The URL can be used to link to this page

Home My WebLink AboutMansfield Service 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:. ELIAS KAZAN Whose place of business is: MANSFIELD SERVICE, INC. 189 CHAUNCY STREET Permit Expires: December 31, 2018 License Number: FS-76 Food Fee: $125.00 Milk & Cream FBI BOARD OF HEALTH 9blichaeINcCCean, 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: MANSFIELD SERVICE, INC. 189 CHAUNCY STREET License Number: FS-76 Permit Expires: December 31, 2018 BOARD OF HEALTH NichaeCMcCCean, 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 i I This is to certify that: ELIAS KAZAN having a place of business at: MANSFIELD SERVICE, INC. 189 CHAUNCY 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-76 Board of Health NichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Ql� FOR BOARD OF HEALTH USE ONLY Permit #Issued FS-76 J FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD SERVICE, INC. 2) Establishment Address 189 CHAUNCY STREET 3) Establishment Mailing Address (if different) 189 CHALINCY STREET r k MANSFIELD, MA 02048 J, k -, 3" 4) Establishment Telephone No (508) 339-9054 ------ 5) Applicant Name & Title: ELIAS KAZAN, PRESIDENT 6) Applicant Address 18 TALBOTT FARM DRIVE, MENDON, MA 01756 7) Applicant Telephone No,: (508) 473-2722 24 Hour Emergency No.: (774) 573-7465 (508) 339-2074 8) Owners Name & Title ELIAS KAZAN 9) Owner Address (if different from applicant) 18 TALBOTT FARM DRIVE, MENDON, MA 01766 Owner's telephone number (508) 473-2722 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. V A Corporation 1 Name Title Address An Individual J A Partnership I Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: J,ELIAS KAZAN, PRESIDENT t Address: 18 TALBOTT FARM DRIVE, MENDON, MA 01765 Telephone No: 1(508) 473-2722 24 Hour Emergency No: (774) 573-7465 (508) 339-2074 FAX: E-mail: EWKAZAN(ci)GMA_IL.COM Alt E-Mail: J 13) District Or Regional Supervisor (if applicable) Name & Title: i Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 7 DAYs - 24 HRs. Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 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): I... 20) Location: ICI Permanent Location 22) Establishment Type i Moblie Moblie Start Date: f ] Retail ( Sq Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: !./ Annual ] Seasonal Seasonal Dates: ,Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: U 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 iJ, 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 I1 Tobacco Products $25.00 23) Food Operations Definitions:PHF- Potentially hazardous food(time4emperature controls required) Non-PHFs - non -potentially hazardous food(no time4emperature controls required) !..(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no turtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs IJ', Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs i Reheating of Commercially Processed Foods for Service Within 4 Hours i._i Customer Self -Service of Non PHF and Non - Perishable Foods Only i ;Preparation of Non-PHFs I 1 PHFCooked To Order ! ] 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 Retail Sale and Packaged for Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations id] Juice Manufactured and Packaged for; F] 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 I " -- ! Total Permit Fee: $ 0 Payment is due with application I w ived 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 copes of 105 CMR 90.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under thil penalties of perjury that I, to my best knowledge and belief, have fled all state lax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 74-3234569 ��/ 1 O / 26) Signature of Individual or Corporate Name: ® l air! S' (,! r fLl r,iNtB• 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: MANSFIELD SERVICE, INC. ADDRESS: 189 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-9054 FAX NUMBER: (508) 339-2074 OWNER OF BUSINESS: ELIAS KAZAN TELEPHONE OF OWNER: (508) 473-2722 FEDERAL ID/SS NUMBER: 74-3234559 FEE: $10.00 PERMIT NUMBER: FS-76 SIGNATURE: f y� DATE: `C/ f Ti ! / zo'7" Town of Mansfield Town of Mansfield - 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: MANSFIELD SERVICE, INC. LOCATION OF SALE OF TOBACCO PRODUCTS: 189 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-9054 OWNER OF BUSINESS: ELIAS KAZAN ADDRESS OF OWNER: 18 TALBOTT FARM DRIVE, MENDON, MA 01765 TELEPHONE OF OWNER: (508) 473-2722 FAX NUMBER: (508) 339-2074 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: 727691264 FEDERAL ID/SS NUMBER: 74-3234559 SIGNATURE: +� DATE: 1012cY I%7 Uh ----'�,_----------�---- - -------- _ - -_---------------------------------------- Hsu s�ia M[ASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T`" RetailerLicense for Sale of Cigarettes r'�mrot This license muse posted and visible at all times. The sale of tobacco products o anyone udder 18 years of age is prohibited. MANSFIELD SERVICE INC Account ID: CGL-11477902-007 189 CHAUNCY ST License Number: 727691264 MANSFIELD MA 02048-1355 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: December 8, 2016 Expiration Date: September 30, 2018 c"us MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T M 7 Retailer License for Sale of Cigars and Smot ing Tobacco Ehr ors ` 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 SERVICE INC Account ID: CRL- 11477902-0 10 189 CHAUNCY ST License Number: 2014629888 MANSFIELD MA 02048-1355 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: December 7, 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. I&lr ( n r !'PY Se(y /— Signature & Individual or Corporate Name By: Corporate Officer (Aindatory, if Applicable) y-�l "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:\Hea1th\Janes Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of lndustrialAecidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/d1a Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organizatio n Are you an employer? Check the appropriate box: 1, K I am a employer with __L_ employees (full and/ or part-time).* 2. ❑ lam 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 j #: S'o ? - 331- Busin ss Type (required): 5. RRetail 6. Restaurant/Bar/Fating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10, ❑ Manufacturing 1111 Health Care 12.❑ Other tAny applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempb d themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box N. [am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: baUP/T g�°-e^®� 96, {yc 4903yz a City/State/Zip: b6xKf�lLS 1 & JS 6/6 — ? V 7- Policy # or Self -ins. Lie. #- & S t9U 13 — 'Ii_ 87-6-06 Expira:6on Date: //—Z S -- f r) 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. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct K 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 Ph V DAC: xaono WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S60UB-9701 L87-6-16 ) RENEWAL OF (GS60UB-9701L87-6-15) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY INSURED: MANSFIELD SERVICE INC 189 CHAUNCY STREET MANSFIELD MA 02048-1355 NCCI CO CODE: 10456 PRODUCER: R D MURPHY INS AGENCY 75 HANCOCK STREET BRAINTREE MA 02185 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 1 1 -25-16 to 11 -25-17 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 state(s) 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: $ 100000 Each Accident Bodily Injury by Disease: 8 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy Includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 11 -07-16 WC ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: R D MURPHY INS AGENCY 75TBC 004889 z 0 LLM V W V W Q x w w U 0 z z W z P4 z w 0 W w tM4 E M�O w M M +„ s nd .� i