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HomeMy WebLinkAboutCannan Fuels -6/1/20107 Commonwealth 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:. SAMEH KANAN Whose place of business is: CANNANFUELES 157 PRATT STREET License Number: S-77 Permit Expires: June 01, 2010 Food Fee: $10.00 Milk & Cream ❑ BOARD OF HEALTH 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: CANNANFUELES 157 PRATT STREET License Number: S-77 Permit Expires: ,June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-77 FOOD ESTABLISHMENT PERMIT APPLICATION (AppliCatipn must be submitted at least 30 days before the planned openino date) 1) Establishment Name: CANNAN FUELES 2) Establishment Address 157 PRATT STREET 3) Establishment Mailing Address (if different) 157 PRATT STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (509) 339-3317 5) Applicant Name & Title: SAMEH KANAN 6) Applicant Address 77 POND AVENUE #907, BROOKLINE, MA 02445 _ 7) Applicant Telephone No.: (517) 407-9977 (508) 824.1300 24 Hour Emergency No.: (617) 407-, n U 8) Owners Name & Title SAMEH KANAN F_ 9) Owner Address (If different from applicant): 77 POND STREET #907, BROOKLINE, MA § 5 10) Establishment Owned By: ❑ An Association PIA 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 r 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) 9 q-4 5 Name & Title: Address: 1 ycilA SN jj MA ct>^A 9 Telephone No: c 24 Hour Emergency No: sox �'� FAX: 5 of 33h OCI �S 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 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 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CANNAN FUELES LOCATION OF SALE OF TOBACCO PRODUCTS: 157 PRATT STREET TELEPHONE AT LOCATION: (508) 339-3317 OWNER OF BUSINESS: SAMEH KANAN ADDRESS OF OWNER: 77 POND AVENUE, #907, BROOKLINE, MA 02445 TELEPHONE OF OWNER: (617) 407-9977 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. Isc,Tv, e� CA C,\bo01' FEDERAL ID/SS NUMBER: 263898693 PERMIT NUMBER: S-77 SIGNATURE: / DATE: / la 0 /— � -/ — Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: M-F 6-9 SAT 7-9 SUN 8-6 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: 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): ❑ 20) Location: ❑d Permanent Location 22) Establishment Type ❑ Bakery $25 ❑ Mobile Mobile Start Date: A'fietail ( 'If✓7S 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: RJ Annual or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: t Meals/Day) ❑ Retail Food $50 Temporary End Date: [] Retail Snack Food $10 Temporary Time: 0 Tobacco Products No Fee Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-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 fudherprocessing) 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 ❑ 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 - Perishable Foods Only Other Food Operations Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale Juice Manufactured and Packaged t Retail Sale I ❑I Offers RTE PHF in Bulk Quantities I Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 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 be 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 of 105 CMR 590,000 aSO4he fe_dapI Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the I and paid state taxes required under law. 25) Social Security Number or Federal ID: 263898693 26) Signature of Individual or Corporate Name: of perjury that I, to my best knowledge and belief, have filed all state tax returns 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) 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 Annlicant Information Please Print Legibly Business/Organization Name one #: t50 0 — —3 tl � I Are yo" employer? Check the appropriate box: Business Type (required): 1. �1 am a employer with employees (full and/ 5. eRetail ,_ 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. 8, ❑ 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 10.0 Manufacturing no employees. [No workers' comp, insurance requ red]* 4. ❑ We by 11.❑Health Care are a non-profit organization, staffed volunteers , with no employees. rNo workers' comp. insurance req.j 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 #l. I am an employer that is provi ft workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 'bbp jn! f �t u YAn C 'c— k � t� 1 Insurer's Address: m ' Q 0.J \a O D?f10 City/State/Zip: McAnsj ^ 0 Li Policy # or Self -ins. Lic. # w 0 % 1-1 .I� a� T _ Expiration Date: G `IG 10 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_W,d penalties ofperjury that the information provided above is true and correct. Official use only. Do not ivrite 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 AGENTNUMBERI POLICY NUMBER /19• 11 WC 007-42-2178 GRANITE STATE INSURANCE COMPANY 13102 CANNAN FUELS PO BOX 13 TAUNTON, MA 02780-00o0 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 I.D# MA UI#: 013-66-0209-00 Member Companies of American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW VORK, N.V. 10270 LEWIS R GAMMONS INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS 328 BEDFORD STREET LIABILITY POLICY INFORMATION PAGE P 0 BOX 1235 LA EVILLE. MA 02147-0000 INSURED IS PREVIOUS POLICY NUMBER S-CORP I NEW OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD Met AM. standard time at the insured's mailing address FROM 02/14/09 To 02/14/10 ITEMS A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed In Item &A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM4 The premium for this policy 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. Estimated Total Rate Per Estimated Classifications Code Number Remuneration © Annual ❑ 3 Year $100 OF Re, muneration Premium a Annual ❑ 3 Year SEE EXTENSION OF ITEM 4, OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $86 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) 8 MA MINIMUM PREMIUM $ 266 MA TOTAL ESTIMATED PREMIUM $ 1 , 71 9 If Indicated below, Interim adjustments of premium shall be made: ❑ Saml-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM 03/12/09 ASSIGNED RISK 66 Issue Date Issuing Office Representative WC 00 00 01