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HomeMy WebLinkAboutHoliday Inn - 12/31/2020S 9 � - 36y FOR BOARD OF HEALTH USE ONLY Permit # Issued n -- — 4 17r, x FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) f ZA, Establishment Name '- o J-/)/) ) Establishment Address fiW Establishment Mailing Address (if different) �/��/2�� Establishment Telephone No��9 ocq?Gr/ Applicant Name & Title: Applicant Address j/ Hod Applicant Telephone No.: 244 Hour Emergency No.: ApplicantEmail (i���l �lU7L�0�5,�03�) Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or E] An Association partner. D A Corporation D An Individual Name Title / Address Ick l 07) da%APSAI' 0 A Partnership ther legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:��L Address: �J / 1-MlIT'S & �7t Telephone No: ��p�75�j�/� �77fi G��U%� 24 Hour Emergency No: FAX-', � 399 -mow E-mail: /�0 YO, �0�)'� Alt E -Mail: District Or Regional Supervisor (if applica le) Name & Title: I o eza, ��Q l/d Address: �/ IlCtA" ov5 Telephone No: 24 Hour Emergency No: FAX: /� E-mail: /P64-64@ kkx&ld,L61 — Food Establishment Information WATER SOURCE: Azvlc�' SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: ��Clr�in Name of Person(s) In Charge Certified in Allergen Awareness Training �17CLrhyl QHS �z ACU 125 Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 peop a or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. Yes Does this establishment require a FOG permit? L ry S If yes, please attach the FOG permit application. of Permit: Establishment Type: �Length LIYAnnual Retail Food $125.00 0 Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: [ood Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 D Residential Kitchen $100.00 Rain Date: .-.--�1ilk &Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (timaAemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no timelTempareture controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I] Sale of Commercially Pre -Packaged Non-PHFs [jHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs [reparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility [] Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self and/or HACCP Plan (including bare hand C:7 Customer Self -Service of Non PHF and Non- -Service contact alternative, time as a public health Perishable Foods Only 0 Ice Manufactured and Packaged for control) Preparation of Non-PHFs p Retail Sale Offers Raw Or Undercooked Food Of EJ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill [offers RTE PHF in Bulk Quantities D Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, 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 -the federal Food Code. 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. 7 ' /U Social Security Number or Federal ID: �/ `ll//c /7zex� AI& C//a� Signature of Individual or Corporate Name: 6 s .,,fdly completing Ike m.,kxds sei fodh which is v,c,,Ated ky the Amemon Nnnooal Si hkaxi r Coli(iaAim Emandion, ee for Food Praedion (CFP). 1/2812024 DATE OF EXPIRATION dial regoirenenls. rr„h,.mh of r1r AEF_ N,,.d 1m.,,ra A;,.. o,—)lla— 6, C-1, :1,.nJrgar : , 12395 ",4t,I .. WI,N.Imago d 1V01 CERTIFICATE OF Name of Recipient: MARTIN OSHE Certificate Number: 30e0W4 Date of Completion: 'v1312016 Date of Expiration: 1MM13 71ie above-named person is hereby issned this certxmte for completing an allergen awareness tiainingprogrann recognized by the Massa dmsettsDepartin ent ofPublicHealth in arcorctmnce with 105 CMR 590.009(C)(3)(a). 71ifs certificate will be valid fo five (5)yearsf vin date ofconrpletion. Issued By: i y t NATIONAL RESTAURANT ASSOCIATIONo Massachusetts Rcsdumnt Association 800.765.2122 333 Turnpike Road, Suite 102 mnerest¢urnnaarg Southbaro gh,MA 01772 508-303-9905 rnnvmaest¢ur¢ntassoc.org o. o e Z w y,, � � m Q a V d o. o e w a W V z z J W z W 3 d z Q. Q. W Ei a 0 F .y dtix � 3 � LLOl Z p�j O O N N O O W M a a O ej) Cd o N c U �J U k- O w O (u z ti U N Q cid Q a 0 .y dtix � O y f�, o. w . v a z d a tt �o tt o � O y a 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. Signature of Individual or Corporate Name Lf`7-3/ /,-,z/yy "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. C:\Usen\sleite\Desktop\Scotts Doc=entAllood Establishments- Temp\TAX CERTIFICATION FORM.doc Workers' Compensation and Employers Liability Insurance Policy EMPLOYERS PREFERRED INS. CO. $ Policy Number From olicy PeriodTo A Stock Company Bodily Injury by Disease EIG 2656163 01 06/24/2019 06[24/2020 policy limit . Bodily Injury by Disease $ 72dnA.M.Standard T'meattheatldress ofthe 1 Insured as stated herein each employee Transaction AMENDED DECLARATIONS Effective: 06/24/2019 NCCI Carrier # 31283 WCIRB CARRIER# PRIOR POLICY NUMBER EIG265616300 I. Named Insured and Address Agent VISION HAMPSHIRE LLC DIVERSIFIED INS INDUSTRIES INC 6465200 DBA HOLIDAY INN MANSFIELD 307 INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer # Carrier # FEIN # Risk ID # Entity of Insured 3.1283 473112140 001033835 LIM LIABILITY CO Additional Locations: 2. The Policy Period is from 06/24/2019 to 06/24/2020 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit . Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except HI, ND, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule, I. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All informatiori required below is subject to verification and change by audit. Minimum Premium $ Assessments and Taxes $ 231 Expense Constant $ 338 Premium Discount $ -1,440 Total Estimated AnnualPremium $ 26,439 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly :ountersigned this Day of ssued Date: 06/28/2019 Authorized Representative isuing Office EMPLOYERS PREFERRED INS. CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 sued Date 06/28/2019 /C990630 (5/98 Ed.) INSURED COPY H �I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY INFORMATION PAGE ENDORSEMENT WC 89 06 00 A (Ed. 07-87) The following item(s) [ ] Insured's Name (WC 89 06 01) [ ] Item 3.A. States (WC 89 06 11) [ ] Policy Number (WC 89 06 02) [ ] Item 3.13. Limits (WC 89 06 12) [ ] Effective Date (WC 89 06 03) [ ] Item 3.C. States (WC 89 06 13) [ ] Expiration Date (WC 89 06 04) [ ] Item 3.D. Endorsement Numbers (WC 89 06 14) [ ] Insured's Mailing Address (WC 89 06 05) [x] Item 4.* Class, Rate, Other (WC 89 04 15) [ ] Experience Modification (WC 89 04 06) [ ] Interim Adjustment of Premium (WC 89 04 16) [ ] Producer's Name (WC 89 06 07) [ ] Carrier Servicing Office (WC 89 06 17) [ ] Change in Workplace of Insured (WC 89 06 08) [ ] Interstate/Intrastate Risk ID Number (WC 89 06 18) [ ] Insured's Legal Status (WC 89 06 10) [ ] Carrier Number (WC 89 06 19) is changed to read: EFFECTIVE 06/24/19 AMEND TO INCREASE PAYROLL FOR CLASS CODE 9052 FROM 1,045,440 TO 1,057,000; CLASS CODE 9058 FROM 828,026 TO 1,010,000 AND CLASS CODE 8810 FROM 118,800 TO 310,000 PER THE AGENT'S REQUEST. *Item 4. Change To: Total Estimated Annual Premium $ 26,439 Minimum Premium $ 231 Deposit Premium $ 2,413.30 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (rhe information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective 06/24/2019 Policy No. EIG 2656163 01 Issued to VISION HAMPSHIRE LLC Premium $26,439 Countersigned at at 12:01 AM standard time, forms a part of Of the EMPLOYERS PREFERRED INS. CO. Carrier Code 31283 Endorsement No. 001 on By: Authorized Representative WC 89 06 00 A (Ed. 07-87) ® 1987 National Council on Compensation Insurance, Inc. Premium Basis Rate Per $100 Classifications Code Total Estimated of Estimated No. Annual Remuneration Annual Premium Remuneration Total Estimated Annual Premium $ 26,439 Minimum Premium $ 231 Deposit Premium $ 2,413.30 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (rhe information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective 06/24/2019 Policy No. EIG 2656163 01 Issued to VISION HAMPSHIRE LLC Premium $26,439 Countersigned at at 12:01 AM standard time, forms a part of Of the EMPLOYERS PREFERRED INS. CO. Carrier Code 31283 Endorsement No. 001 on By: Authorized Representative WC 89 06 00 A (Ed. 07-87) ® 1987 National Council on Compensation Insurance, Inc. acoRH CERTIFICATE OF LIABILITY INSURANCE il..