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Home My WebLink AboutFancheezical 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: XFINITY FOOD PERMIT 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:. NATHAN BROWN Whose place of business is: FANCHEEZICAL @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: NATHAN BROWN Permit Expires: December31,2018 Food Fee: $125.00 License Number: XFS-57 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit #Issued II FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name hi lk'c'LE 2) Establishment Address A-f � 5w,>,, A p 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 5) Applicant Name & Title: VA16— - 6) Applicant Address t 01T_L/d 7) Applicant Telephone No.; 24 Hour Emergency No.: ZI K, 1—/3 , if FLI 8) Owners Name & Title 9) Owner Address (if different from applicant) Owner's telephone number I I -1-0) Establishment Owned By: 1 _1) If a —corporation or partnership, give name, title, and home address of officers F1 An Association or partner. [AACorporation Name Title Address F�An Individual A Partnership _._J other JeqaLfjbtL____ _j 12) Person Directly Rpsponslble For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: * - ---- -W- Ad, dress: Telephone No., 24 Hour Emergency No; FAX: __ � . 0 E-mail: b 42? Alt-E-Mail: 13) District Or Regional Supervisor (if applicable) FName & Title: Address: Telephone No: 24 Hour Emergen FAX E-mail; Food Establishment Information 14) WATER SOURCE; 5�' A,t I M 15) SEWAGE DISPOSAL. Jw «u CEP Public Water Supply No: (If applicable) ,18) No Of Food Employees; 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: I If more than 3 individuals are certified, complete list is on file. I Requffed as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy or , catlirwale 19) Person Trained in An0-Choking Procedures (If 25 Seals or more): [.J 20) Location: ❑ Permanent Location 22) Establishment Type l [J Caterer $25.00 e-M;blie Mobile Start Dale: Retail ( Sq. Ft) [ �. Milk & Cream $10.00 Mobile End Date: rJ Food Service up to 100 or j^7, oblle Footl & Consesslon $75.00 Mobile Comments; up to 10' PHF display $125A0 [, Manufacture Frozen Dessertshoe Cream ,. ..._..__...._. ..__.._. 21) Length of Permit: [J Food Service up to 101 -200 $25.00/freezer ual Of up to 25' PHF display $150.00 D Pushcart $25.00 a of Pushcarts: Seasonal Food Service up to 201 t ❑Residential Kitchen $100.00 `- or 25'+ PHF display $275,00 Retail Food $100.00 Seasonal Dates: l Temporary [:J Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) I[ J Tobacco Products $25.00,. Temporary End Date: j Temporary Time: ' •: Rain Dale: _. _.-- _. __—.... _.__ .. I ' 23) Food Operations 0eMiffons PHF, Potentially hazardous food fllmeAumperemre commis mquireo) '(Check all that apply): Non-PHFs -non-polendoly hazardous/ood(no time4emperalure controls required) RTE- ready{Deal foods (Exsandwiches, salads, muffins which need no Nrtherprocessirg) Sale of Commercially Pre -Packaged Non-PHFs l Sale of Commercially Pre -Packaged PHFs �[J Delivery of Packaged PHFs I Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non. Perishable Foods Only I F J Preparation of Non-PHFs [J 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 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF end RTE Foods Prepared For Highly Susceptible Population Facility 17 Vacuum Packaging / Cook Chill [� Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, line as a public health '.. Other Food Operations CJ uu'�ce Manufaqured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF In Bulk quantities Prepares Foodt8ingle Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, out -of -Date ---- 1 or Reconditioned Food To be compreted by the Board o/Health Total Permit Fee: Payment is due with application [_ J waived _ I, the undersigned, attest to the accuracy of the Information provided In this application and ofhrm that the food eslabllshmenl operation will comply with 10¢ CMR 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain copies pf CMR 590,OpQand the federal Food Code. 24) Signature of Applicant: _ W JAv°�/ Pursuant to MOIL Ch.52C, sec. 49A. I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all stale tax returns and paid state taxes required under law, / 25) Snature of Number or Federal to: 28) Signature or Individual or Corporate Name: k.tt�u Vt 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. 1„ — Signat&e of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) *"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. o.�u..rr1.� �.,,,+. tw��..�..,i..\➢FRMI'1' APPLJCATIONS\TAX CERTV1CAT[ON FORKdoo E.�.iYrJ6'tH�`rv.+.a+..'++w:e4a�.'.turn.:,nn.OaLJYr�'Mn�A�:INIYJhiYGTA,curyyyLYY:.sA4Pna4rw.��^'++��'�"�^...w+e..•. The Commonlvealth ofMassachusells Department of Indlutrial Accidents p(J%e of Investigatlons Ulf 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dla Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please I Business/Organization Name: t'f .� Address:g _ 1� 1 �/ i u� L� l o V S c-4 ,4 '-V r, iti( U City/State/ZiD: Phone #_ Are you an employer" Check the appropriate box: ], am a employer withemployees (full and/ or part-time).