Loading...
HomeMy WebLinkAboutJuice on Main 12/31/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health. Permit to Operate a Food Service Establishment Type: FOOD 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:. LORI A. DELANG Whose place of business is: JUICE ON MAIN, LTD 240 NORTH MAIN STREET PERSON(S) IN CHARGE: LORI A. DELANG Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-100 BOARD OF HEALTH Michael .McCCean, Chairman M FOR BOARD OF HEALTH USE ONLY Permit# Issued FS 100 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name JUICE ON MAIN, LTD 2) Establishment Address 240 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 240 NORTH MAIN STREET I' MANSFIELD, MA 02048 4) Establishment Telephone No (774) 284-4485 5) Applicant Name & Title: LORI A. DELANG 6) Applicant Address 37 DAVIS STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title LORI A. DELANG 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corl ❑ An Association or partner. C 1 A Corporation Name I An Individual A Partnership J Other legal Entity_ _ -- 7742660782 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title LORI A DELANG Address: 37 DAVIS STREET, MANSFIELD, MA 02048 Telephone No: FAX: - E-mail: 266-0782 Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX. 24 Hour Emergency No: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 3 17) DAYS/HOURS: M-F 7-6 SAT 94 18) Name of Person In Charge Certified in Food Protection Management: LORI A. DELANG 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: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: [I Annual Ij Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) l] 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 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) Caterer $25.00 ❑ Milk & Cream $10.00 [ I 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 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/lemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ,Check all that; RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [j Sale of Commercially Pre -Packaged Non-PHFs [ _] PHFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held Ill Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service [] PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility [] Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours -- -- ---- --- --------I ----- ------------ ❑ Customer Self -Service of Non PHF and Non- t j Customer Seif-Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ------------ - ❑ Ice Manufactured and Packaged for contact alternative, time as a public health (yj Preparation of Non-PHFs Retail Sale _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 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: $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 complypith 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain co es of.10 : MR 90.0 0 and the federal Food Code. ` 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of jury 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: 47-4436085 26) Signature of Individual or Corporate Name: 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 Corpor Name q-446�0V *"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 of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PER UTTING AUTHORITY. Bus iness/Organization City/State/Zip: 00 Phone /i Vf L r - ff Are on an employer? Check the appropriate box: Business Type (required): I I am a employer with employees (full and/ 5, ❑ Retail . -3- or part-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 3. ❑ [No workers' comp. insurance required] We are 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 most also fill out the section below showing their Workers' compensation policy information. **If the corporate o0cers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box M. am an employer that is providing workers' compensation insurance for my employees. rBel11 ow is the policy informatloh. Insurance Insurer's City/State/Zip: 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. do hereby certify, under the $ain gn.d penalties of perjury that the information provided above is true and correct 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 www.mass.gov/dia Phone i� JUICE-5 OP ID: DIV OATE(MMIDDIYYYV) 12127/2017 4b CERTIFICATE OF LIABILITY INSURANCE 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(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 endorsements . PRODUCER 888-467-3330 Mark J. Kapatoes 2374 Post Rd Suite 200 Warwick, RI 02886 CO eOT Dane Meisler PHONE 888467-3330 �P^X 888-453-5755 A/C, No, Ext): (AID, No): E-MppI cianegkisllc.com INSURER S AFFORDING COVERAGE NAIC q _ INSURER A: WESCO INSURANCE CO 25011 INSURED Juice On Main LTD Jon Coppolino INSURERS: 240 North Main St,,.,,'. INSURER C: INSURER D: Mansfield, MA 02048 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 TYPE OF INSURANCE DDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE DAMAGE TO RENTED PREMISES Ea ocence ca $ $ GEN'L _ MED EXP (Any oneperson) _ $ PERSONAL B ADV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY u za El LOD OTHER', GENERAL AGGREGATE___, PRODUCTS - COMP/OP AGO $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED _ AUTOS ONLY AUTOS WWNN AUTOS ONLY AUTNOOSONLV COMBINED SINGLE LIMIT rAl $ BODILY INJURY Pet arson $ BODILY INJURY Per accitlent $ PPeOacutlenl AMAGE $ UMBRELLA LIAR EXCESS LIAR LJ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PRRO�jPREIIET9O�RRIPARTNER/EXECUTIVE t N'dOddlC'My IONHI EXCLUDED9 If yes, describe under DESCRIPTION OF OPERATIONS below N/A WWC3260417 02/27/2017 02/271201.8=> PER SIAIUI OTH- "EL. EACH ACCIDENT,_ E.L. DISEASE - EA EMPLOYEE 500,000 $_,__._„_-,__,_ $ 500,000 E.L. DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORDIei,Addltional Remarks Schedule,maybeaaechedirmore space is required) for informational purposes only, loc: 240 North Main St, Mansfield, MA 02048 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE .Juice on Main LTD - - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. for informational purposes AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Wesco Insurance Company A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ncci Code: 26135 1. Insured: Juice On Main, LTD 240 N Main St Mansfield, MA 02048 Other workplaces not shown above: None Producer: AmTrust North America, Inc. c/o Mark Kapatoes 2374 Post Road, Suite 200 Warwick, RI 02886 WC 99 00 01 B 1 of 5 INFORMATION PAGE Policy Number: WWC3260417 Individual Partnership _Corporation X Other Federal Tax ID: 474436085 Risk Id: Renewal of: New 2. The policy period is from 2/27/2017 to 2/27/2018 12:01 a.m. 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: Massachusetts 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: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $500,000 each accident $500,000 policy limit $500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: See Extension of Information Page 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. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 650 STATE ASSESSMENT 18 TOTAL ESTIMATED COST 668 Minimum Premium 319 Deposit Premium 180 Issue Date: 2/23/2017 Countersigned by: rr 0 1