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Home My WebLink AboutBristol Liquors - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Snack Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. BOARD OF HEALTH 5d o 1 11_C._. e Whose place of business is: BRISTOL LIQUORS 670 EAST STREET License Number: S-48 Permit Expires: June 01, 2010 Food Fee: $10.00 Milk & Cream W Dr. Raymond Martin, Chairman Permit for the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: BRISTOL LIQUORS 670 EAST STREET License Number: S-48 Permit Expires: June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that. DAVID DIMARZIO having a place of business at: BRISTOL LIQUORS 670 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 No.: S-48 Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-48 FOOD ESTABLISHMENT PERMIT APPLICATION (Aoolication must be submitted at least 30 days before the planned opening date) 1) Establishment Name: BRISTOL LIQUORS 2) Establishment Address 670 EAST STREET 3) Establishment Mailing Address (if different) 670 EAST STREET MANSFIELD, MA 02048 D ( p b 4) Establishment Telephone No: (508) 339-3782 APRI Mn 5) Applicant Name & Title: DAVID DIMARZIO IBy 6) Applicant Address 120 COLLEGE ROAD, BRIDGEWATER, MA 02324 7) Applicant Telephone No.: (508) 697-2956 24 Hour Emergency No.: (508) 697-2956 8) Owners Name & Title DAVID DIMARZIO 9) Owner Address (If different from applicant): 120 COLLEGE ROAD, BRIDGEWATER, MA 02324 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 L1Avi D pA1. IVr 7 1 C' 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: , y� ;) << -fit 0 G� Cd Address: Telephone No: _ 24 Hour Emergency No: C) L� ( c 5 � ` r2 FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: -- Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: BRISTOL LIQUORS ADDRESS: 670 EAST STREET TELEPHONE AT LOCATION: (508) 339-3782 FAX NUMBER: (508) 337-2923 OWNER OF BUSINESS: DAVID DIMARZIO TELEPHONE OF OWNER: (508) 697-2956 FEDERAL ID/SS NUMBER: 04-2640834 FEE: $2.00 PERMIT NUMBER: S-48 SIGNATURE: DATE: ��.. m -! 1 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: Pv 17) DAYS/HOURS: MON - SUN 9 AM-10 PM 18) Name of Person In Charge Certified in Food Protection Management: r� If more than 3 individuals are certified, complete list is on file. 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): ❑ fJ� 20) Location: IS6 Permanent Location 22) Establishment Type ❑ Bakery $25 ❑ Mobile Mobile Start Date: V 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 ❑ Food Service up to 101 -200 [] Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: ❑d Annual or up to 25' PHF display $100 ❑ Mobile Food Temporary $25 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ 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) 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-PFHs ❑ 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 ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ 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- Customer Self -Service ❑Use of Process Requiring di Variance ❑ ❑ 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 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 conies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: {. f!Vr Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. that I, to my best knowledge and belief, have flied all state tax returns 25) Social Security Number or Federal ID: 04-264083411 /ft� 26) Signature of Individual or Corporate Name: h k(� rPL Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June Ist of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: BRISTOL LIQUORS LOCATION OF SALE OF TOBACCO PRODUCTS: 670 EAST STREET TELEPHONE AT LOCATION: (508) 339-3782 OWNER OF BUSINESS: DAVID DIMARZIO ADDRESS OF OWNER: 120 COLLEGE ROAD, BRIDGEWATER, MA 02324 TELEPHONE OF OWNER: (508) 697-2956 FAX NUMBER: (508) 337-2923 If a corporation or partnership, give name, title, and home address of officers or partner. FEDERAL ID/SS NUMBER: 04-2640834 PERMIT NUMBER: S-48 SIGNATURE: / S � � < DATE: fCry C i 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. tt4 a oG J e9fJ Cr1CNr Itvc- * Signature of Individual or Corporate Name (Mandatory) �44cs% Flo�i f'JEe By: Corporate Officer (Mandatory, if applicable) ** 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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:? 2 / S` i G+ a rfJ Elfii 7 / O " Address: C, 7n t-4 f '!:�T Are you an employer? Check the appropriate box: Business Type (required): 1.4 1 am a employer with _ !� employees (full and/ 5. [0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. B. ❑ 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. ElManufacturing 4. ❑ no employees. [No workers' comp, insurance required]* We by 11. ❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers'. comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also till 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 Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 DIA for insurance coverage verification. do hereby gceer}tify, under thepains and penalties of perjury that the information provided above is true and correct. Sitinatare: dl'(Z44-ems' r 40' a,2--'3c�a Date' 41 - 14- Official use only. Do not write in this area, to be completed by city or town official 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 www,mass.gov/dia Phone WORKERS COMPENSATION AND EMPLOYERS L'IABILITY INSURANCE CERTIFICATE =N INE,ORMATION PAGE RENEWAL AGREEMENT MA Retail Merchants WC Group Inc. 10 British American Blvd. Latham, NY 12110 (Carrier Code: 34355) 1. The Employer: Bristol Liquors Bristal Management Inc Mailing Address: 670 East St. Mansfield, MA 02048 Other workplaces not shown above: NO OTHER WORKPLACES FOR THIS POLICY Producer: Agent# 960 Association Benefits Ins Agcy Inc 210 Broadway, Unit 201 Lynnfield, MA 01940 Certificate #: 014005031741109 Prior Certificate #: 014005031741108 Fein: 042640834 Type of Business: Corporation Risk ID: 2. The certificate period is from 12:01 a.m. on I/O1/2009 to 12:01 a.m. on 1/01/2010 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part One of the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Coverage: Part Two of the certificate applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500.000 certificate limit Bodily Injury by Disease $ 100,000 each employee C. Other States Coverage: D. This certificate includes these endorsements and schedules: WCOOOOOOA(04/92) WC000310(04/84) WC000402(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200405(06/01) WC200601(06/92) 4. The contribution for this certificate 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. Classifications Code Contribution Basis Rate Per Estimated No. Total Estimated $100 of Annual -.' Annual Remuneration muneration Contribution SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution Minimum Contribution $ 624.00 220.00 Expense Constant $ 11 WC 00 00 01 A Issue Date: 1/08/2009 Countersigned by