HomeMy WebLinkAboutFamily Food Mart - 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:.
TOUMA, INC.
Whose place of business is: FAMILY FOOD MART
660 EAST STREET
License Number: FS-76
Permit Expires: June 01, 2010
Food Fee: $75.00
Milk & Cream ❑O
BOARD OF HEALTH V
Dr R mond 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:
FAMILY FOOD MART
660 EAST STREET
License Number: FS-76
Permit Expires: June 01, 2010
BOARD OF HEALTH
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:
TOUMA, INC.
having a place of business at.
FAMILY FOOD MART
660 EAST 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-76
i
Scott te, 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-76
FOOD ESTABLISHMENT PERMIT APPLICATIO
(Application must be submitted at leastdays before the planned opening date)
1) Establishment Name: FAMILY FOOD MART
2) Establishment Address 660 EAST STREET
3) Establishment Mailing Address (if different) 660 EAST STREET"
MANSFIELD MA 02048
4) Establishment Telephone No: (508) 339-2689
5) Applicant Name & Title: RAAFAT TOUMA
6) Applicant Address 89 COTTAGE STREET, NORWOOD, MA 02062
7) Applicant Telephone No. (508) 339-2689 24 Hour Emergency No.: (781) 249-9212
8) Owners Name & Title TOUMA, INC.
9) Owner Address (If different from applicant): 660 EAST STREET, MANSFIELD, MA 02048
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
----
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
IV v 1 -io
Address:
Telephone No:
24 Hour Emergency No: 6 ( -7 8�
FAX:
E-mail:
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
14) WATER SOURCE: TOWN
Food Establishment Information
15) SEWAGE DISPOSAL SEPTIC
DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 4
17) DAYS/HOURS: 7:09 AM -10:00 PM
18) Name of Person In Charge Certified in Food Protection
Management:
1f .... _ "-- O :..d0..: d....l........... h:F...d ,........ L.M I:.h i.. -- f:l-
Required as of 1011/2001 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: Permanent Location
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type:
Retail ( 2,600 Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $75
Food Service up to 101 -200
or up to 26 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 Ntchen $25
Retail Food $50
Retail Snack Food $10
Tobacco Products No Fee
23) Food Operations: Defintions PHF - Potentially hazardous food(hma/temperature controls mquirerq
Non-PHF's-non-pote Uallyhazardousfood(wtimeRernperatumcontrolsrequired)
(Check all chat apply): RTE- ready-lceat foods (Er. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
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:
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, Out -Of -Date
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
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee: $76.00
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 ob i c !as of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applican .
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 17:t�0_mys3zgwIedge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-3285919
26) Signature of Individual or Corporate Name: 1
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: FAMILY FOOD MART
ADDRESS: 660 EAST STREET
TELEPHONE AT LOCATION: (508) 339-2689
FAX NUMBER: (508) 339-2083
OWNER OF BUSINESS: TOLIMA, INC.
TELEPHONE OF OWNER: (508) 339-2689
FEDERAL ID/SS NUMBER: 04-3285919
FEE: $2.00
PERMIT NUMBER: FS-76
SIGNATURE
DATE: --- J l.z Jn °)
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: FAMILY FOOD MART
LOCATION OF SALE OF TOBACCO PRODUCTS: 660 EAST STREET
TELEPHONE AT LOCATION
54 3 3 y--a 6',v9
OWNER OF BUSINESS: TOLIMA, INC.
ADDRESS OF OWNER: 660 EAST STREET, MANSFIELD, MA 02048
TELEPHONE OF OWNER: (508) 339-2689
FAX NUMBER: (508) 339-2083
If a corporation or partnership, give name, title, and home address of officers or partner.
FEDERAL ID/SS NUMBER: 04-3285919
PERMIT NUMBER: FS-76
SIGNATURE:',
DATE:
TAX CERTIFICATION FORM
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.
'R AA -A —i --)G G MA
Signature of ludividual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this 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 Massachusetts General Law
Chapter 62C, section 49A.
C:\Scou's Documents\Food Establislnnents• Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf tvww. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:- Tc2 (A iLlJ I Al c 9 1% ti (EMI L k T ®o n 064 R-
Address: 6h o 6 p 5 i 5�
City/State/Zip: r.4\(an1 .?v 4 K Phone
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (fill and/
5. M Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establisluuent
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.
8. ❑ Non-profit
[No workers' comp. insurance required]
3.4
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
no employees. [No workers' comp. insurance required]*
11.0 Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
I
with no employees. [No workers' comp. insurance req]
12.❑ Other
*Any applicant that checks box #1 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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
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 Drat a copy of this statement may be forwarded to the Office of
InvestiEations of the DIA for insurance coverage verification.
I do hereby cer(tfy, under 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