HomeMy WebLinkAboutCork's Fine Wine - 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:.
BILL CLEMMEY & MEGAN FOLEY
Whose place of business is:
CORK'S FINE WINE & LIQUORS, LLC
390 WEST STREET
License Number: S-99
Permit Expires: June 01, 2010
Food Fee: $10.00
Milk & Cream ❑
BOARD OF HEALTH
Dr. Raymond Martin, Chair Xan
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:
CORK'S FINE WINE & LIQUORS, LLC
390 WEST STREET
License Number: S-99
Permit Expires: June 01, 2010
BOARD OF HEALTH
Dar.. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
[Date received: Date Inspected: Approved By: Permit # Issued
S-99
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A lication must oe suornuleu al luaa, �� uu u - - • • --
Name: CORK'S FINE WINE & LIQUORS, LLC
blishment Address 390 WEST STREET
LI)Establishment
blishment Mailing Address (if different) P.O. BOX 715 �r
MANSFIELD, MA 02048
09
4) Establishment Telephone No: (508) 337-9463
5) Applicant Name & Title: MEGAN FOLEY By
6) Applicant Address 65 OLD FARM ROAD, MANSFIELD, MA 02048
7 Applicant Telephone No.: (508) 738-0092 24 Hour Emergency No.: (508) 738-0092
8) Owners Name & Title BILL CLEMMEY & MEGAN FOLEY
9) Owner Address (If different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
Name Title Address
❑ A Corporation
❑ An Individual
❑ A Partnership
O Other legal Entity
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12) Ferson uirecny Kespunaiu,u
Name & Title:
ram, ,.a„y _rI.......
jYl ?iIV 'd l LLC
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Address:
11 �OAM � S �t'I
Telephone No:
/ C �) �G3� �j — �� 24 Hour Emergency No: �60 % 3 0 - b D
l J
FAX:
k 3 3
n' 1::-.a n. oG,ncrvicnr [if annlicable)
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: CORK'S FINE WINE & LIQUORS LLC
LOCATION OF SALE OF TOBACCO PRODUCTS: 390 WEST STREET
TELEPHONE AT LOCATION: (508) 337-9463
OWNER OF BUSINESS: BILL CLEMMEY & MEGAN FOLEY
ADDRESS OF OWNER: ( /a (OArn d 1AA Od->
TELEPHONE OF OWNER: (508) 738-0092
FAX NUMBER: (508) 337-9462
If a corporation or partnership, give name, title, and home address of officers or partner.
FEDERAL ID/SS NUMBER: (a98j 33� 9�62 a Q r �I 3� L
PERMIT NUMBER:
SIGNATURE:
DATE:
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 5
Fat�
RS: M-T 9 AM-10 PM F-SAT 9 AM-11 PM SUN 12 PM-6 PM
of Person In Charge Certified in Food Protection Management:
an 3 individuals arecertified, complete list is on file.
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): ❑
20) Location: W Permanent Location 22) Establishment Type
❑ Mobile Moblie 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 Permit:
[] Annual
❑ Seasonal
Seasonal Dates:
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
❑ 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
f 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
f-1 Retail Food $50
W Retail Snack Food $10
❑ Tobacco Products No Fee
23 FoodO erations
p
Definitions:PHF-Potentially hazardous food (time/temperature controls required)
Non-PHF's-non-potentiallyhazardous/ood(no time/femperature controls required)
which need no further processing)
Check all that apply):
ftTE-ready-to-eat
foods (Ex. sandwiches, salads, muffins
Sale of Commercially Pre -Packaged Non-PFHs
❑ PHFCooked To Order
of PHF Cooked and Cooled or Hot
❑ Hor More Than a Single Meal Serviceeld
❑ Sale of Commercially Pre -Packaged PHFs
❑ Coid Holding FoHSinglerMeal 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
acuum Packaging / Cook Chill
❑V
Processed Foods for Service Within 4 Hours
❑ Use of Process Requiring A Variance
❑ Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Perishable Foods Only
n Ice Manufactured and Packaged for
] Preparation of Non-PHFs Retail Sale __""-'
Other Food Operations ❑Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food rpay7ment
eted by the Board of Health
Fee: $10.00
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 Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, 1 ce i under the penalties of pe ury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal to: 20-16137�9 /__1%
26) Signature of Individual or Corporate Name: f
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.
* Signatu of Individual or
Corpora a Name (Mandatory)
By: I Corpo to off �er
(Maud tory, if applicable)
,�_a —I �-t 3 7 9 Z
** 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
Business/Organization Name: r`I ll� � jr-.()-A, iM / t
AridrejlA W4r 5!- PO 60v-- qls
City/State/Zip: M "5 Ft Q 1 it M rT 01" �' Phone #: L 510 3 3 1-3 Y 6 3
Are you an employer? Check the appropriate box:
I. (f I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole 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. [No workers' comp. insurance req.]
Business Type (required):
5. E3Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.0 Health Care
12.0 Other _
*Any applicant that checks box 41 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 t11.
I am an employer that isproviding workers' compensat io.n. insurance for my employees. Below 1s the policy information.
Insurance Company Name: /'t 55 P U 0J—.l d J r nAAi JLAXt j °-1 M 4 f f /I'I tk�Q (✓ S it t ` ( (�
Insurer's
City /State/Zip•
010
M A albs
^
Policy # or Self -ins, Lic. # H I/U C G ] ZQ 2ZD a Expiration Date: l V lio
—
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 penalties of perjury that the Information provided above is true and correct.
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
Phone
www,mass.gov/dia