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Home My WebLink AboutPlymouth Party, LLC - 12/31/2020-3 FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Mobile Food Establishment (MFE) Permit Application ` )n (Application must be submitted at least 14 business days before the planned opening` date) 1) MFE Name: pi j m, r l l {� � 12 ( G L L 2) Applicant/Owner Name & Title: Applicant/Owner Address: 6 I� zl e T 7 2 5 L t) 0 Applicant/Owner Telephone No: CL/- i,�3- � zZY "",e Applicant/Owner Email address: 3) Person In Charge of Onsite Operations & Title: s,a c PIC Address: S 7 r c PIC Telephone No: Emergency/onsite Telephone No: S �' S"' 3 PIC Email Address: Sr9 4) Location of Service: v Date(s) if applicable: /}1/ Go,cr,r D�I�cs Event Name if applicable: Event/ Service Location: Event/ Service time: 5) Length of Permit: 6) Solid waste disposal plan: Y M Annual nrr4, n1jC o Temporary i Dates: 7) Water Source: 6) Sewage disposal plan: /774rrY, .. /r... re wn Gv3tC.2 %f'l lr �,G 9) Food will be prepared: V Onsite for immediate consumption o Onsite and held at proper hot/ cold holding temperatures o Offsite and held at proper hot) cold holding temperatures O Offsite, cooled and reheated on site o Other: 19) Please attach a menu or a website link to the menu or give a brief description of the food to be served: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: M4 rz G [ 64 ci c t Allergen Awareness: M 4,Z ec Ga r' lr i f 12) Please describe on site hand washing facilities that will be utilized: 0"V /"� S—V& �✓Yh /'vnnihy l�or y Cc lcl �4. �?rira 13) Please list all sanitizing solutions that will be on site: G Su /1 /A/z ;.vC 14) Do you have propane, fryolators and/or hoods on your truck? / 1/ 0 If yes, you must first be inspected and approved by the Mansfield Fire Department. Phone number: 508-261.7321 Fire Department Signature of Approval: 15) If applicable, please describe your FOG management plan or attach the written plan: 41111 16) Location of Base of Operations or Commissary: Please attach copies of Base of Operations or Commissary Permit. Scc �rjecUBo 17) Please list additional communities where a food permit is held: I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 0.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105`MR,590-000.and the federal Food Code. 18)Signature of Pursuant to MGL Ch. 62C, sec. 49A, I ci have filed all state tax returns and paid 19) Social Security Number or Federal 20) Signature of Individual or Corporat artio(under the penalties of perjury that I, to my best knowledge and belief, state taxes required under law. ID: L f �.... e Name: Department oflndustrial Accidents � t; Office of Investigations c H 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information Please Print Le¢ibly Business/Organization Name: JlI I lj f't) 6ry TH Address: 5 Lrlay. S'tl PCrz r>> Are you an employer? Check the appropriate box: I . ❑ I am a employer with employees (full and/ or part-time).* 2.R I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.(',Ua` 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.R We ate a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. Retail 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. nEntertainment 10.n Manufacturing I Ln Health Care 12. �Other Crs i s •, c *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **tf 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 #l. 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. Lie. 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 in urance coverage verification. I do hereby certify, unde?Wand penalties ofperjury that the information provided above is true and correct 3t3- zaZy 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 Person: Phone #: www.mass.gov/dia 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. YI)`lrnovrti ty Lt6, Signature of Individual or Corporate Name R�-I �S'1 LfS"C/ **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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. CAUsers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A z O mimim W u Q F— J V W x O LSI� G K • z ± �& =ck � U 0.4 u z\\\ 7z \ {ƒƒ\ , � � \ � / A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYYI 11/18/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COURT STREET INSURANCE AGENCY INC CONTACT NAME: Jill Tassinari (508) 747-7670 FAA No: ADORess; jillt@counstreelinsurance.com Eksx�iillt@courtstreetinsurance.com 120 COURT ST INSURERS AFFORDING COVERAGE NAIC If PLYMOUTH MA 02360 INSURER A: AIM MUTUAL INS CO 33758 INSURED PLYMOUTH PARTY LLC INSURER 8: INSURER C: INSURER D : 25 LADY SLIPPER DRIVE INSURER E : PLYMOUTH MA 02360 INSURERFI COVERAGES CERTIFICATF NlfMRPP- d7,17n9 oEV!S!0 l MIWEED. