HomeMy WebLinkAboutMansfield True Value 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: RETAIL SNACK FOOD
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:.
LINCOLN & CHRISTOPHER TODD
Whose place of business is:
MANSFIELD TRUE VALUE
284 NORTH MAIN STREET
PERSON(S) IN CHARGE:
R. LINCOLN TODD, JR.
Permit Expires: December 31, 2018
Food Fee: $25.00
License Number: RS-23
BOARD OF HEALTH
MichaeC,%1cCCean, Chairman
r
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at leastdays before the planned opening date)
1) Establishment Name qn� ( I 'ram 1 VcAl J�
2) Establishment Address o
or . rn S�' Qns�relc� �f�- dzs�l8'
3) Establishment Mailing Address (if different)
4) Establishment Telephone No ��o8) 339 - 51 15
5) Applicant Name & Title:
fin-
6) Applicant Address '46 A
C,ci,nde�vtr/� '.tc4q Jit� a
_
7) Applicant Telephone No.: _ 24 Oour Emergency No.:
8) Owners Name & Title (_) . lei oM Cl-, rt s. Lcp4r-
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By:
Association
Corporation
0 An Individual
A Partnership
H Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
/ e�¢(� C Tvc(dr 6�nrr crop Mnr tzle FV„�� y 3n�lyrr4�v�r
(jvr )g{o�4er
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
t{0 Sv �qJ 9 d
Telephone No:
�_8I L(Z, 24 Hour Emergency No:
FAX:
E-mail:
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
0Vb2 y
7y
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 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.
C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
kviDepartment of Industrial Accidents
�i l /Boston, MA 02111
/ // / / /
Workers'Compensation i r Businesses
Anitlicaut Information Please Print Leffibly
Business/Organization
Jc.
Address: 7-8
LA
/Uoi-A(A 01r j A
Sk,
City/State/Zip:
rAQ i6 -}I
(
4,4 MA- 020 HS
Phone #: Ca�),359 —61 1$
Are you an employer? Check the appropriate box: Business Type (required):
I. ❑ I am a employer with \ Is h gmployees (full and/ 5. Retail
or part-time).* H ` 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I 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.
[No workers' comp. insurance required] 8• ❑ Non-profit
3. ❑ 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]* I LEl Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 1 12.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the Polley information.
Insurance Company Name: NO Ao1 �: S �� �G a "Q T � dS�
Insurer's
City/State/Zip:
p Zo')-L
Policy # or Self -ins. Lic. # "E 0 '7 Sy 9 7 1 Expiration Date: \ 0)2L I I g'
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 ofperjmy 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: Phone #:
WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY •--- INFORMATION PAGE
INSURER: POLICY NO: WE079497A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 04-2859354
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
TODD PROPERTIES INC DBA MANSFIELD TRUE VALUE NUMBER ONE INS AGCY, INC
HARDWARE. C/O REID—HOFMAN INS AGCY
284 NORTH MAIN ST CORP
MANSFIELD, MA 02048 155 HOWARD ST
WEST BRIDGEWATER, MA 02379
AGENT NO.: 20001REI
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 10/26/2017 To: 10/26/2018
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 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 liability under Part Two are:
Bodily Injury by Accident: $ 100,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Minimum Premium: $
Audit Period: ANNUAL
Issued At:
Date:09/18/2017
Total Estimated
229 Annual Premium: $ 254
Additional / Return Premium:
Comments:
Countersigned by
WC 00 00 01 A
Copyright 1987 National Council on Compensation Insurance
INSURED COPY
The Commonwealth Of Massach
Departlirent of Industrial Accidents
Office of Investigations - Dept. 153
One Congress Street— I'olh Floor..Boston, MassaghuseltsuA 114
httpt/twww. mass.gov/dia
InvesIJSWO ID
Chapter 169 of the Acts of 2002 amended M.G.L. c. IS2, ,$1(4) by adding the following parabmaph:
"This chapter shall be elective for an officer or director of a corporation 'who owns at least 25 percent of
the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter, Said commissioner.shall promulgate regulations to carry out the
purpose of.this paragraph...V..iolations_of,tbis.paragraph sh,411.Subject the corporation, to the penalties set
forth in section 25C.
Pursuant to M.G.L. c. 152, §1(4) as amended, I/We the undersigned officers of:
ral
(Name of Corporation and AddrtsO
each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation policy covering the undersigned corporate offrcer(s) or director(s). 1/We the
undersigned do also.waive any and all rights to make claims for benefits as defined in M,G.L. c. 152 for
any injuries that may be sustained while in the employ of the above -named corporation.
Further, I/we the undersigned do understand that, should the above -named corporation hire or have in
its employ' any employee(s) in addition to the undersigned corporate officer(s) or dire6tor(s), said .
corporation is required to obtain workers' compensation coverage for the emp►oyeg(s) as prescribed by
M.G.L, c. 152, §25A.
Me the undersigned have read and understand the statements and obligations as delineated above and
I/we have chocked the appropriate box below my/our name(s) indicating my/our desire to be exempt or
not to be•exempt from the provisions of M.G.L, c. 152.
under the pains and penalties of perjury;
I wish to exercise my right of exemption or
gnaff, e "
I wish to exercise my right of exemption or ❑
Print Namo & Title
I wish NOT to exercise my light of exem tion
Print Noma & Titre
1 wish NOT to oeralso my right of exemption
ri' C3 Z�/1>
Date (mrrvdd/ )
Date ( rWddlyyyy)
Signaturo Print Noma & Tillo' Data (mmlddlYYYy)
'❑ I wish to exercise my eight ofexemption or ❑ I wish NOT to oxorolsc my right of exemption
sig iatwe Print Name & Title' 'Date (mmtdd/yyyy)
❑ I wish to exercise my right of exemption or ❑ 1 wish NOT to exwdisc my right of exemption
Nule: A, ELIGIBLE'CORPOaATE OFFICERS MUST SIGN. THERE CAN DE NO MORE THAN 4 SIGNATURES: %nstrdCNOnS
on baeh Form 133 - iteviaed Oq•M=10
Sheet4
TOWN OF MANSFIEL
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURERS
No. DEPT: BOARD OF HEALTH Date: 7/18/2018
Type of Payment, CASH ACCOUNT NO: 01612-445006
FROM WHOM AMOUNT
CHRIS TODD 284 NORTH MAIN ST/FOOD PERMIT----- $25.00
SUB -TOTAL: $25.00
Dept: BOARD OF HEALTH
Typa of Payment: CASH
To the Departmental Officer making the payment _
Receipt of:
for the period ending and as per schedule of this date anfiled in my office.
Treasurer
TOWN OF MANSFIELD
PAK)
JUL 1 0 20
Page 1 �HISCK# L 2
AmT_
Sheet4
TOWN OF MANSFIELD
PAR)
Page 1 JUL 1 8 2018
CHECK# CCON
AMT Ls- w __-
Ii C \�e \�o,�\3c
Town of Mansfield
6 Park Bow, Mansfield, Massachusetts 02048
9. `e Health Department
a�snoa Amy Donovan -Palmer, Health Agent
Massachusetts state law requires food establishments obtain a permit from the local board of health.
A food establishment is defined as:
"... an operation that stores, prepares, packages, serves, vends or otherwise provides food for human
consumption. A food establishment includes an operation that is conducted in a ... temporary or
permanent facility or location; where consumption is on or off the premises; regardless of whether
there is a charge for the food." [Food means a raw, cooked, or processed edible substance, ice,
beverage used in whole or in part for human consumption.]
Please use the following checklist to ensure you have all the necessary documentation for a complete
food establishment application:
❑ Food Establishment Permit Application.
❑ All Food Service establishments must attach'copies of Serve Safe and allergen training
certificates.
❑ If there is seating capacity for 25 or more, include anti -choking training
certificates.
❑ Tax Certification Form.
Worker's Compensation Insurance Affidavit: General Business is required. (Read the third
paragraph on the "Information and Instructions" sheet.) It must be filled out by the
organization that is actually vending the product.
❑ Attach a copy of the workers' compensation policy declaration page (showing
.the policy number and expiration date).
In order to obtain a permit, all documents must be filled out, signed and returned to the Health
Department, 6 Park Row, Mansfield, MA 02048. If your establishment is cooking food and has indoor
seating, you must obtain a common victualler license from the Selectmen's Office.
Any filing for that does not meet these requirements will be returned and no permit will be issued.
4
Amy Donovan -Palmer, MPH, RS
Health Agent
Phone (508)261-7366 Fax (508)261-7425 Email ad
palme,@man fieldma. com