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Home My WebLink AboutCafe on the Common - 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: FOOD SERVICE 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:. DIANE BEATTY, PRESIDENT Whose place of business is: CAFE ON THE COMMON, INC. 12 SOUTH MAIN STREET PERSON(S) IN CHARGE: BILL FISHER & JIM PHIPPS, MANAGERS Permit Expires: June 01, 2010 License Number: FS-5 Food Fee: $75.00 Milk & Cream W 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: DIANE BEATTY, PRESIDENT having a place of business at: CAFE ON THE COMMON, INC. 12 SOUTH MAIN 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.: FS-5 Scott Lute, 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 FS-5 FOOD ESTABLISHMENT PERMIT APPLICATION (Annlirntinn must he submitted at least 30 days before the planned .», ra r� 1) Establishment Name: CAFE ON THE COMMON, INC. 2) Establishment Address 12 SOUTH MAIN STREET APR 3) Establishment Mailing Address (if different) 16 AUDUBON DRIVE By WALPOLE, MA 0208 1 4) Establishment Telephone No: (508) 339-9130 5) Applicant Name & Title: DIANE BEATTY, PRESIDENT 6) Applicant Address 16 AUDUBON DRIVE, WALPOLE, MA 02081 7) Applicant Telephone No.: H (508) 668-0231 24 Hour Emergency No.: (508) 668-0231 c (603) 817-6393 8) Owners Name & Title DIANE BEATTY, PRESIDENT 9) Owner Address (If different from applicant): 16 AUDUBON DRIVE, WALPOLE, MA 02081 10) Establishment Owned By: ❑ An Association ❑O A Corporation El An Individual ❑ A Partnership�t ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name p Title Address Oi/z�� /i � ' .IPht l d ,4kAf-a%evi 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: - Address: I�j -P Telephone No: 3 j 24 Hour Emergency No:� FAX: �%� �/Af W 13 13) District Or Regional Supervisor (if applicable) Name & Title: > . Address: Telephone No: I (G GCC n v))�� 3� 24 Hour Emergency No: ko FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 19 17) DAYS/HOURS: 7 DAYS 6 AM-3 PM FRIDAY UNTIL 9 PM 18) Name of Person In Charge Certified in Food Protection Management: WILLIAM FISHER JR If more than 3 individuals are certified, complete list is on file. RYAN BEATTY Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate JAMES M. PHIPPS 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): V 20) Location: W Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑� Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 0 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, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑d 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 PHF s For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Reheating of Commercially ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill 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 Customer Self -Service and Packaged for Retail Sale ❑ Juice Manufactured and Packaged Retail Sale I I I Offers RTE PHF in Bulk Quantities I Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ 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: $75.00 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 of 105 CMR 590.000 and the federal Fq9d Code. 24) Signature of Applicant: W7 ( /„ [//(a . I_t df Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties p( and paid state taxes required under law. 25) Social Security Number or Federal ID: 027-46-9164 `1 26) Signature of Individual or Corporate Name: N that I, to my best knowledge and belief, have filed all state tax returns 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 1 st of each year. NAME OF BUSINESS: CAFE ON THE COMMON, INC. ADDRESS: 12 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-9130 FAX NUMBER: (508) 660-9013 OWNER OF BUSINESS: DIANE BEATTY, PRESIDENT TELEPHONE OF OWNER: (508) 668-0231 FEDERAL ID/SS NUMBER: 027-46-9164 FEE: $2.00 PERMIT NUMBER: FS-5 SIGNATURE: �%� / G /� k%�01// r-l-'- DATE: q b t;oLo 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) 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. r 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 /i Please Print Legibly Business/Organization Name: I fit . �Q M /-7-7 pin Z r-\ C Address: I Av Phone #: Are you an employer? Check the appropriate box: Business Type (required): am a employer with P_ 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. g ❑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]* 4. ❑ We by 11.❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers',comp. insurance req.] 12.0 Other *Any applicant that checks box # 1 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 Insurer's Address: H00, M I,/[ (,' K 5e-ii- Lgl ,,t. l 2 e City/State/Zip: / 3`ll3 Policy # or Self -ins. Lic. # d (S tl/ S C._ ji/l\ I D, 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. I do hereby certify, under the pains and penahies,of perjury that the information provided above is true and correct. R 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 Person: Phone www,mass.gov/dia 12 (Policy Provisions: WC 00 00 00 A) 62 NK INFORMATION PAGE WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115 NCCI Company Number: 20605 Company Code: G POLICY NUMBER: 08 WEC NK6212 Previous Policy Number: 08 WEC NK 12 HOUSING CODE: DW Named Insured and Mailing Address: CAFE ON THE COMMON INC (No., Street, Town, State, Zip Code) 16 AUDOBON RD FEIN Number: 043552431 WALPOLE, MA 02081 State Identification Number(s): UxN: The Named Insured is: CORPORATION Business of Named Insured: RESTAURANT FAMILY STYLE: FRANC Other workplaces not shown above: 12-14 MAIN ST MANSFIELD MA 02048 2. Policy Period: From 04/01/09 TO 04/01/10 12:01 a.m., Standard time at the insured's mailing address. Producers Name: UNDERWRITERS INS BRGE INC/PHS 301 WOODS PARK DRIVE CLINTON, NY 13323 Producer's Cade: 088324 issuing Office: THE HARTFORD 301 WOODS PARR DRIVE suffix LARS RENEWAL 04 CLINTON NY 13323 (866) 467-8730 Total Estimated Annual Premium: $3 , 577 Deposit Premium: Policy Minimum Premium: $268 MA (INCLUDES INCREASED LIMIT MIN. PREM.) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized re resentative. " Countersigned by 02 /21l09 Authorized Representative Date Form WC QO QQ 01 A (1) Printed in U.S.A. Page 1 (Continued on ne page) Process Date: 02/21/09 Policy Expiration Date 04/01/10 ORIGINAL x o -i n pm m C pZ .n `9 Q i % 1 4 Vj i ( Z Z m C i m y m = m N� mud z x xi aQ 0 s THE NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES RYAN BRATTY aHAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR ll THE FOOD SAFETY MANAGER CERTIFICATION EXAMINATION President:--L-�22 1mvmnvv J. Lindl LIX ISSUE DATE: MAY 18, 2006 CERTIFICATE No: KB20018516 TFST FORM: KGB K 0 z m 4 pNp�� A Vw THE NATIONAL REGISTRY OF FOOD SAFE T Y PROFESSIONALS® CERTIFIES HAS SUCCESSFULLY SATISFIED THE RFQuiRemEry T S FOR THE FOOD SAFETY MANAGER CERTIFICATION EXAMINATION President lm+�eocr J. P.tinrl� ISSUE DATE: MAY 18, 2006; CERTIFICATE No: KB2001851 01 TEST FORM: KBBI THE NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALSO CERTIFIES HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER CERTIFICATION EXAMINATION r /zo- 1. !'resident wWmn1.!'Inch ISSUE DATE: APRIL 25, 2000 CERTIFICATE NO: KB2001 1487 TEST FORM: KBB: 'ITh,.,Wc,m h eel wlid for mwe a !�aQeoop j THE NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® � w O - - - CERTIFIES SARAH VIEIRA RTIFlB HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR ':uparcwwe THE FOOD SAFETY MANAGER i CERTIFICATION EXAMINATION 21 sue# 1 .... President: Zsfi 41 try�aPFned SnPe��nfa£amnnis i 1mrmlcc J./jwh 9$yviYon�he)tinl'fCpplt� TeFitnBilt,' ISSUE DATE: APRIL 25, 2006 ' ( CERTIFICATE NO: KB2001 1486 Trctr FORM' KBB