HomeMy WebLinkAboutEqual Exchange - 9/20/2008TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD, MA 02048
PERMIT TO OPERATE A MOBILE FOOD TEMP 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:
DANIEL STEINBERG
Whose Place of Business is:
EQUAL EXCHANGE @ THE COMCAST CENTER
Permit expires September 20, 2008
License Number. MF-305T
Food Fee: $25.00
Milk & Cream: NO
BOARD OF HEALTH
�)ti� _ y
Dr. Raymond Martin, Chairman
Date Received
Date Inspected
ONLY
Approved By Permit # Issued
66
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
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1)Establishment Name:
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2 Establishment Address: �'� ��;..{.f,fJ
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3) Establishment Mailing Address (if different)
4) Establishment Telephone No!t
5) Applicant Name & Title: I I
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6) Applicant Address: `� 0 - � 4- r)
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7) Applicant Telephone No.: (w� }�4 i 7 40
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C ..3
i 24 Hour Emergency No.:. 6('7 ✓ l
b yy
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
❑ An Association
❑ A Corporation
❑ An I_qdividual
❑&41artnership
Other legal entity
WorvP( 0wthe) (00 yr, iJe
12) Person Directiv Responsible For Dailv Operations (Owner, person in charge, supervisor. Manaaer, etc.)
Name &Title:
SQPAe 45 wnf
Address:
Telephone No:
Fax:(y$
Emergency Telephone No:
6-1 35 q 64yq
13 District Or Regional supervisor if a licable
Name & Title:
Address:
Telephone No: Fax:
Food Establishment Information
14.) Water Source
15) Sewage Disposal
DEP Public Water Supply No: (if applicable):
16) Days and Hours of Operation:
17) No. of Food Employees
16) Name of Person In Charge Certified in Food Protection Management:
Required as of 1 CY112001 in accordance with 105
CMR 590. 009(A) Please attach cro
of cert/hcate
19) Person Trained in Anti -Choking Procedures (if 25 seats or more):
20) Location:
22) Establishment Type:
❑ Caterer
❑ Retail ( Sq. Ft)
❑ Food Delivery
❑ Food Service — ( ) Seats
❑ Residential Kitchen for Retail Sale
❑ nnanent V
�0 i7 d
❑ Food Service - Institution
❑ Residential Kitchen for Bed & Breakfast Home
Mobile (Dates)
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast
Establishment
❑ Frozen Dessert Manufacturer
Other (Describe)
21) Length Of Permit:
it) Ito Qk'lOry -kr'4 P,erl' n
(check one)
❑Annual
❑Seasonal/Dates
❑ Temporary/Dates/Times
(rH Cnps P{, SQ45 6X
P;t-Pa <Icu�fJ, lonel, tli
23) Food Operations:
Definitions: PHF—PoientiaV hazardous food "meliemperaturA onhols required)
(check all that apply):
Non-PHFs— non -potentially hazardous rood (no tlmeRemperalure controls required)
RTE
—rea -to-eat foods . Sandwiches, salads, muffins which need no ludher mcessin )
❑ Sale of commercially Pre-
❑ PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held for
Packaged Non-PHFs
More Than a Single Meal Service
❑ Sale of Commercially Pre-
❑ Preparation Of PHFs For Hot And cold
❑ PHF and RTE Foods Prepared For Highly
Packa ed PHFs
HoldingFor Single Meal Service
Susceptible Population Facility
❑ Delivery of Packaged PHFs
❑ Sale of Raw Animal Foods Intended to
❑ Vacuum Packaging/Cook Chill
be Prepared b Consumer
❑ Reheating of commercially
❑ Customer Self -Service
❑ Use of Process Requiring A Variance and/or
Processed Foods For Service
HACCP Plan (including bare hand contact
Within 4 Hours.
alternative, time as a public health control
❑ Customer Self -Service of Non
❑ Ice Manufactured and Packaged for
❑ Offers Raw Or undercooked Food Of Animal
PHF and Non -Perishable Foods
Retail Sale
Origin
Only.
❑ Preparation of Non-PHFs
❑ Juice Manufactured and packaged for
❑ Prepares Food/Single Meals for Catered
Retail Sale
Events or institutional Food Service
El Offers RTE PH in Bulk Quantities To be completed by the Board of Health
Other (Describe):
❑ Retail Sale of Salvage, Out-0O&Date or Total Permit Fee:
Reconditioned Food h Payment is due with application
I, the undersigned, attest tokie a of the information provided in this application and I affirm that the food establishment
operation will comply with 1C000 and all other applicable law. I have been instructed by the board of health on how to
obtain copies of 105 CMR 5�p 0 the federal Food Code.