* 2. ❑ I 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]' 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.1 Business Type (required): 5. 0 Retail &A Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales (incl, real estate, auto, eta) 8. 0 Non-profit 9. 0 Entertainment 10.0 Manufacturing 11.0 Health Care 12.0 Other •Any apph.tthat checks box 41 must also till out the seedon below showing MO workers' compensation policy information. •sif dw corporate officera have oxempled diemselves, but the corporation has other employers, s wmrken' compensation policy is required and such ea organvadon should check box N 1. ana I am an employer that Is Insurance Company Nam Insurer's 1-0 City/State/Zip: ( V -i - {��, ? 1 , Expiration Date: Policy # or Self -ins. Lic. # ��D —r }�-`-`�—� -- . Attach a copy of the workers' compensation policy deelaraGon page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 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. mfneria v that the Information provided above iv true and correct n. employees. Below is Ihepoltcy rnjorm I do hereby 0 Official use only. Am nor write In this area, to be coinpfeted by city or town official. Permit/License # City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, Cityifown Clerk 4. Licensing Board 5, Selectmen's Office 6. Other Contact Phone A��-��a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 05/01/2018 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 policy(ies) must be endorsed. If SUBROGATIONIS 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 endomement(s). PRODUCER CONTACT NAME: PHONE (877) 287-1312 INC, No, Ext): PAX (888) 443-6112 IAIQ No): PAYCHEX INSURANCE AGENCY INC/PAC 76250881 EMAIL 150 SAWGRASS DRIVE ADDRESS: INSURERIS) AFFORDING COVERAGE NAIC# ROCHESTER NY14620 INSURERA: The Hartford Accident and Indemnity Insurance 22357 Company INSURED INSURER B : NATHANIEL S"BROWN DBA FANCHEEZICAL- INSURERC: PANNIS & WEENIES INSURERD: 531 WILBUR AVE # B INSURERE; SWANSEA MA 02777-2125 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. WISH LTR TYPE OF INSURANCE ADDL INSR SUB Me POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDANNY LIMITS COMMERCIAL GENERAL LIABILITY RRENCE $ CLAIMS MADE ❑OCCUR RENTED a NTED ncey $ one person) "OU ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GREGATE $ POLICY ❑PRO ❑LOC ECT -COMPIOP AGG $ $ OTHER'. AUTOMOBILE LIABILITY CO eBINED SINGLE LIMIT flF.ANY $ BODILY INJURY (Per person) $ AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE (Per acdtlenl) $ HIRED AUTOS NON -OWNED AUTOS UMBRELLq LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' YIN X 10 - STATUTE ER $ E.L. EACH ACCIDENT $ 100,000 A ANY PROPRIETORRARTNERIEXECUTIVE EXCLUDED? OFFICER/MEMBER EXCLUDED'! NIA 76 WEG AA1UT7 04/17l2018 04l17/2019 E.L. DISEASE -EA EMPLOYEE $ 1QQ,000 (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below I $ $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be aflachetl If more space Is requlretl) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION FOR INFORMATIONAL PURPOSES ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 531 WILBUR AVE # B EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SWANSEA MA 02777-2125 AUTHORIZED REPRESENTATIVE I J'Ccea/l cc C�taiu�> ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD z a, O m Q Z- " X W C u o O v X Q c V d .2 _ w U 3 d m K m J W N N N z °i in uo .G .0 0...' 2 0 U 0 0 qc0 0 w v tl � tl a w „ c 42 W ti tl `L � 4" Fv. �' Bank N Pkt# TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: BOARD OF HEALTH - FOOD PERMIT Date. 5-23-201$ Schedule JED 52318 _ From Whom Account Number Amount _ NATHAN BROWN 01512A45006 ` $125.00:.: _ I Cash $ 125oo Checks $ Total $ 125.00 Online or Wire Receipt $ ---- TOTAL: $ 125.00_:_.. Mansfield, MA 5-23-2018 To The Officer Makin the Payments: The above is a detailed list of moneys collected by me, amounting in the aggregate to $ 125.o0 I for the period ending-23-2018 which I have paid to the Town Treasurer whose receipt I hold therefor. . ----- / I "A Employee or Dept Head FOR BOARD OF HEALTH USE ONLY permit #issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned . opening date) 1) Establishment Name Fei 2) Establishment Address Go Av_� x 1 3) Establishment Mailing Address (if different) I 4) Establishment Telephone No Z. I 6) Applicant Name & Title: 6) Applicant Address 0 t -c/d 7) Applicant Telephone No.; 24 Hour Emergency No.: 8) Owners Name &Title 9) Owner Address (if different from applicant) Owner's telephone number 10) Establishment 11) If a corporation or partnership, give name, title, and home address of officers 0 r An Association or partner. I I A Corporation Name Title Address FTA—n Individual F]APartnership -.-IQther JegaLEWty_____ ........ ... 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Gti IV. — A A, /I- A -7 -7-vt Telephone No: FAX: A*lt E-Mail: 13) District Or Regional Supervisor (if applicable) FName & Title: Address: Telephone No: FAX: 24 Hour Emergency No: 24 Hour Emergency No: