �. I' )PHF RTE Foods For Highly Delivery of Packaged PHFs L. Sale Raw An a Foods Intended Susceptible Population Facility al 4 �!, Reheating of Commercially -1 to be Prepared by Consumer - Vacuum Packaging [Cook Chill Processed Foods for Service Within 4 Hours --r - -- --- Customer Self -Service of Non PHF and Non ! i Customer Self -Service J Use of Process Requiring A Variance - and/or HACCP Plan (Including bare hand Perishable Foods Only - , _- _.I I Ice Manufactured and Packaged for contact alternative time as a public health J Preparation of Non PHFs Retail Sale 1 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 _. li Catered Events or Institutional Food Service - ❑ Retail Sale of Salvage, Out -Of -Date I or Reconditioned Food To be completed by the Board of Health I Total Permit Fee: !, Payment is due with application i ICI waived ! I, the undersigned, attest to the accuracy of the formation provided in this application and affirm -.. that the food establishment operation will comply h 105 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain co ias f 105 R 590.000 and the federal Food Code. 24) Signature of Applicant: i Pursuant to MGL Ch.62C, sec. 49A, I cert u der 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: 22-2543620 26) Signature of Individual or Corporate Name: HealthCare Options, Inc. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milli and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: MANSFIELD ADULT DAY HEALTH CENTER ADDRESS: 300 BRANCH STREET TELEPHONE AT LOCATION: (508) 339-2119 FAX NUMBER: OWNER OF BUSINESS: (508)339-3820 HEALTHCARE OPTIONS TELEPHONE OF OWNER: (508) 222-0118 FEDERAL ID/SS NUMBER: 22-2543620 FEE: $10.00 PERMIT NUMBER: FS-41 SIGNATURE: ^ DATE: November 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. Healthcare Options, Inc. Signature of Individual or Corporate Name 22-2543620 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) L *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:\HealthVan&s Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth dfMassftchusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FLLED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LggjbI Business/Organization Name: HealthCare Options, Inc. Address: 10 Emory Street City/State/Zip: Attleboro, MA 02703 Phonet 508-222-0118 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 124 employees (full and/ 5. ❑ Retail or part-time).* 6. Restaurant/Bar/BatingEstablishment 2: 0 I 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. Q 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, ❑ Manufacturing no employees. [No workers' comp. insurance required]* l l.❑ 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 checks box #1 must also fill out the section below showing their workers' compensation policy inf0nn860n. **If the corporate officers have exempted themselves, but fie corporation has other employees, a workers' compensation policy is required and such sa organization should check box M. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. InsuranceComnanvName: Liberty Mutual Insurance Insurer's Address: 175 Berkeley Street City/State/Zip: Boston, MA Policy#or Self-ins,Lic.#- WC5731S-388495-017 Expiration Date: 1/1/2018 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, [do 222-0 information provided above is true and correct. November 1, 2017 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: Phone WORKERS COMPENSATION AND EMPLOfERS LIABILITY INSURANCE POLICY Liberty Mutual. vV� INSURANCE AR INFORMATION PAGE 176 Berkeley Street Boston, MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-388495-017 issuing Office 016C RENEWAL OF: WC5-31S-388495-016 Issue Date 12-01-16 Account Number 1-388495 Sub Account 0000 1. Insured and Mailing Address HEALTHCARE OPTIONS INC RISK ID 000773171 10 EMORY STREET ATTLEBORO, MA 02703 Status 03 — CORPORATION Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 01-01-2017 to 01-01-2018 ,12:01 A.M. standard time at the Insured's mailing address. 3. Coverage 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 $ . 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease '$ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE.END WC 20 03 068 D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: 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. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium Minimum Premium $ 309 Premium will be billed ANNUAL Producer 0004-012498 MARSH 6 MCLENNAN AGENCY LLC PROTECTOR GROU 100 FRONT ST STE 800 WORCESTER MA 01608 if Information Page (MA) Total Estimated Annual Premium $ 581154 DBA THE WC 00 00 01 A ©1967 National Council on Compensation Insurance,inc. WC W 00 01 B (CA) Ed. 07/01 /2011 All Rights Reserved Page 1 of 1 Mansfield Board of Health Date November 1, 2017 We, Healthcare Options, Inc. request a waiver of the Food Service Permit Fee for the following reason We are a non-profit agency Thank you, ture Executive Director & CEO Title 4/2/2017 Your Card I eFoodcard Food Handier # Food Industry Training 7" 1��� 1i[ 1 is recogni%ed for successfully completing the eFoodcard Food Handler Basics Course. certificate Number: MA-593160 issued: 04/02/2017 Valid Through: 04/02/2020 c k'.:vT-9YCw.N ff r%' 11 Food Handier F oodcard i ev dficate n completion pawl alioto efoodcard.com 388.2130222 is rsccori_ac ror ;uue;iul:�ccr:,pletina eFoodcard Food Han!kr H.,>r-_ I[;v .lam—.. L� `•d:d 7h:_uor Conciratulationc You have successfully completed the eFoodcard Food Handler Basics Course. Cut cards along dotted lines. Provide one to your employer and keep one for your records. If you have questions, call 888.243.0222. eFoodCard - Robeit D. Anderson, REHS efciodcard.conn 0 .988.243.0222 Y` :4, _, . ICE Food Handler R'Ddcard Cel'Zlflcate Of completion Paul alioto efoodcmd.com 883243.0222 is racc_acrzu fcr;uc<x;;ivr�cemeL;ti^.= the eFoodcard Food Haool•;r 5_slcs •=aor--. Cartiticxc-iIumte;--"- _ n Y3 �r x i elic-I'da s Ha terminado con exito el curso basico eFoodcard de manejador de alimentos. Corte las tarjetas a to largo de las lineas punteadas. De una a su empleador y guarde la otra Para sus registros escritos. Si tiene preguntas, flame al 888.243.0222. https:I/www.efoodcwd.com/accounYdownlOad,cardl358*e9756f78aBc88efld5blc2844bb 1/1