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Home My WebLink AboutMansfield Deli 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 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:. THOMAS E. REILLY Whose place of business is: MANSFIELD DELI 72 PRATT STREET License Number: FS-43 Permit Expires: December 31, 2018 BOARD OF HEALTH Food Fee: $125.00 Milk & Cream W MichaeCMcCCean, Chairman Permit for the Sale of Tobacco Products j 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: MANSFIELD DELI 72 PRATT STREET License Number: FS-43 Permit Expires: December 31, 2018 BOARD OF HEALTH MlchaeCMCCCean, 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 THOMAS E. REILLY having a place of business at: MANSFIELD DELI 72 PRATT 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-43 Board of Health MichaeCNcCCean, 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 FS-43 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD DELI 2) Establishment Address 72 PRATT STREET 3) Establishment Mailing Address (if different) 72 PRATT STREET NOV2 8 MANSFIELD, MA 02048 `r 4) Establishment Telephone No (508) 339-2994 5) Applicant Name & Title: THOMAS E. REILLY 6) Applicant Address 3 GROVER LANE, FOXBORO, MA 02035 7) Applicant Telephone No.: (508) 543-2405 24 Hour Emergency No.: (774) 571-0215 8) Owners Name & Title THOMAS E. REILLY 9) Owner Address (If different from applicant) 3 GROVER LANE, FOXBORO, MA 02035 Owner's telephone number (508) 543-2405 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ) A Corporation Name Title Address ❑ An Individual 1 A Partnership 'LJ Other legal -Entity_____ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ITHOMAS E. REILLY Address: I3 GROVER LANE, FOXBORO, MA 02035 Telephone No: 1(774) 571-0215 24 Hour Emergency No: (774) 571-0215 FAX- E-mail: LTEREILLY97(cDCOMCAST NET Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: I _ - - Wo 24 Hour Emergency No: E-mail: _rL t Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 16 17) DAYS/HOURS: 7 DAYS MON-SAT 6 AM - 7 PM SUN 7 AM - 3 PM 18) Name of Person In Charge Certified in Food Protection Management: Gr uA9 fiTu rr ET 4E-R 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 C9) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ 20) Location: [JI Permanent Location Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: i� Annual ❑ Seasonal Seasonal Dates: [ ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type n Retail ( Sq. Ft) fy] 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 ❑ 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 ❑J 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) U Sale of Commercially Pre Packaged Non-PHFs ill PHFCooked To Order ❑vI Hot PHF Cooked and Cooled or Hot Held - - o - -- -- ag--- -- Sale of Commercially Pre -Packaged PHFs [J Preparation of PHFs For Hot And for More Than a Single Meal Service - --- - - --------- - Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highlt Delivery of Packaged PHFs Susceptible Population Facility ---- ------ i. Sale of Raw Animal Foods Intended -— [� Reheating Vacuum Packaging /Cook Chill F Commercially to be Prepared by Consumer ❑ Processed Foods for Service Within 4 Hours --e -- - - ----- ---- ❑ Use of Process Requiring A Variance Customer Self Servicof Non PHF_ and Non- [] Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only V1 Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) - Other Food Operations U Juice Manufactured and Packaged for [ j 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 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 105AR 590.000 and the federal Food Code. 24) Signature of Applicant: -471•• -1� /is Pursuant to MGL Ch.62C, sec. 49A, I certify under and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-302 26) Signature of Individual or Corporate Name: _ penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit 1 hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: MANSFIELD DELI ADDRESS: 72 PRATT STREET TELEPHONE AT LOCATION: (508) 339-2994 FAX NUMBER: OWNER OF BUSINESS: THOMAS E. REILLY TELEPHONE OF OWNER: (508) 543-2405 FEDERAL ID/SS NUMBER: 04-3026085 FEE: $10.00 PERMIT NUMBER: FS-43 SIGNATURE: • /� ,., DATE: ) J • L��1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS-43 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: MANSFIELD DELI LOCATION OF SALE OF TOBACCO PRODUCTS: 72 PRATT STREET TELEPHONE AT LOCATION: (508) 339-2994 OWNER OF BUSINESS: THOMAS E. REILLY ADDRESS OF OWNER: 3 GLOVER LANE, FOXBORO, MA 02035 TELEPHONE OF OWNER: (508) 543-2405 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: 1983082496 FEDERAL ID/SS NUMBER: 04-3026085 SIGNATURE: v , DATE: MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L1675893760 o rl N PO BOX 7044 Notice Date: January 4, 2017 BOSTON, MA 02204-7044 Account ID: CGL-10938204-006 CONTACT CENTER (617) 887-6367 RETAILER LICENSE FOR SALE OF CIGARETTES 16111h111'I"IIIIIII�III'IIIIIII'll'llllllll�llll'll'll"'III MANSFIELD DELI LLC MANSFIELD DELI 72 PRATT ST MANSFIELD MA 02048-1927 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 $SgncrrvS``�s MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a , Retailer License for Sale of Cigarettes gh eye This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. MANSFIELD DELI LLC Account ID: CGL-10938204-006 MANSFIELD DELI License Number: 1983082496 72 PRATT ST MANSFIELD MA 02048-1927 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: January 4, 2017 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. Signature of Individual or eorporate 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\FInhWane's Doou ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street; Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. pplicant InfoXD7.Aii4A. _. _ _ < P1 Business/OrganizaP2,14 TE MEN"T Address: MANSH L NSA 02048 City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 16. employees (full and/ or part-time).* 10 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption per c, 152, § 1(4), and we have no employees, [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance mq.] o,d 33 `t- z.,y cp: Business Type (required): 5. ❑ Retail 6. F]RestaurantBar/EatingEstablishment 7. ❑ Office and/or Sales (ind. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment to, El Manufacturing 1l.❑ Health Care 12.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corpoate officers have exempted themselves, but the corporation has other employees, a workers' compensation p lky is required and such an organization should check box M. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: —TH(:^ H wZ? 1- ood Insurer's Address: 0 ,,- Q6r?,� ✓�SL�. ,,i0 �, 50 -7-A City/State/Zip: $� (' ") L. U s e ✓ ^.11 (r�'L 0 policy #or Self -ins, Lie.#- 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 e. 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 the pahAand penalties ofperjuty 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/Towu Clerk 4, Licensing Board 5. Selectmen's Office 6. Other Contact Ph 11/27/2017 10;26 AM FOOD: Fes 508-339-4811 Hewlett-Parl:ard Company TO: 15082AI7343 PAGE: 002 OF 002 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 1M611DDYYYY) W e. 11/27/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELY 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 pollcy(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 endorsement(s). PRODUCER NAMEpCT Lisa Fonseca C & S Insurance Agency, Inc. PHONE (508)339 2951 All.lc (508)339-0811 A/C! nEA : ANo): 190 Chauncy SUeet/P.0 Box 406 Lisa@candsins.com INSUIER(S) AFFORDING COVERAGE NAICI Mansfield MA 02048 INSURERA: Employers Mutual Casualty Company 21415 INSURED INSURERS: Commerce Insurance Co 34754 MANSFIELD DELI LLC " INSURER C. Hartford Casualty Insurance Co 29424 72 PRATT ST INSURERO. Hospitality Mutual Insurance Company INSURERE: MANSFIELD MA 02048-1927 INSURER F: COVERAGES CERTIFICATE NUMBER: 2017 Ced of Lion REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. BR LTR TYPE OF INSURANCE ISD WVO POLICY NUMBER 0 CIF MMIDNYYY POLICYEXP MMDDIYYV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMSMADE X OCCUR PREMIYS Ee otawrence $ 500,000 MED EV (Any one person) $ 5,000 PERSONAL&ADV INJURE $ A 5W07628 02/10/2017 02/10/2018 GEN'L AGGREGATE LIMIT APPLIES HER GENERALAG'GREGATE $ 2,000,000 X POLICY JECi LOC PROWGTS-COMPIOPAGG A 2,000,000 OTHER AUTOMOBILELIANUTY CO$ F.e eccldtd) 1,000,000 BODILY INJURY(Per OBT.) $ ANY AUTO B vAMED SCHEDULED AUTOS ONLY AUTOS BBZOWJ 02/20/2017 02/20/2018 BODILY INJURY (Per as:den0 $ X HIRED IdON-OWNED AUrOS ONLY X AUTOS ONLY PROPERTY DAMAGE Pereonent $ UMBRELLALIAB OCCUR EACH OCCURRENCE '$ EXCESS LIAB CIAIMSMACE AGGREGATE $ DIED RETEIJTION $ $ WORKERS COMPENSATION XSAATUTE I FRH C ANDEMPLOYERTLIABILITY YIN ANY PROPRIETORIPARTNENEY.ECUTIVE OFFICERNEMEER EXrLaDED1 (MendelorylRNHQ NIA 08WECTJ1416 04/24/2017 04/24/2018- I EL. EACH ACCIDENT $ 100,000 EL. EFEASE-EA EMPLOYEE $ 100,000 It yes, deeanda un6,r DESCRIPLON OP OPERATIONS bel. E1. USEASE-POLICY LIMIT $ 500,000 D Liquor Liability 000768JOLL 02/10/2017 02/10/2018 $1,000,000 $2,000,000 DESCRIPTIONOF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additlonel Remake Schedule, may bo Punched If more Brutus required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 @ 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 2512016103) The ACORD name and logo are registered marks of ACORD Certificate of Achievement Im ANSI ACCNEOITED PROGRAM CERTIFICATE ISSUER #06SS This certificate is awarded to DANIEL JONES Congratulations! You have completed ServSafe° Food Handler Employee Food Safety Online Course and Exam National Restaurant Association Cemrcate N.mber 3178876 Date 12/4/2017 175 W. Jackson Blvd, Ste.1500 Exirallon Dale 12/4/2020 1 0 Chicago, IL 60604-2814 '� 800.765.2122 in Chicago area 312.715.1010 Restaurant.org I ServSafe.com Q s JL Certificate of Achievement ANSI ACCREDITED PROGRAM CERTIFICATE ISSUER #0655 National Restaurant Association 175 W. Jackson Blvd, Ste. 1500 Chicago, IL 60604-2814 800.765.2122 in Chicago area 312.715.1010 Restaurant org I ServSafe.com This certificate is awarded to DANIEL JONES Congratulations! You have completed ServSafe° Food Handler Employee Food Safety Online Course and Exam Cenmcate Number 3178876 Dann 12/4/2017 Expiration Dale 12/4/2020 10 50 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient:-NieLdON- Certificate Number: VIM Date of Completion: =2 2016 Date of Expiration: 112ws,21 Be above -named person is hereby issuer/ this certi6rate for completing an allergen awareness trainingprogranr recognized by the Massachusetts Department of Public Mealtb in accordance with 105 CMR 590,009(G)(8)(a). This rert!firate will be valid forfive (5) year from date of, ..pletion. lewod Ry: NATIONAL RESTAURANT ASSOCIATION. Mas,eehu,etut Resw..t Aes.eution 800.7652122 333 T rnpAu Rond, Suite 102 w ..metaumntarg Southbomugh,MA 01772 509-303-9905 w.vw.mareamunnnasocorg