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HomeMy WebLinkAboutD'Angelo's Sandwich Shop - 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, $action 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. BRIAN J. MCLAUGHLIN, PRESIDENT Whose place of business is: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY STREET PERSON(S) IN CHARGE: BETH MASTROIANNI, GENERAL MANAGER Permit Expires: June 01, 2010 License Number: FS-14 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: BRIAN J. MCLAUGHLIN, PRESIDENT having a place of business at: D'ANGELO'S SANDWICH SHOP 260 CHAUNCY 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-14 Scott Leite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 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 1st of each year. NAME OF BUSINESS: D'ANGELO'S SANDWICH SHOP ADDRESS: 260 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8603 FAX NUMBER: (508) 580-0644 OWNER OF BUSINESS: BRIAN J. MCLAUGHLIN, PRESIDENT TELEPHONE OF OWNER: (508) 586-8456 FEDERAL ID/SS NUMBER: 04-2522583 FEE: $2.00 PERMIT NUMBER: FS-14 SIGNATURE: DATE: &64-1*_ j g64� fFI,�(e� Cad' FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-14 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openinq date_y,%i 1) Establishment Name: D'ANGELO'S SANDWICH SHOP �) q U 2) Establishment Address 260 CHAUNCY STREET 1VA 3) Establishment Mailing Address (if different) P.O. BOX 279 WEST BRIDGEWATER, MA 02379 \t o 4) Establishment Telephone No: (508) 339-8603 5) Applicant Name & Title: MARIVA, INCORPORATED 6) Applicant Address PO BOX 279, WEST BRIDGEWATER, MA 02379 7) Applicant Telephone No.: (508) 586-8456 24 Hour Emergency No.: (508) 922.1594 8) Owners Name & Title BRIAN J. MCLAUGHLIN, PRESIDENT 9) Owner Address (If different from applicant): P.O. BOX 337, WEST BRIDGEWATER, MA 02379 10) Establishment Owned By: ❑ An Association ❑ A Corporation El 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 gncu, 0 . � .., r h(Fs� PfcS (acAt P-0. buk W _ I'UR4 dA 0 23)-6320 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc,) Name & Title: Address: 9- fa e- 'a�k-t Telephone No: 24 Hour Emergency No: i ts�\\ �P'] fr 5� 3 2 SOrY 92L45 V FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: ,� c 0 nds%e- Eo cwl ,_�e�— 1>2R 0270 Telephone No: F 6 _34 �a 24 Hour Emergency No: � _ FAX: -) S�6-06gL� 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. Mn rcdO� CXrI(A * Signature of Individual or Corporate Name (Mandatory) By: Corporate Off cer (Mandatory, if applicable) 0q-2522.59�3 ** 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 Please Print Leeibly Business/Organization Address: 2. cal Gm4 City/State/Zip: Are ya an employer? Check the appropriate box: 1. ✓ I am a employer with I2xS,;r— 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 emplovees. Me workers' come. insurance real -Phone #: Q6S I Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment ME] Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box #I 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 # I. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy information. Insurance Company Name: o-4c Aw c� e tP r4A c,; Insurer's City/State/Zip: Policy # or Self -ins. Lie. 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 pol(tsland penalties ofperjuty Official use only. Do not write In ails area, to be completed by city or town ofcial City or Town: Permit/License ,e is true and correct. or 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 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 20 17) DAYS/HOURS: MON-SUN 10 AM-10 PM 18) Name of Person In Charge Certified in Food Protection Management: ELIZABETH MASTROIANNI 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): W 20) Location: iW Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: ❑ Retail ( 800 Sq. Ft) Mobile End Date: L_V] Food Service up to 100 or Moblie Comments: up to 10' PHF display $75 21) Length of Permit: ❑J Annual ❑ Seasonal Seasonal Dates: ❑ Temporary 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 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 (tima/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 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 PHFs For Hot And Cold Holding For Single Meal 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 ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service Perishable Foods Only Other Food Operations Customer Ice Manufac Retail Sale U 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 FPayment mpleted by the Board of Health rmit Fee: $75.00 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 590.00p and the federal Food Qode. 24) Signature of Applicant: "-4, lyy Ab#. : Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2522583 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Client#: 14795 DANGELOINC ACORD. CERTIFICATE OF LIABILITY INSURANCE 2125/MIDDIYYYY) 02125/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 299 Ballardvale St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington, MA 01887 978 657-5100 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental Casualty Company 20443 Mariva, Inc. PO Box 519 INSURER B: 323 Manley Street INSURER C: West Bridgewater, MA 02379 INSURER D: INSURER E: COVERAGES 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 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MFFECTIY POLICY EXPIRATION DATE EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY _ DAMAGE TO RENTED $ES_Se occurrence) _ $ CLAIMS MADE F—IOCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO $ POLICY PEo- LOG AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT E. acddinq $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Peraccldenl) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accidani) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGO EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE Is OCCUR CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND WC287989524 12131108 12/31109 X WC M STOTH- EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE EL EACH ACCIDENT $SOO,000 E.L. DISEASE - EA EMPLOYEE $500,000 OFFICERIMEMBER EXCLUDED? If yes, cribe under SPECSIALPROVISIONS below E.L. DISEASE - POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Mariva, Inc. dba D'Angelo Sandwich Shop 260 Chauncy Street Mansfield, MA 02048 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10_ DAYS WRITTEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTMORRESENTATIE —V. ACORD 25 (2001/08) 1 of 2 #S222324/M222319 CB003 © ACORD CORPORATION 1988 0§ ) }) )( _ oI § k )§ 3 \ / (' )� k .41 § m A !o{ % ±)) f lE § m LL i )�� � 2a 2 0 ) 15 ) - ` 0 0 « ; f>) f # : ,j §�� krl ®f` ■ pi ( ) { } | \ (