HomeMy WebLinkAboutBenny's - 6/1/2010Commonwealth 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: SNACK
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:.
BENNY'S OF MASS, INC.
Whose place of business is:
BENNY'S OF MASS
65 COPELAND DRIVE
PERSON(S) IN CHARGE:
VICTOR POLUBINKSI, STORE MANAGER
Permit Expires: ,June 01, 2010
License Number: S-30
Food Fee: $10.00
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
S-30
FOOD ESTABLISHMENT PERMI I APPLIUA I IUN
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1) Establishment Name: BENNY'S OF MASS
2) Establishment Address 65 COPELAND DRIVE
3) Establishment Mailing Address (if different) 65 COPELAND DRIVE p
MANSFIELD, MA02048 APR a
'Z009 D
4) Establishment Telephone No: (508) 339.6027
5) Applicant Name & Title: HOWARD BROMBERG, PRESIDENT By
6) Applicant Address 340 WATERMAN AVENUE, ESMOND, RI 02917
7) Applicant Telephone No.: (401) 231.1000 24 Hour Emergency No.:
8) Owners Name & Title BENNY'S OF MASS, INC.
9) Owner Address (If different from applicant): 340 WATERMAN AVENUE, ESMOND, RI 02917
10) Establishment Owned By:
❑ An Association
O A Corporation
❑ An Individual
❑ A Partnership
❑ Other legal Entity
11) If a corporation or partnership, give name, title, and home address
or partner.
Name Title Address
Jr
7=l 4-423Y-0 zw-V'o-V"'- �
of officers
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191 Pmmnn Directly Responsible For Dailv Operations (owner, person in charge, supervisor, manager etc.)
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Name & Title:
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Address:
Telephone No:
fi24 Hour Emergency No: y,, J _ 2 -
FAX:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: TOWN P15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 6) NO. Of Food Employees:
17) DAYS/HOURS: 9 AM-9 PM MON-SAT 9 AM-5 PM SUN
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): ❑ �ii
20) Location: ❑J Permanent Location
22) Establishment Type
❑ Bakery $25
❑ Mobile Mobile Start Dale:
[-Retail ( Sq. Ft)
❑ Caterer $25
Mobile End Date:
❑ Food Service up to 100 or
❑ Food Delivery $25
''..
Mobile Comments:
up to 10' PHF display $75
❑ Milk & Cream $2
21) Length Of Permit:
❑ Food Service up to 101 -200
❑ Mobile Food & Consession $50
W Annual
or up to 25' PHF display $100
❑ Mobile Food Temporary $25
El Seasonal
❑ Food Service up to 201 +
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
or 25'+ PHF display $125
Seasonal Dates:
❑ Pushcart $25 # of Pushcarts:
❑ Food Service - Institution
❑Residential Kitchen $25
El Temporary
Temporary Start Date:
( Meals/Day)
❑ Retail Food $50
Temporary End Date:
W Retail Snack Food $10
Temporary Time:
❑ Tobacco Products No Fee
Rain Date:
23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required)
Nan-PHF's - 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)
OV Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs Susceptible Population Facility
❑ Sale of Raw Animal Foods Intended
❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
�] Customer Self -Service of Non PHF and Non-
❑ Use of Process Requiring A Variance
❑d Customer Self -Service 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
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food Board of fh-�
—" $10.00
=isdue
lica waived
I, the undersigned, attest to the accuracy of th
for tion provided in this application and affirm that the food
establishment operation will comp) ;with 105
R O.g00 and all other applicable law. I have been instructed by the
board of health on how to obt i opies of 1 C
5�0.000 and the federal Food Code.
24) Signature of Applicant:� �*i .—�7Z
Pursuant to MGL Ch.62C, e �49A, I certify under the pens ies of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes regY red under law.
25) Social Security NunVber or Federal ID: 05-0299803
9ZIAN
26) Signature of Individual or Corporate Name:
551 In c--
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: BENNY' S of MASS INC
Address: 65 COPRLANO DRIVE
City/State/Zip: MANSFIELD, MA Phone #: (508) 339-6027
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. M 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 (me]. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10,0 Manufacturing
no employees. [No workers' comp, insurance required]* l 1.❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers'.comp. insurance req.] 12.0 Other
*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 # I.
I ape an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Argonaut Insurance
Insurer's Address: c/o AON Risk Services Inc of Rhode Island
City/State/Zip: 50 Kennedy Plaza, loth Floor , Providence, RI 02902-2392
Policy # or Self -ins. Lie, # WC47729824518 Expiration Date: April 1, 2010
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 D14 fopinsurance overage yefification.
I do hereby
Official use
City or Town:
pains
IQi[IDA:
that the
Do not write to this area, to be completed by city or town official
Permit/License
above 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.govidia
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.
J k1')/' S r '"os-x. /. �
* Signature of Individual or
Corporate Name (Mandatory)
** 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.