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HomeMy WebLinkAboutBlockbuster Video - 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:. Fl:13CTl1A7io7:Wi7§T1�I#7 Whose place of business is: BLOCKBUSTER VIDEO 242 CHAUNCY STREET PERSON(S) IN CHARGE: DAN MARCOTTE, MANAGER Permit Expires: June 01, 2010 License Number: S-20 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-20 FOOD ESTABLISHMENT PERMIT APPLICATION Mnnlirntinn must he .cuhmitted at least 30 days before the planned ooenina date) 1) Establishment Name: BLOCKBUSTER VIDEO 2) Establishment Address 242 CHAUNCY STREET 3) Establishment Mailing Address (if different) 242 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 337-9422 5) Applicant Name & Title: MANSFIELD VIDEO, INC. DBA BLOCKBUSTER VIDEO 6) Applicant Address 242 CHAUNCY STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 337-9422 24 Hour Emergency No.: (04.W64727-PAIMR C10IZS-73..e 8) Owners Name & Title JERRY JORGE, OWNER 9) Owner Address (If different from applicant): 65 ROCKRIDGE ROAD, LINCOLN, RI 02865 10) Establishment Owned By: ❑ An Association W A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address e� r y a. ;L I��as ��a E G,5 " i / "'1 �(. /, ,ed�� d T. Ca ) > )Zd, JinCJlyI 2,- doh old'Riyer 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) rC S pk6 5 Name & Title: _ ��.e,w. Address: v Telephone No: 5 % �� y 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 1 17) DAYS/HOURS: s-s 10 AM - 10 PM Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: A I� 18) Name of Person In Charge Certified in Food Protection Management: IjF1 If more than 3 individuals are certified, complete list is on file. f j 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): ❑ 0/14 20) Location:❑ Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑; Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑d Retail ( 5,600 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $75 ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution Meals/Day) Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 ❑ Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: Residential Kitchen $25 Retail Food $50 Retail Snack Food $10 Tobacco Products No Fee 23) Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHF's - non -potentially hazardous lood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) ❑ 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 ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly r, ,.. - Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: — $10.00 Payment is due with application ❑ 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 pJ 105 CMR 590,000 and tiny federalfood Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under )he penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3507346 26) Signature of Individual or Corporate Name: III Cvvxg F' e i that I, to my best knowledge and belief, have filed all state tax returns PO The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AmAicant Information // Please Print Legibly Business/Organization Name: (1 iartbFi c.l� V l dc19 tTi�C./a��/dCKBus�x�V Phone Are you an employer? Check the appropriate box: Business Type (required): 1.K I am a employer with employees (full and/ 5. gRetail 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 e. I52, §1(4), and we have 10.❑ Manufacturing 4. ❑ no employees, [No workers' comp. insurance required]* We by I L ❑ Health Care are a non-profit organization, staffed volunteers, with no elrDlovees. rNo workers' coma. insurance reD.l 12.0 Other *Any applicant that checks box HI 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 N 1. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Insurer's Address: C /— (' ,2 vA e `r City/state/zip: H"v, C o•�e� 1 C4- 06 l F3 - IM F Policy # or Self -ins. Lic. # j iy C> 0=' 7*7 M -�Z9 Fl Expiration Date: Zh 0 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 I do hereby certify, under the pains and penalties ofperjuty that the Official use only. Do not write in this area, to be completed by city or town officlal City or Town: 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 www.mass.gov/dia Phone Apr 22 2009 1:39PM HP LHSERJET FAX p.2 A`CP CERTIFICATE OF LIABILITY INSURANCE 4 22/05 PRooucEa Durcan-Cuddy Insurance Agency 5 Man Mer Drive Plainville, MA 02762 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Hudson Video, Inc. 65 Rockridge Road Lincoln, RI 02865 INSURERA Travelers Insurance INSURER D. INSURER INSURER Q � INSURER E THE POLICESOF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE NSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY COWRACT OR CTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAJDCLAIMS. TwencauxnRAurs POLICY NUMBER VE EXPIRA OATEIMMID __. LIMITS GENBRALUASIUTY EACH OCCURRENCE _ S COMMERCIAL GENERAL LIABILITY CIAMS MADE ❑OCCUR D GE TO RENTED nee WED EXP§Aryaw Paem) i i PERSONALS ADV INJURY S GENERAL AGGREGATE _ i GEN'LAGGREGATE LMITAPPUESPER POLICY M FR LOC PRODUCTS -OOMPMP AGG i AUTOMOBILEDABUTY ANY AU'10 COHWINEDSNGLELBIB (EeeaideR) $ ALLOVMEDAUTOS SCHEWLEDAUTOS BODILY INJURY $ HIREDAUTOS NQNIC PEDAUTOS BODILYINJVRY (PaTeceidenQ S PROPERTYDAMAGE (Peracdden,J S GARAGELMAMUTY AUTO ONLY• EA ACCIDENT S OTHER THAN EAACC B ANYAUTD S AUTOONLY: AGO IUMBRELLADABIDTY EACH OCCURRENCE SN CUR CLAS MADE FIETENT" AGGREGATE S DUCTIBLE A WORKERS COMPENSATION AND BHPLOVERS' LIABIL"Y ANYPROPRIEMISFARTNEREXELUTWE Y� OFFICERMEhWER EXCLUDED? IKUB-0577M29-8-09 2/18/09 2/18/10 X. VdC 6TATU- OTH• E.L.EAOHACpOEM $ 1Q0 00Q E,L.OISEASE-EAEWPL YE i 100,000 fftntieloMIn NH) E yes deecrlunder E.L. DISEASE- POLICYLIMIT i 500 OOD ades SPECIAL PROVISIONSbel OVER DESCRIPTION OF OPERATIONS I LOCA71ONS I VEHICLES /EXCLUSIONS ADDEDErY ENDOR9FMEHTI SPECIAL PROVISIONS CERTIFICATE HOLDER r.ANrla I ATIned SHOULD ANYOFTHEASOVE DESCRIBEDPOLICIESBECANCELLEDBEFORE THE EXPIRATION DATE THEREOF, THE 188UNGIra IAER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Mansfield Board of Health NOTICE TO7HE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Attn : Insurance Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND WON THE I URER ITS AGENTS OR 6 Park Row REPRESENTATIVES. Mansfield, MA Q2048 AUOIORIUD REPRESENTATn'E Carole Simons ACORD 2b (2009f01) _ ©7988 00 E RD CO RATION, All rights reserved. The AC ORD name and logo are registered marks of AOO RD 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. r'11 cL1 Fi � j G V' Jeo 0 —Vg c * Signature of Individual or Corporate Name (Mandatory) By: Corporate 0�1 erf (Mandatory, if applicable) Uy- 3fO 73 y� ** 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.