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Home My WebLink AboutDub's Discount Liquors - 6/1/2010f' 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:. WILLIAM SARRO Whose place of business is: F&W INC. dba DUE'S DISCOUNT LIQUORS 30 CHAUNCY STREET License Number: S-24 Permit Expires: ,June 01, 2010 Food Fee: $10.00 Milk & Cream W 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: F&W INC. dba DUB'S DISCOUNT LIQUORS 30 CHAUNCY STREET License Number: S-24 Permit Expires: ,June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman i`� 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: WILLIAM SARRO having a place of business at: F&W INC. dba DUB'S DISCOUNT LIQUORS 30 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 Ljoense No.: S-24 s Scott Leite, 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: FOon FSTARI_ISHMENT PERMIT APPLI Mph rroit k I"99d S-24 /A—H. nfinn muef ha euhmut.,4 at laacf an lfave hafnra tha ntannert nnaninn data) 1) Establishment Name: F&W INC. dba DUB'S DISCOUNT LIQUORS 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 34 MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-3454 5) Applicant Name & Title: WILLIAM R. SARRO, PRESIDENT 6) Applicant Address 15 RESERVOIR STREET, UNIT 31, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-6204 24 Hour Emergency No.: (508) 339-6204 (508) 339-1427 (508) 339-8369 (774)244.1094 8) Owners Name & Title WILLIAM SARRO 9) Owner Address (if different from applicant): 15 RESERVOIR STREET, UNIT 31, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association O 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 tkwQ( ,` Z(L " - 11V A ; '4 . 00ki " * f �(4 � V rnG, y " �'Ajin� �u 2'aj 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) let) lCc Gmssst-1 C4 iIa 6266 �a jc� 1 24Hour Emergency No:-J-" (-. - � q_ Name & Title: Address: Telephone No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: 4' - Ii�"� Address: i 6 i L. `'O° l t t_ t i 1 ) ii + Telephone No: 1---, '' 24 Hour Emergency No: FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 17) DAYS/HOURS: MON-THURS 8 AM-10 PM FRI-SAT 8 AM-11 PM SUN 12-6 PM 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: iW Permanent Location 22) Establishment Type ❑ Bakery $25 ❑Mobile Mobile Start Date: Retail ( 'Ji; CO Sq. Ft) ❑ Caterer $25 Moblie 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 lV Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: Annual or up to 25' PHF display $100 ❑ Mobile Food Temporary $25 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: [] Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Retail Food $50 Temporary End Date: ❑�/ Retail Snack Food $10 Temporary Time: Tobacco Products No Fee Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (timaltemperature 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 furtherprocessing) ❑J 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 Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly EJ 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 of Non PHF and Non- Perishable Foods Only .— ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) — ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date _ or Reconditioned Food To be completed by the Board of Health 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-and-ths-kderal 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 tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2826185 26) Signature of Individual or Corporate Name: t 1r -- Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit 1 hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: F&W INC. dba DUB'S DISCOUNT LIQUORS ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-3454 FAX NUMBER: (508) 339-6391 OWNER OF BUSINESS: WILLIAM SARRO TELEPHONE OF OWNER: (508) 339-6204 FEDERAL ID/SS NUMBER: 04-2826185 FEE: $2.00 PERMIT NUMBER: S-24 SIGNATURE: DATE: 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: F&W INC. DUB'S DISCOUNT LIQUORS LOCATION OF SALE OF TOBACCO PRODUCTS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: OWNER OF BUSINESS: WILLIAM SARRO ADDRESS OF OWNER: 15 RESERVOIR STREET, UNIT 31, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 339-6204 FAX NUMBER: (508) 339-3941 If a corporation or partnership, give name, title, and home address of officers or partner. t i?0 L 112 C . _S (t /Z tz 0 FEDERAL ID/SS NUMBER: 04-2826185 PERMIT NUMBER: S-24 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. * Signature of Individual or Corporate Name (Mandatory) 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 Please Print Legibly Business/Organization Name:T t ( 0, c�J Address:3L.) Are you an employer? Check the appropriate box: Busine 'Type (required): 1.0 1 am a employer with Q employees (full and/ 5. ElRetail 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. S. ❑ 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.