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Home My WebLink AboutCat Man Cafe - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment 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:. STEPHEN I CERULLO Whose place of business is: CAT MAN CAFE 16 OLD COLONY WAY License Number: FS-7 Permit Expires: June 01, 2010 BOARD OF HEALTH Food Fee: $75.00 Milk & Cream ❑O ti. Dr. Raymond Martin, Chairman Permit_for the Sale of Tobacco Products J 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: CAT MAN CAFE 16 OLD COLONY WAY License Number: FS-7 Permit Expires: June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 License to Sell Milk and Cream This is to certify that: STEPHENJ.CERULLO having a place of business at: CAT MAN CAFE 16 OLD COLONY WAY 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 License No.: FS-7 Scott Ceite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Approved B Permit #Issued Date received: Date Inspected: y FS-7 FOOD ESTABLISHMENT PERMIT APPLICATION' 1) Establishment Name: CAT MAN CAFE 2) Establishment Address 16 OLD COLONY WAY 3) Establishment Mailing Address (if different) 16 OLD COLONY WAY D MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-0038 5) Applicant Name & Title: STEPHEN CERULLO 6) Applicant Address 19 WAMPUM ROAD, NORTON, MA 285.7712 24 Hour Emergency No.: (774) 219-1843 7) Applicant Telephone No.: (518 ) 8) Owners Name & Title STEPHEN J. CERULLO 9) Owner Address (If different from applicant): 19 WAMPUM ROAD, NORTON, MA rOAn blishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. ssociation Title Address NameQrporation C�vv�� 'lickwc"mVJM R�}tP�S� ' C o�7itndividual c rtnership Nv ❑ Other legal Entity — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: S Cle Telephone No: 24 Hour Emergency No: FAX: — 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 01M 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 10 17) DAYS/HOURS: 5:30 AM - 12 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Cv- rsN'a P� f M C-M pik"," `r 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): U 20) Location: 0 Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: Food Service up to 100 or up to 10' PHF display $75 Mobile Comments: 21) Length of Perm W Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ 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 t 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 of iiratbas: PHF - Potentially hazardous rood (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no lime/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations 0 PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, or Reconditioned Food Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill 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 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 590.0�00 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 043-57-6340 26) Signature of Individual or Corporate Name: 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: CAT MAN CAFE ADDRESS: 16 OLD COLONY WAY TELEPHONE AT LOCATION: (508) 339-0038 FAX NUMBER: OWNER OF BUSINESS: STEPHEN J. CERULLO TELEPHONE OF OWNER: (508) 285-7712 FEDERAL ID/SS NUMBER: 043-57-6340 FEE: $2.00 PERMIT NUMBER: FS-7 SIGNATURE: � Lv& DATE: sl�" y' k) I 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: CAT MAN CAFE LOCATION OF SALE OF TOBACCO PRODUCTS: 16 OLD COLONY WAY TELEPHONE AT LOCATION: OWNER OF BUSINESS: STEPHEN J. CERULLO ADDRESS OF OWNER: 19 WAMPUM ROAD, NORTON, MA TELEPHONE OF OWNER: (508) 285-7712 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. FEDERAL IDISS NUMBER: 043-57-6340 PERMIT NUMBER: SIGNATURE: _ AS - DATE: 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. �A�� GJXV * Signature of Individual or Corporate Name (Mandatory) Q J 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 nn Please Print Legibly Business/Organization Name: C*t C'lc lC cs L o Co,q Are you an employer? Check the appropriate box: 1. � am a employer with �_ employees (full and/ part-time)?* 2. ❑ I am a so a proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. rNo workers' comp. insurance req.] Phone #: / SO � 33 9 0 03 Y Business Type (required): 5. ❑ Retail 6. &a estaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other _ *Any applicant that checks box 01 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 lnsurancefor my employees. Below is the policy information. Insurance Company Name: ko skyy r qv-j .� Insurer's Address: 3o 0 ,- c5.,V 'Dj y'k 'e l `V t% City/State/Zip: Yh&55 --Vc 1 y31 Z5®_() 0►S '3�1ZO0 7 Policy # or Self -ins. Lic. # `J � _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 nmad p aalties ofperluty that the information provided above is true and correct. e;....�t„�,.. _JXA_1 � L , I (�Y,& Date: b y l) C1 Phone #: SV�? A,:�01 - 1703-� Official use only. Do not write in this area, to be completed by city or town offietal City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone www.mass.gowma ACORD CERTIFICATE OF LIABILITY INSURANCE OPID CR DATE IMMmOrr9 CATMA-2 03 25 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NorthStar Ins. Services, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 300 First Ave, Suite 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Needham MA 02494 Phone:781-431-2500 Fax:781-431-6134 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA U.S. Liability Ins_ Co. INSURER IS:Aa+eciaNa employers X.O. C.. Chamberlain Ave Enterprises db CCafe INSURER C: The Liquor Liability Joint 19 Wampum Road Norton HA 02766-1701 INSURER IF THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAW. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N*H RUBLTR NSRO TYPEOFINSURANCE POLICY NUMBER DATE M P@Vj ❑HITS C GENERALLIASILT X COMMERCIALGENERAL LIABILITY CLAIMS MADE ❑ OCCUR CLP1124989A 04/16/08 I 04/16/09 EACHOCCURRENCE $1,000,000 PREMISEEs E«wrnRa $ 100 000 MED EXP (Any m pms ) s5,000 PERSONAL A ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE'"MAPPLIESPER: ,PRO POLICY PRO LOC PRODUCTS-COMPMPAGG $2,000,000 A AUTOMOBILE LIABILITY' ANY AUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIRED AUTOS NONOWNEDAUTOS CLP1124889A 04/16/08 I 04/16/09 COMBINED SINGLE LtlIUT (Ee $1,000, 000 BODILY INJURY (Pm person) $ R BODILYWJURY (Per awdw) $ X PROPERTY DAMAGE (Pet QC d. ) $ GARAGE LWBILRV ANY AUTO AUTO ONLY -EA ACCIDENT $ OTHERTHAN EAACC AUTO ONLY: AGO $ $ I EXCESBAINBRELLALIAMUITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION S I EACH OCCURRENCE $ AGGREGATE $ S $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIIAEMBER EXCLUDED? It yes, d aiM undm SPECIAL PROVISIONS Irebv 5001573012007 02 / /09 OB 02/08/10 X I TORYLIMITS I I ER E.G. EACHACCIDENT $100000 E.L. DISEASE - EAEMPLOYE $100 000 EL DISEASE -POLICYLIMIT $500 000 C OTHER Liquor Liability 070003859 04/16/08 04/16/09 Occurrent 250,000 Aggregate 500,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS PROOFOF SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOP. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYSWRNTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TQ THE LEFT, BUTFAILORETO DO SO SHALL PTOO£ O£ InSUTanC@ IMPOSE NO OBLIGATION OR LUIBILRYOFANV RIND UPON THE INSURER, ITS AGENTS OR REPRMENTATNES.