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Home My WebLink AboutNorth Easton Savings Bank - 7/14/2009Commonwealth 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: MOBILE TEMPORARY 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:. NORTH EASTON SAVINGS BANK Whose place of business is: NORTH EASTON SAVINGS BANK 20 EASTMAN STREET PERSON(S) IN CHARGE Permit Expires: ,July 14, 2009 RAIN DATE 7/15/2009 License Number: MF-16T Food Fee: $0,00 BOARD F, HEALTH f._/ 4i/ Dr. aym nd Martin, Chairman FOR BOARD OF HEALTH USE ONLY [Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION picaion�be submit e a least ays efdrb-the p ann�g date) 1) Establishment Name: North Easton Savings Bank 2) Establishment Address 20 Eastman Street South Easton, MA 02375 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 508-238-2007 5) Applicant Name & Title: Courtney N. Palm , Marketing Officer 6) Applicant Address 20 Eastman Street South Easton, MA 02375 7) Applicant Telephone No.: 508-238-2007 24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant): 10) Establishment Owned By: Cl An Association El A Corporation 0 An Individual A Partnership 11 Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address it) reracn uuecuy rtespunmuie rut Udny vNciauuns kuwnci, Nni suit in ui iai yc, sUpul vwui, inaiiayci cu../ 13) District Or Regional Supervisor (if applicable) 14) WATER SOURCE: DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: 16) No. of Food 17) DAYS/HOURS: July 14, 2009 6-9 P.M. 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: [] Permanent Location 22) Establishment Type Moblie Moblie Start Date: 07/14/09 ] Retail ( Sq. Ft) Moblie End Date: 07/ 14/09 ] Food Service up to 100 or Moblie Comments: up to 10' PHF display $75 21) Length of Permit: Annual 07/14/09 Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ] Food Service up to 101 -200 or up to 25' PHF display $100 0 Food Service up to 201 + or 25'+ PHF display $125 ] Food Service - Institution Meals/Day) [] Bakery $25 ] Caterer $25 ] Food Delivery $25 0] Milk & Cream $2 Mobile Food & Consession $50 Mobile Food Temporary $25 Ei Manufacture Frozen Desserts/Ice Cream $5/freezer i] Pushcart $25 # of Pushcarts: Residential Kitchen $25 I] Retail Food $50 R] Retail Snack Food $10 Tobacco Products No Fee 23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ] Hot PHF Cooked and Cooled or Hot Held --- -- for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs Preparation of PHFs For Hot And -- - ----- Cold Holding For Single Meal Service ] PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _ _-....__ Susceptible Population Facility --- ------------ E] Sale of Raw Animal Foods Intended 0 Reheating of Commercially to be Prepared by Consumer 0 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _ ... __ _.... _._..-... ........._ __..__— - ------ ❑} Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health Ice Manufactured and Packaged for Preparation of Non-PHFs Retail Sale control) Other Food Operations I] Juice Manufactured and Packaged for C] Offers Raw Or Undercooked Food Of r Retail Sale Animal Origin Snacks purchased from BJ s --- in Taunton, MA to be given ] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for out at Family Fun Night - 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: - Payment is due with application t the ]waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm thafood 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 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: 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: 26) Signature of Individual or Corporate Name: 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 (Mandatory) Corplate Officer (Mandato.. . - ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N Eastman Street North Easton Savings Bank City/State/Zip: South Easton, MA 02375 Phone #: 508-238-2007 Are you an employer? Cheek appropriate box: Business Type (required): /t�he/ 1. �1 am a employer with � 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. $. ❑ 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, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.['Other2 t )'o &!i& &A with no employees. [No workers' comp, insurance req.] .) *Any applicant that checks box Nl must also fill out the section below showing their workers' compensation policy informinion. **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 Nl. I am an employer that is providing workery,' compensation Insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: VI U r I U UL;,� /I, Policy # or Self -ins. Lic. # 1f�p'D �'2� "( w�_ Expiration Date: 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify, under the pains ap4pepalties ofperjury that the information provided apove if true and correct Official use only. Do not write in this area, to be completed by city or town offtcial 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 Phone www.mass.gov/dia One Beacon. Workers Compensation and Employers Liability s l R AN c F Insurance Policy OneBeacon Insurance Company 1 Beacon Lane Canton, MA02021-1030 Information Page ;332-7000 Rewrite of No. NCCI 11 10359 Renewal of No. 406 - 0 1 - 6 1 - 22 - 000 1 Policy Number: 406-01-61-22 -0002 Item 1. INSURED. The Insured and Mailing Address: ID# NORTH EASTON SAVINGS BANK FEIN 041677530 PO BOX 299 NORTH EASTON, MA 02356-0299 Other workplaces not shown at left: SEE G1690B ❑INDIVIDUAL ❑ PARTNERSHIP P9 CORPORATION ❑ OTHER Item 2.POLICY PERIOD. From: March 24, 2009 To:March 24, 2010 INSURE01 M.MANINGADRDARD EATTHE 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 Iistedhere:SEE G1690B o. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The Limits of our liability under Part Two are: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $ 500 . 000 each accident $ 500 , 000 policy limit $ 500 , 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except North Dakota, Ohio, Washington, Wyoming and states designated in Item 3.A. of the Information Page. D. This policy includes these endorsements and schedules: SEE G1690B SCHEDULE OF ENDORSEMENTS Item 4. PREMIUM. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rarino Plana All information reouired below Is subiectto verification and change bV audit. Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium See Extension of Information Page 5 , 468 . OC 3 3 8. O C Expense Constant Charge Minimum $183 (MA) Interim Deposit Total, $51 806.00 Premium Adjustments Premium Estimated Cost Representative Agent or Broker SMITH BUCKLEY & HUNT INSURANCE Address 500 FOREST AVENUE BROCKTON, MA DATE OF ISSUE: ENN 02/ 10/09 02301-5749 SERVICING OFFICE: MASSACHUSETTS LJ This is a Three Year Fixed Rate Po icy RENEWED BY POLICY NUMBER CAD W Countersigned by d R t t' Date Aulhonze emesen a rve 4Q 4419f-1 (07 99) Copyright 1987 National Council on Compensation Insurance WC 00 00 01113 (NJ) WC 00 0001A INSURED