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We by I1.❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers'.comp. insurance req.] 12.0 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 HI. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: (Y} _sf re_t [ I ky� c1,)( rChC_ n ck_� C C I lk_ > I Y )f - Insurer's Address: i b & —6t) L CY') e,C I CC City/State/Zip: [Z�L4'h6t ffl , r_) Cf 3L"/.3 �J Policy # or Self -ins. Lie. # i UU% Z3 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 certify, under the pains and penalties of perjury that the information provided above is true and correct ', Phone #: .�� 7 1 :,4 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 WORKERS COMPENS9110 h':ID NlrLOT R,;: _ 1 'Y INS)iRANCE CERTIFICATE INFORMATION PAGE RENEWAL AGREh'MKur Producer: Agent# 921 MA Retail Merchants WC Group Inc. Dowling Insurance Agency, Inc. 10 British American Blvd. PO Box 850962 Latham, NY 12110 Braintree, MA 02185 (Carrier Code: 34355) Certificate #: 014005031781109 Prior Certificate #: 014005031781108 1. The Employer: Dub's Liquors F & W, Inc. Mailing Address: PO Box 34 Mansfield, MA 02048 Other workplaces not shown above: SEE SCHEDULE OF OPERATIONS Fein: 042826185 Type of Business: Corporation Risk ID: 2. The certificate period is from 12:01 a.m, on 1/01/2009 to 12:01 a.m. on 1/01/2010 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part One of the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Coverage: Part Two of the certificate applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 certificate limit Bodily Injury by Disease $ 500,000 each employee C. Other States Coverage: D. This certificate includes these endorsements and schedules: WCOOOOOOA(04/92) WC000310(04/84) WC000402(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200405(06/01) WC200601(06/92) 4. The contribution for this certificate 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. Classifications Code Contribution Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration xemuueration Contribution SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution 2,665.00 Minimum Contribution $ 270.00 Expense Constant $ .00 WC 00 00 01 A Issue Date: 1/08/2009 Countersigned by J } `�, ) HEALTH CCU V1l� IUK13`_�Al10NIS INC- Trainer: Wayne Smith (33462) Dale Held: 09/28/2008 For State: MA Processed: 10/13/2008 Total: 9 No. Passed: 9 No. Failed: 0 No, Retakes: 0 (N = New, R = Retake) No. Printed: 9 Course: TIPS Participant Off Premise Session ID: 210976 Received: 10/06/2008 Rush? N Invoice#: 0 2461508 N Pass ROBERT JOSEPHS Dubs's Liquors and Fine Wines Expires: 9/28/2011 46 Gilmore Rd North Easton, MA 02356-2100 2461509 N Pass LEO MACDONALD Dubs's Liquors and Fine Wines Expires: 9/28/2011 30 Chauncy St Mansfield, MA 02048-1958 2461510 N Pass DANIEL SMITH Dubs's Liquors and Fine Wines Expires: 9/28/2011 6 JUDYS LN Mansfield, MA 02048 2461511 N Pass ASHLEIGH MARTIN Dubs's Liquors and Fine Wines Expires: 9/28/2011 82 Laurelwood Dr North Attleboro, MA 02760-2703 acmartinl@ccri.edu 2461512 N Pass FREDERICK BADGER Dubs's Liquors and Fine Wines Expires: 9/28/2011 1 Villa St Apt B Mansfield, MA 02048-2135 2461513 N Pass MATTHEW ARMS Dubs's Liquors and Fine Wines Expires: 9/28/2011 118 Westover Pkwy Norwood, MA 02062-1629 2461514 N Pass CARL SOUZA Dubs's Liquors and Fine Wines Expires: 9/28/2011 26 Elyse Rd Mansfield, MA 02048-3315 2461515 N Pass RONALD LESIEUR Dubs's Liquors and Fine Wines Expires: 9/28/2011 225 Mckeon Dr North Attleboro, MA 02760-4515 2461516 N Pass ROBERT LEE Dubs's Liquors and Fine Wines Expires: 9/28/2011 30 Chauncy St Mansfield, MA 02048-1958 Note: Due to state privacy restrictions, Social Security Number is now only listed when required by state law Printed on: 10/13/2008 .... Conge; >Ions SSN: XXX XX-XXX%X ;. Issued: ' 5111120 07 Expires:. - 5/.9/2010 Ipih. :. <'id2•t3C D.O.B.: XX/XY✓XXXX - JOHN F11 T 3r; Hodge, 1 M-iansfie.il, MA. 02048-2224 For suvice visit us online a; xvvw.grttips.c;an. Nadgeda Jourdan, 46254 o o w E, o `� as a❑ w e° rn o Ua O O Q% y b o 00 a^M1 0 CO'' O F „°� °0 , 0 0 ° ° 9 0 0 00 0 0 o rn rn c T N u c c mO a O fn N O J 0CD O O 3 a r g< 0 m A N O N O N 0 m b y o z f N O EA x w o y O X x w no oo ri °� y y £ '� K' ?. 0 r a bJ O nw r7 GO G O A G b fGi C 0.^ `.• o n woo G° ,`d c R r.�. R❑ G s N £. `° ,< O o �. (A o f. $, y w 0 cr m o U K N seC 0 0 5'0 0 0 0 w ry 3 0 H w a p o ry o c_ w no a 0 0 o N o 3 0 O G n0 ^O 0o yrOOp m ro•-• • ^. 0.rn MF.4Fi� ^ n GG n tRD G, o .O+ n n H 0 N G w O £ d W b ^. C �J R Imo• 0 G 6 XI W Ci rya 11 0 ° n o y .� 0 tp G ��yy o .a D 0 'S s o i n w '`\ „'� 0 rn o 0 o a as N �. �' o. .< " 0 o F a 3 O❑ o o N Y+. 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