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR A L INSO UBR VIVO POLICYNUMBER POLICY MnYTYPEOFINSURANCIE MMIbDmY LIMITS COMMERCIAL GENERAL LIABILITY CLAIM&MADE ❑ OCCUR EACHOCCURRENCE S PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL B ADV INJURY $ N/A. GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- ❑ JECT LOC GENERALAGGREGATE S PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acrAdenf $ BODILY INJURY (Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NONAWNED AUTOS J N/A H BODILY INJURY (Per accident) S PROPERTY DAMAGE Pet occiden $ $ - UMBRELLA LIAR OCCUR EACHOCCURRENCE $ AGGREGATE $ E%CESS LIAe CLAIMS MADE N/A DED RETENTIONS $ JWORKERSCOMPENSAITON AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOWARTNERIA OFFICERMEM Eft XCLODED?ECUTIVE NW (Mandatory In but Dyyes, deacdbe under DESCRIPTON un OPERATIONS belay NIA NIA AWC40070372352019A 06/01/2019 06/01/2020 X SPTATUTEER EROTH eL. EACH ACCIDENT s 1,000,000 EL, DISEASE � EA EMPLOYEE $ 1,000,000 E.L. DISEASE. POLICY LIMIT ]$ 1,000,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Romadis Schedule, may be affached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensatlon/Investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE. WILL BE DELIVERED IN TOWN OF MANSFIELD ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED REPRESENTATIVE MANSFIELD MA 02048 PX Daniel M. CrgWJey, CPCU, Vice President— Residual Market— WCRIBMA ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD All riohfB raeervad. #cairn YYY CERTIFICATE OF LIABILITY INSURANCE DATE �-- � 11/18/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR. PRODUCER, AND THE CERTIFICATE HOLDER. _, ..._ �_.._...__,...__...................,......,w..,....� y, o,,,mmia VI ue auwrsuu. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ERICA 13EVILACQUA NAME: Court Street Insurance Agency Inc PHONE (508) 747-7670 FAX ($OB) 747-7951 AIC o Exi: AIC No 120 Court Street ADDRESS: ericab@courtstreetinsuranee.com Plymouth INSURERIS) AFFORDING COVERAGE NAICN MA 02360 INSURERA: Scottsdale Insurance Company INSURED INSURERS: Pilgrim Insurance 21750 Plymouth Party LLC INSURER C: LLOYDS 25 Lady Slipper Or INSURER D: INSURER E: _ Plymouth MA 02360 IN$URERF: COVERAGES. CFRTIFICATF MI IaaRFO• CI 1g111An99A5 .,....._. _..-....-___ -- --- 11 rVIV1Y 1Y V1 VI GFR: THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TERMS, ILTR TYPE OF INSURANCE INSO WVD POLICY NUMBER MMIDDY EFF MMIDONYYP LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE S 11000.000 CLAIMS•MADE OCCUR PREMISES lee occurrence S 100,000 A MED EXP(Any one person) S 1,000 CPS3191974 06/10/2019 06/10/2020 PERSONAL BAOV INJURY S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRO- GENERALAGGREGATE S 3,000,000 POLICY JECT LOC . PRODUCTS - COMP/OPAGG $ 3,000,000 OTHER; Employee Benefits $ AUTOMOBILE LIABILITY COMSI OSINGL SINGLE -LIMIT S 1,000,000 NY AUTO EaaceMenl BODILY INJURY(Perperson) S WNED SCHEDULED UTOS QNLY x AUTDS CSCOOOOIO03218 06/30/2019 06/3O12020 BODILY INJURY (Per acddenn $ IRED NON�ONMED UTOS ONLY AUTOSONLY PROPERTY DAMAGE S (Peraccidonl 450 Uninsured motorist BI S AU a OCCUR ep"• "'"' EACHOCCURRENCE S 1,000,000 AGGREGATE $ iAB CLAIMS -MADE XSZ140377 08/16/2019 08116/2020 RETENTION S WORKERS COMPENSATION PER OTH- $ AND EMPLOYERS' LIABILITY YIN STATUTE ER E.L. EACH STATUTACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER E%CLUOED? ❑ NIA (Mandatory In NH) In If yas, atory under El, DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Sohetlale, may be attachod If more space Is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED ON CGL POLICY CAPTIONED ABOVE WITH RESPECT TO THE WORK BEING PERFORMED BY INSURED, TOWN OF MANSFIELD 6 PARK ROW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MANSFIELD MA 02048 ACORD CORPORATION. All rights resarvari. P.UUKU ZO t2UTblU3) The ACORD name and logo are registered marks of ACORD PLYMOUTH PARTY MENU Fresh Spun Cotton Candy Snow Cones Frozen Desserts Popcorn Soda Bottled Water THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH J „ is PUBLIC HEALTH DEPARTMENT 2019 BUSINESS LICENSE PLYMOUTH PARTY LLC 25 LADY SLIPPER DRIVE PLYMOUTH, MA 02360 DBA: PLYMOUTH PARTY LLC CID #:312422 BL ID #: 102234 LICENSE #: 4967 Your 2019 Business License for A LICENSE TO OPERATE A CATERING ESTABLISHMENT is printed below. Please retain a copy for your records. If you have any questions, please call the Public Health Department at 508-747-1620 ext. 10118. Doing Business In: Has been granted: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH PUBLIC HEALTH DEPARTMENT 2019 PLYMOUTH PARTY LLC PLYMOUTH, MA 02360 A LICENSE TO OPERATE A CATERING ESTABLISHMENT FEE PAID $ 160 In accordance with Regulations promulgated under authorit) of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws and 105 CMR 590.000 Expiration date: December 31, 2019 Signature LICENSES ARE NOT TRANSFERABLE ( } k R R ! � q �� 9 , LLI LU m \ ' , .24 'co � , U. Q,� �! p Gam@/ $ % uj ¥ � • o m: uj � } \ ■ ; p �; ■ 2 E \:_ . ) R� ; £ : > �] E: : • o: # • 3 � u:: /?�_ §. E! LL . .. . . . ± ._ ; .�. Q : o: 3{ § d n