� DATE(MM/DDNYYY) 1 11/22/2019 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 have ADDITIONAL INSURED provisions or 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 Diversified Insurance Industries, Inc. 307 International Circle NANTACT ME: Brlanna Foertschbeck PHONE :4I0-433-3000 ac No:410-433-3440 Suite 610 Hunt Valley MD 21030 EMAIL AooREss: brianna.foertschbeck dii-ins.com INSURERS AFFORDING COVERAGE NAIL B INSURERA: CINCINNATI INSURANCE CO 10677 MED EXP (Any one person) $500 INSURED GLOS-01 Vision Hampshire, LLC tie Holiday Inn Mansfield, MA INSURER B: Continental Insurance CO.` 35289 INSURER C: Ohio Casualty Ins Co' 24074 INSURER D: A c/o Hospitality Cover Plus, LLC P.O. Box 1572 Cockeysville MD 21030 INSURER E: INSURER F 11/1/2019 COVERAGES CERTIFICATE NUMBER: 2062719696 REVISION NUMBER: 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 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. INSR LTR TYPE OF INSURANCE ADDLSUBR Town of Mansfield POLICY NUMBER MMIIDmYF MM/DIDYEXP LIMITS A X COMMERCIAL GENERALLIABILITY CLAIMS -MADE OCCUR X Emal Benefits INN0003005 11/1/2019 11/1/2020 EACH OCCURRENCE $2,000,000 _ DAMAGE TO RENTED PREMISES Eaoccunence $1,000,000 MED EXP (Any one person) $500 X Liquor Liability PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PECTRO- [X]LOGPRODUCTS-CONFIDE J OTHER: GENERAL AGGREGATE $2,000,000 AGO $2,000,000 Empt Bent/Liquor $ 1,000,000 A AUTOMOBILE XANY LIABILITY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY CAA5250328 11/1/2019 11/1/2020 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY (Per person) $ () BODILY INJURY Per accident $ X PROPERTY DAMAGE $ Per accident B X UMBRELLAUABX EXCESS LIAR OCCUR CLAIMS -MADE 5094764769 11/1/2019 11/1/2020 EACH OCCURRENCE $25,000,000 AGGREGATE $25,000,000' DED I X I RETENTION$ 1, _ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIE�(ECUTIVE OFFICER/MEMBEREXCLUOEO? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER Eol STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ C A Excess Llablllryry Excess Auto Liabllity ECO1956977539 EX80510142 11/1/2019 11/1/2019 11/1/2020 11/1/2020 Urnit/Aggregate 25,000,000 CSL Limit 4,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Holiday Inn Mansfield - 31 Hampshire Street, Mansfield, MA 02048 General Proof of Coverage CERTIFICATE HOLDER CANCFI.I. ATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment �-9/ Mailing Address: -id 17,54-101 mfi Phone/Fax Number: lid 9— JPa o Email: %j�2nDo�/�!I/�`U`D,C(%)7J a_Wf Contact Person/Title for Grease Traps: �/�C/C t �� q%�nU ���%�/���c�`Iv- Z91— Name 9rName of Company scheduled to pump internal grease trap(s) monthly: s-1dkk� Name of Company scheduled to pump external grease trap quarterly:8A Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date I a Print Name Facility Operational information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday Thursday 7a- -/ww Sunday Gl Tuesday �Q / In Friday 7a - 4a22 Wednesday Saturday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU / 3 compartment sink (] Handwashing sink S Commercial Dishwasher /) Barsink Mop Sink / Garbage Disposal jlU Ice Making Machines a nv Fryolators 00 Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes No Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? p/ Yes No Size / ��D gallons Where is the existing outdoor GRU located? :)Wzy)/ �r / , Jik/ cy d/ en If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Addres Property Owner's Telephone Number: "DOf - V J 06411y Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit How often is this grease storage unit Please list the vendor who removes the />/l /-888-x/&/- 9f3/ 3 !J Please list fixtures attached to each grease trap Grease Trap 1 // C c-/ r o' SC.�-1` Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? p/ Yes No Size / ��D gallons Where is the existing outdoor GRU located? :)Wzy)/ �r / , Jik/ cy d/ en If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Addres Property Owner's Telephone Number: "DOf - V J 06411y Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit How often is this grease storage unit Please list the vendor who removes the />/l /-888-x/&/- 9f3/ 3 !J