24) Signature of
Pursuant to MGL Ch.62C, 9A, cer* under the penalties of
returns and paid state taxe equ un r law. tt ``
25) Social Securtty Number or Federal ID: b(l. 67. 6�6
26) Signature of Individual or Corporate Name:
BLANK FOOD PH!Wrr PPLICAYION
my best knowledge and belief, have filed all state
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.
d
Individual or Corporate Name By: Corporate Officer (Mandatory, iifApplicable)
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*"Social Security No. (Voluntary) orL5d_erqL
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:\HmIthVmds Documents\TAX CERTIFICATION FORM.doc
9L The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
�,fA Business/Organization Name: '��✓�t� I✓i«h"�2
So U :��j��U
,e'`)
n-L-)e>4_ 9,
23 1i
Phone #: —b — 3-3 6 y
Are you an employer? Check the appropriate box:
Business Type (required):
1. [Z I am a employer with 100 employees (full and/
5. [-]Retail
or part-time).*
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.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §I(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We by
1 I.❑ Health Care
are a non-profit organization, staffed volunteers,
with no employees. [No workers' comp. insurance req.]
12.ROther WOl-l4,e t- Owbr E,f Goo�eva�; ve
*Any applicant that checks box # I 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 policy information.
Insurance Company Name: It 1.1>°
Insurer's Address: O Coe- 5+. Nety Y,lf 0-Li0
City/State/Zip:
Policy # or Self -ins. Lie. # 106 _ l Z- Expiration Date: ` 12-9b i
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 o9�e-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250. a day a a the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigation o the D f surance coveraue verification.
I do hereby
and penalties ofperjury that the
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
is true and correct
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
www.mass.gov/dia
ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY
COMPANYTHE INSURANCE OF THE STATE OF PENNSYLVANIA
ii•
AGENT NUMBER POLICY NUMBER
•• • 1111 WC :• • i
1 1 18 11
`0 UNITEDDRIVE Member Companies of
50 UNITED DRIVE
dill
WEST BRIDGEWATER, MA 02379-0000 F American International
Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# 911452464•••• • .•••
TPA INSURANCE AGENCY, INC.
WORKERS COMPENSATION AND EMPLOYERS 10 NEW ENGLAND BUS CTR DR
LIABILITY POLICY INFORMATION PAGE ANDOVER, MA 01810-1096
INSURED IS
CORPORATION
PREVIOUS POLICY NUMBER
RENEWAL 001 68212
OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME AND ADDRESS SCHEDULE - wc9go6i0
ITEM 2
POLICY PERIOD 12:01 A.M. standard time at the insured's
mailing address FROM 03/01/08 TO 03/01/09
ITEM 3
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
CT MA ME MN NH NY OR VT WI
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 , 000,000
each accident
Bodily Injury by Disease $ _ 1 .000, 000
policy Limit
Bodily Injury by Disease $ 1 .000.000
each employee
C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here:
AK AL AR AZ CO DC DE FL GA HI IA ID IL IN KS KY LA MD MI NO MS MT NC NE NJ
NM NV OK PA
RI SC SD TN TX UT VA
ITEM 4
The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total
Rate Per
Estimated
Oassifications
Cade Number
Remuneration
FAnnual ❑ 3 Year
S100 OF Be-
muneratimi
Premium
Annual ❑ 3 Year
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES
$2,000
EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $ 18 MA
MINIMUM PREMIUM $875 NY TOTAL ESTIMATED PREMIUM $39, 029
If indicated below, interim adjustments of premium shall be made:
Semi -Annually LJ Quarterly
ENDORSEMENTS (FORM NUMBER)
01/07/08 PARSIPPANY
Monthly
SEE ATTACHED FORM SCHEDULE -
m
DEPOSIT PREMIUM
Issue Date
39967
Issuing ORice
Authorized Represent Wive wC 00 00 01
Town of Mansfield
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER
Board of Health
Dept: Board of Health
To the Departmental Officer making the Payment:
for the period
Collections as per schedule of this date, filed in my office
TOWN OF SFIELD
PAID
SEP 19 2008
Receipt of �� C
Treasurer