HomeMy WebLinkAboutMMAS 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:.
MARK BLANCHETT
Whose place of business is:
MMAS BLACK BOX
377 NORTH MAIN STREET
PERSON(S) IN CHARGE:
KEN BUTLER, EXEC. DIRECTOR
Permit Expires: December 31, 2018
Food Fee:
License Number: RS-18
V27-17FEVE
BOARD OF HEALTH
Michae(McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued RFM-
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
(' r
1) Establishment Name �� ,4 IJtCL,(-V-
2) Establishment Address
J' j? J)0i1Z-r (-( MAIN L')' E CW`
3) Establishment Mailing Address (if different)
�C>c /2 & 3 AN n�° I�
4) Establishment Telephone No
G`rc�
5) Applicant Name &-- cTitle:
6) Applicant Address (`jv` �S tMr t-v "7,5A :r d - -
7) Applicant Telephone No.: 24 Hour Emergency No.:
508 �2,?-- /6 43
8) Owners Name & Title INA 42�c j17licwc_l�c
Owner Address
fferent
g) Owner's tteleph nlednlumber from applicant)
ed 7 5 % (, c 3 G - - - -
10) Establishment Owned By: 11 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
A Partnership
12) Person onlegal Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title '' ff
Address:
Telephone No.
24 Hour Emergency No: i
FAX:
E-mail: 114MA,S, 0 e
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
14) WATER SOURCE:
Food Establishment Information
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) i 16) No. of Food Employees
17) DAYS/HOURS: h
F3 so esS ft%Xs ri4— F t6t-'-1(r_vaifs+lyS -
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: 1 YPermanent Location
22) Establishment Type
Mobile Mobile Start Date:
r. -.. Retail ( Sq. Ft)
Mobile End Date:
I_ _� Food Service up to 100 or
Mobile Comments:
i up to 10' PHF display INCLUDING
FOOD TRUCKS $125.00
21) Length of Permit:
D Food Service up to 101 -200
nnual
! or up to 25' PHF display $150.00
Seasonal
] Food Service up to 201 +
or 25'+ PHF display $275.00
Seasonal Dates:
,Temporary
([_] Food Service - Institution
Temporary Start Date:
( Meals/Day)
Temporary End Date:
j
Temporary Time:
.
❑ Caterer $25.00
Milk & Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $75,00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
I_] Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
❑ Retail Food $100.00
lketail Snack Food $25.00 '
❑ Tobacco Products $25.00
Rain Date:__.__
i
',. 23) Food Operations Definitions: PHF- Potentially hazardous food ftimeRemperature controls required)
Non-PHFs
- non -potentially hazardous foodfno time4emperature controls required)
'.(Check all that apply): 1 RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs
I PHFCooked To Order
I [] Hot PHF Cooked and Cooled or Hot Held
--- - -
I Sale of Commercially Pre Packaged PHFs I
For -Hot And ,
;Preparation of PHFsFor And
for More Than a Single Meal Service
__
1
Cold Holding For Single Meal Service
I I ] PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs i.
_
Susceptible Population Facility
--i
Sale of Raw Animal Foods Intended
Reheating of Commercially
to be Prepared by Consumer
1 Vacuum Packaging / Cook Chill
Processed Foods 4 Hours
Vcustomer Self-service r Service Within
Non-
' Customer Self
Use of Process Requiring A Variance
ce of Non PHand
-Service
and/or HACCP Plan (including bare hand
Perishable Foods Only
I
' Ice Manufactured and Packaged for
contact alternative time as a public health
Preparation of Non-PHFs Retail Sale control)
Other Food Operations 1. Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of II,
Retail Sale Animal Origin !
f Offers RTE PHF in Bulk Quantities I 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: $0.00/ I
Payment is due with application waived
1, 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 690.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copp!ps of 1005 CMR 590.000 and the federal Food Code.
24) Signature of Applicant '" 41 `
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: 1 Cr �/
26) Signature of Individual or Corporate Name: 1 III
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.
M k�4 S
Signature of Individual or Corporate Name
0114-3i �SLi(�_(
""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.
CAUsersls1eiteWo9ktoplSc0tt'8 Docommtffood Establishments-Teint UAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
U1VDepartment oflndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information Please Print Legibly
Business/Organization Name: • M. Pc. �j � V-1�,
Address: 377 AJor-ff,
Are you an employer? Check toe appropriate box:
1. [ I am a employer with i 13ivf employees (full and/
orpart-time).*
2. ❑ 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. ElWe are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp: insurance req.l
meM J5bg'-35q- Z'E� Z.Z
Business Type (required):
5. ❑ Retail
6. ❑Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ® Non-profit
9. ❑ Entertainment
ME] Manufacturing
I L[] Health Care
12.❑ Other
---
'Any applicant that checks box #I must also all out the section below showing thweir workers' compensation policy information.
''If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensmien policy is required and such an
organization should check box# I.
I am an employer that Is providing workers' coanpensailoit insurance for atyemployees, Below is file policy information.
Insurance Company Name: B& r Mtn t,rL V'ct, Irl"A ),:L2 t �i )6X"K-> Insurer's Address:)r) k4e, \k,,\, 5 `�l 5U.f'�->�-� i��iC9ftJ,.t V �y� O_Qve� kji 3r , ti
Pr City/State/Zip: � cAo nn
n Iv` A C:31
Policy # or Self -ins. Lie. # Po AwC-06 3 51 q Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex iration 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 $250.00a 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 rto hereby cerlo, under the pales and penalties of perjury ilia/ Ale information provided above is trite and correct.
Officlat use only. Do not write lit this area, to be completed by city or town of/Ictal.
City or Town:
Permit/License
Issuing Authority (circle one):
t. Board of Health 2. Building Department 3, Cityfrown Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact
Phone #•
NOTICE
EMPLOYEES
IN
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:
AmGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
R2WC917990 02/10/2018 02/10/2019
POLICY NUMBER 1 Village Green North EFFECTIVE DATES
HOLLIS INSURANCE AGENCY Plymouth, MA 02360 508-209-0400
NAME OF INSURANCE AGENT ADDRESS PHONE #
M M A S INC 377 NORTH MAIN STREET MANSFIELD, MA 02048
EMPLOYER ADDRESS
01/17/2018
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 hospital 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 of the ser-
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
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