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Home My WebLink AboutThe Store 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:. HITESHKUMAR PATEL, OWNER Whose place of business is: KANKU, INC. dba THE STORE 213 SOUTH MAIN STREET Permit Expires: December 31, 2018 License Number: RF-10 Food Fee: $100.00 Milk & Cream L 1 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: KANKU, INC. dba THE STORE 213 SOUTH MAIN STREET License Number : RF-10 Permit Expires: December 31, 2018 BOARD OF HEALTH MichaeCMcCCean, Chairman 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., HITESHKUMAR PATEL, OWNER having a place of business at: KANKU, INC. dba THE STORE 213 SOUTH MAIN 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.: RF-10 Board of Health wlichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HE - -- ALTH USE ONLY Permit #Issued RF-10 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name KANKU, INC. dba THE STORE € " F 2) Establishment Address 213 SOUTH MAIN STREETNo V ` # ; IV a r 3) Establishment Mailing Address (if different) 213 SOUTH MAIN STREET MANSFIELD, MA 02048° ) ma 4) Establishment Telephone No (508) 261-1369 5) Applicant Name & Title: HITESHKUMAR PATEL, OWNER I 6) Applicant Address 213 SOUTH MAIN STREET, MANSFIELD MA 02048 7) Applicant Telephone No.: (608) 261-1369 24 Hour Emergency No,: (508) 261-1369 (508) 409-9228 8) Owners Name & Title HITESHKUMAR PATEL, OWNER 9) Owner Address (If different from applicant) 213 SOUTH MAIN STREET, 2ND FLOOR, MANSFIELD, MA Owner's telephone number (508) 409-9228 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers Ll An Association or partner. ICI A Corporation Name Title Address I An Individual I :I A Partnership -I-Other legal -Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title 'BHIKHAJI PARMAR, MANAGER Address: 213 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No (508) 409 9228 24 Hour Emergency No: (508) 261-1369 (506) 409-9228 FAX: (608) 261 1369 (508) 836-393 HITESH198789(aYYAHOO.COM E-mail: Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title BHIKHAJI S. PARMAR Address: I213 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: i(508) 261-1369 24 Hour Emergency No: (508) 409-9228 j FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT 6:30 AM-9 PM SUN 7 AM-9:00 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 3 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: [J Permanent Location 22) Establishment Type ] Mobile Mobile Start Date: 0 Retail ( 3,200 Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: FV] Annual ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: P.m narP. ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 E 1 Food Service up to 201 + or 25'+ 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 F ] Retail Food $100.00 ❑ Retail Snack Food $25.00 [] Tobacco Products $25.00 23) Food Operations Definitions:PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs I ❑ PHFCooked To Order 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 ._..._. -_...---— Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale [ ] Juice Manufactured and Packaged f Retail Sale Offers RTE PHF in Bulk Quantities ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I1_ 1 PHF and RTE Foods Prepared For Highly Susceptible Population Facility bVacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health [] Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals forI Catered Events or Institutional Food Service [] Retail Sale of Salvage, Out -Of -Date I _ l or Reconditioned Food (� To be completed by the Board of Health Total Permit Fee: $100.00 Payment is due with application [j 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 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 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 ID: 04-3521128 qq t 26) Signature of Individual or Corporate Name: 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: KANKU, INC. dba THE STORE ADDRESS: 213 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-1369 FAX NUMBER: (508) 261-1369 OWNER OF BUSINESS: HITESHKUMAR PATEL, OWNER TELEPHONE OF OWNER: (508) 409-9228 FEDERAL IDISS NUMBER: 04-3521128 FEE: $10.00 PERMIT NUMBER: RF-10 SIGNATURE: v� ''4v t` - l DATE: — J r Town of Mansfield Town o f 'Hansf eld - 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: KANKU, INC. DBA THE STORE LOCATION OF SALE OF TOBACCO PRODUCTS: 213 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 261-1369 OWNER OF BUSINESS: HITESHKUMAR PATEL ADDRESS OF OWNER: 213 SOUTH MAIN STREET, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 409-9228 FAX NUMBER: (508) 261-1369 If a corporation or partnership, give name, title, and home address of officers or partner. HITESHKUMAR PATEL 213 SOUTH MAIN STREET, MANSFIELD, MA 02048 " Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License. FEE: $25.00 CT-3T NUMBER: 193843200 FEDERAL ID/SS NUMBER: 04-3521128 SIGNATURE: \ , DATE: \ � j� ag6�1�4rq. MASSACHUSETTS DEPARTMENT OF REVENUE PO BOX 7044 Letter ID: L1222452224 Notice Date: September 22, 2016 b 4i `f,4 BOSTON, MA 02204-7044 Account IU: CGL 10884290-006 CONTACT CENTER '�Igy.�op4 (617)887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES I�IIa�IIIIIuIIIIII��hIIhLII��IdII'�lull'9�I�dlhd�u�il ®_ KANKU INC N� THESTORE 213 S MAIN ST MANSFIELD MA 02048-2519 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 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T o R 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. KANKUINC THESTORE 213 S MAIN ST MANSFIELD MA 02048-2519 Account ID: CGL-10884290-006 License Number: 193843200 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 yse�p!!ug MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L1226597376 PO BOX 7044 Notice Date: September 21, 2016 BOSTON, MA 02204-7044 Account ID: CRL-10884290-009 CONTACT CENTER 'ANro4�' (617)887-6367 RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO KANKU INC THESTORE u^, 213 S MAIN ST MANSFIELD MA 02048-2519 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (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 csynci,t"F• MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T oA Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. KANKU INC THESTORE 213 S MAIN ST MANSFIELD MA 02048-2519 Account ID: CRL-10884290-009 License Number: 1739862016 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. 'J-C) VA , i , \ 0 L Signature of Individual or Corporate Name *"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:\HealthVane's Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 V 7 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: O'Ch l-Ax 1 4N Address: � • e !a ej,� Y-) A->\- Phone#: '6Q8 "\,°-\,? ,Vl Are you an employer? Check the appropriate box: Business Type (required): 1. ff] I am a employer with employees (full and/ 5. ® Retail _ or part-time).* 6. ❑Restaurant/Bar/Bating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no ?, ❑ 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. El Entertainment their right of exemption per c. 152, § 1(4), and we have I0. ❑ 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 re *Any applicant that checks box #] must also fill out the seotion below showing thcirworkers' mmpense6on policy information. **If the corpemte officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #i. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information Insurance Company Name: M!Jlt _Q=eN-6,� � 'NI L.`le'C ,V� G V�IC �" W � (-4 CC 8'lP'�7 Insurer's Address: JJ City/State/Zip: .9 , jj �� i\t�� z ii R -4- Policy # or Self -ins, Lie. #• 1SL_!2 � 1) ai2S�AExpiration 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 certify, under the pains andpenpaldes ofperjury that the information provided above is true and correct Signature: \" \ 1S " �7 1, Date: to X 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 NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www,state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above -mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 02185 ADDRESS OF INK ANCE COMPANY 014005032484117 1/01/2017 - 1/01/2018 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Baljardvale St, Suite 1 Wilmington, MA 01887 NAME OF INSURANCE AGENT ADDRESS PHONE # The Store 215 South Maig St. Mansfield, MA 02048 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE; MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hpspital and medical services in accordance -with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost Uf the seh'- vices'provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury, In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER