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HomeMy WebLinkAboutFamily Food Mart 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:. PRANAVKUMAR PATEL Whose place of business is: FAMILY FOOD MART DIVYA AKHAND JYOIT CORP. 660 EAST STREET License Number: FS-25 Permit Expires: December 31, 2018 Food Fee: $125.00 Milk & Cream VI BOARD OF HEALTH MichaeC.McCCean, 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: FAMILY FOOD MART DIVYA AKHAND JYOIT CORP. 660 EAST STREET License Number: FS-25 Permit Expires: December 31, 2018 BOARD OF HEALTH Michae[McCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health j License to Sell Milk and Cream This is to certify that: PRANAVKUMAR PATEL having a place of business at: FAMILY FOOD MART DIVYA AKHAND JYOIT CORP. 660 EAST 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-25 Board of Health NichaeCNcCCean, 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-25 ---- - -- --- - -- - - -- -- . -- -- --- - - _-. --------- FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned WeniQg date, , 1) Establishment Name FAMILY FOOD MART DIVYA AKHAND JYOIT CORP; $ I' 2) Establishment Address 660 EAST STREETj :;OCT2017 3) Establishment Mailing Address (if different) 660 EAST STREET— MANSFIELD MA 02048 4) Establishment Telephone No (508) 339-2689 5) Applicant Name & Title PRANAVKUMAR PATELISECRETARY 6) Applicant Address 172 NORTH MAIN STREET, APT. 4, MANSFIELD, MA 02048 7) Applicant Telephone No.: (774) 581-6424 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: (774) 581-6424 PRANAVKUMAR PATEL (774) 581-6424 101 Establishment Owned By. 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. 'i A Corporation Name Title Address C_' An Individual I I A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IPRANAV PATEL Address: I172 NORTH MAIN STREET, APT. 4, MANSFIELD, MA 02048 Telephone No: (508) 339-2689 24 Hour Emergency No: (774) 581-6424 FAX. E-mail: PRANAVSARIKA@YAHOO.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: FAX: - - E-mail: 24 Hour Emergency No: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 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 10/1/2001 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: ] Permanent Location ❑ Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑� Annual ] Seasonal Seasonal Dates: i] Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type L I Retail ( 2,500 Sq. Ft) [] 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) --� Manufacture Frozen Desserts/Ice Cream -� $25.00/freezer Rain Date - - ----- ---- _._ 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) Sale of Commercially Pre -Packaged Non-PHFs [) PHFCooked To Order [ Hot PHF Cooked and Cooled or Hot Held �-I Co ------- - - -- ---- ----- ------ for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs [ _] Preparation -of PHFs-For Hot And 9 _ ----------- ------ Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility -.- -- ------ ------1 El Sale of Raw Animal Foods Intended I .I Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging f Cook Chill Processed Foods for Service Within 4 Hours -- _-- — Customer Self Service of Non PHF and Non- _ --- -- ----.- __ - I Customer Self -Service I_. 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 Preparation of Non-PHFs Retail Sale control) Other Food Operations i. _� Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin I I 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 J or Reconditioned Food - - — To be completed by the Board of HeaRh ---- _-- Total Permit Fee: $125 00 Payment is due with application LJ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of ] 05iMR/590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I ce and paid state taxes required under law. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 461-31-4451 26) Signature of Individual or Corporate Name: r FAMIF01 OP ID: TIL ,4coR0` ITYM CERTIFICATE OF LIABILITY INSURANCE DA10125/TE D017 10/25/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer ri ht$ to the certificate holder in lieu of such endorsements). PRODUCER 508-947-1818 J.K. Olivier! Ins. Agency 64 East Grove St. Middleboro, MA 02346 Kenneth W. Olivier! fiRr,cT Kenneth W. Olivieri PHONE 5pg_gg7_igig FAX A/c No, Ext : A/c, No): E-p AIL INSURERS AFFORDING COVERAGE NAICt INSURER A: Guard Insurance INSURED Family Food Mart Divya Akhand Jyolt Corp 660 East Street INSURER B : INSURER C : INSURER D: Mansfield, MA 02048 INSURER E : INSURER F : IRFVISION NUIsII GOVhHAUlzj CER11FICA, GRVnmU : 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. INSfl A TYPEOFINSURANCE. COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X Business Owners DDL UBR POLICYNUMBER DIBP825533 POLICY EFF 05/12/2017 POLICY UP 05/12/2018 LIMITS EACH OCCURRENCE $ 1,000,000 DAMAGES ERENTED o $ 50,006 MED EXP An one Purser)$ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ jE�T LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGO 2,DOO,000 $ OTHER: AUTOMOBILE LIABILITY EOMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Per rson $ OWNED TU ONLY AUTOS LED X HIRED X NOWOWNED AUTOS ONLY AUTOS ONLY BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ UMBRELLAUAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMSWADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE � FFICE Ory In NH) EXCLUDEDP If yas,deem suntler DESCRIPTION OF OPERATIONS below A N/A DIWC875175 04/15/2017 04/15/20LB X PER OTH- EL EACH ACCIDENT 50D,000 $ E.L DISEASE -EA EMPLOYE 56D,DD6 $ E.L DISEASE - POLICV LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 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 Mansfield, MA 02048 AUTHORIZED �REPRESENTATIVE 25 (2016/031 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks or Acutlu 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: FAMILY FOOD MART DIVYA AKHAND JYOIT CORP. ADDRESS: 660 EAST STREET TELEPHONE AT LOCATION FAX NUMBER: OWNER OF BUSINESS (508)339-2689 PRANAVKUMAR PATEL TELEPHONE OF OWNER: (774) 581-6424 FEDERAL IDISS NUMBER: 461-31-4451 FEE: $10.00 PERMIT NUMBER: FS-25 SIGNATURE: DATE: 10 Id ti Town of Mansfield Town gf'Hunsfeld - Board of Health 6 Park Row Mansfield, MA 02048 PERMIT NUMBER: FS-25 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: FAMILY FOOD MART DIVYA AKHAND JYOIT CORP. LOCATION OF SALE OF TOBACCO PRODUCTS: 660 EAST STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 339-2689 OWNER OF BUSINESS: ADDRESS OF OWNER: PRANAVKUMAR PATEL 172 NORTH MAIN STREET, APT-4, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (774) 581-6424 FAX NUMBER: (508) 339-2083 If a corporation or partnership, give name, title, and home address of officers or partner. Provide a copy of current Department of Revenue FEE: $25.00 CT-3T NUMBER: 1052332032 FEDERAL ID/SS NUMBER: 64-13-144§1 =3T Retail Excise Unit License. SIGNATURE: 4�----- -— DATE: �' L 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. 1)IJ-/A A 1< Hd) 1\4 9 J I o 17 GPa, 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. R:WnIthVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I 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. Applicant Information Please Print Legibly Business/Organization Name: DI V y A 4 j1, L) ll N -1) o I 1 coo 0-0 Address: 6,00 , E—a1 1 S 1 02'11 � Phone#: j0`s- 33'1 '.z 6 Are you an employer? Check the appropriate box: III I am a employer with ___ 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 req.] Business Type (required): 5. [] Retail 6. Restaurant/Bar/Fating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) S. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11,E] Health Care 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing theirworkers' compensation policy information. **If the corporate ogee" have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box ft 1 am an employer that is providing workers'compensation U ion insurance for my employees. Below is the policy information. Insurance Company Name: -lkit hi e •Y`qW*i +-tZ-i� NV S ' +'•^8 insurer's Address: P 9' x 'A "1-1 , 16 . S�QI �/ S V " C.itv/Rtate/iin. W i I �x'es ^-Acl' Ye - PA - ) pO -7o 3 - 0 o2 c, Policy # or Self -ins. Lic, #- 010 C $ I � )') C Expiration Date: O Lt I Is IQ •3 ) 9- 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 thha paiins and penalties of perjury that the information providedabove is true and correct Signature: F�"(C J]__ Date: ),a l ^ h' n Of 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