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HomeMy WebLinkAboutCosi - 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:. HEATHERSTONE PARTNERS Whose place of business is: COST 280 SCHOOL STREET PERSON(S) IN CHARGE: STAN LORING, GENERAL MANAGER Permit Expires: June 01, 2010 License Number: FS-11 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: HEATHERSTONE PARTNERS having a place of business at: COST 280 SCHOOL 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 License No.: FS-11 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-11 FOOD ESTABLISHMENT PERMIT APPLICATION (Anolication must be submitted at least 30 days before the planned openinq date) 1) Establishment Name: COS[ 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET MANSFIELD, MA02048 MAY .) � 2009 4) Establishment Telephone No: (508) 261-8740 5) Applicant Name & Title: STAN LORING, GENERAL MANAGER 6) Applicant Address 3 FRANKLIN STREET, HUDSON, MA 01749 7) Applicant Telephone No.: (506) 261-5740 24 Hour Emergency No.: �H0 ('17 - bd 6 359d 8) Owners Name & Title HEATHERSTONE PARTNERS 9) Owner Address (If different from applicant): 77 MAIN STREET, HOPKINTON, MA 01748 10) Establishment Owned By: ❑ An Association ❑ 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 &,g.?0A441sfn,a )U. °— 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: P 1 ,Qlan �or�'n Address: SG rr+ Telephone No: SOff'a `/- B7r/0 24 Hour Emergency No: �) �. 6 oia-SS%0 FAX: 508-a & 1- �'7 ri 13) District Or Regional Supervisor (if applicable) Name & Title: c�au�n Address: $o mR Telephone No: 508'-i65. 2-/00 24 Hour Emergency No: 7?q- 7&(P-U y'0 -- FAX: SO£f-`i3S—a/yg 0t7Ye 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 30 17) DAYS/HOURS: 7 AM-10 PM 7 DAYS 18) Name of Person In Charge Certified in Food Protection Management: STANLEY M. LORING If more than 3 individuals are certified, 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 Anli-Choking Procedures (If 25 Seats or more): ❑� 20) Location: W Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑J Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 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 0 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-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 0 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs EV Preparation of HHot And Cold Holding For Single rMeal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended _ 0 Reheating of Commercially to be Prepared by Consumer ❑� Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours PHF and Non- I I I Customer Self -Service Perishable Foods Only Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accuracy of the infoi establishment operation will comply with 105 CMR 5 board of health on how to obtain copies of 105 CMR Ice Manufa( Retail Sale ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ 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 of Health Total Permit Fee: $75.00 Payment is due with application ❑ waived d in thislapplicalion and affirm that the food other gpplicable law. I have been instructed by the 24) Signature of Applicant: ' y--" f Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalti 1 of erju ; to y best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26-01294 ' 26) Signature of Individual or Corporate Name: 'qr�n ers Z-141� dbe� C �S I 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: COST ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 261-8740 FAX NUMBER: OWNER OF BUSINESS TELEPHONE OF OWNER: (508)261-8742 HEATHERSTONE PARTNERS FEDERAL ID/SS NUMBER: 26-0129433 FEE: $2.00 PERMIT NUMBER: FS-11 SIGNATURE: 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. d�Aid,ers ad dha &cA: Signature of Individual or Corporate Name (Mandatory) By: Corporate O (Mandatory, a/,- vio9 433 ** 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 n Please Print Legibly Business/Organization Name: db, eos, Address: 77 M&,,t 6f, Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1.2 I am a employer with a/ a employees (full and/ 5. ❑ Retail or part-time).* 6. Q estaurant/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. $• ❑ 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 ]0.❑ Manufacturing no employees. [No workers' comp. insurance required]* I I•❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.) 12.❑ Other *Any applicant that checks box NI 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 pl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State Policy # or Self -ins. Lic. # 2Da 9 , P&S-9C- V3-9 -o 7 Expiration Date: 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 certifyt4ender the pains and penalties ofperjury 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 www,mass.gov/dia Phone TRAVELERS, WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IJUB-2659C43-9-08) RENEWAL OF (IOUB-2659C43-9-07) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED: HEARTHSTONE ASSOCIATES, LLC SEE ENDORSEMENT WC 99 06 01 77 MAIN STREET HOPKINTON MA 01748 Insured Is LIMITED LIAB CORP NCCI CO CODE: 13579 PRODUCER: THOMAS GREGORY ASSOC INS P 0 BOX 555 WAKEFIELD MA 01880-4555 Other work places and Identification numbers are shown in the schedule(s) attached. 2. The policy period is from 12-20-08 to 12-20-09 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ Bodily Injury by Disease: $ Bodily Injury by Disease: $ 500000 Each Accident 500000 Policy Limit 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 1 2-19-08 LH OFFICE: BOXBOROUGH 126 PRODUCER: THOMAS GREGORY ASSOC INS 000394 GU211 DIRECT BILL � r�- 0 0 C�4 � � 5V 0 � � CY)