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HomeMy WebLinkAboutEpicurean Feast/Tyco (5 Hampshire) - 12/31/2019Commonwealth 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: RETAIL FOOD 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:. LPM HOLDING DBA EPICUREAN FEAST Whose place of business is: 5 HAMPSHIRE CAFE 5 HAMPSHIRE STREET PERSON(S) IN CHARGE: JAMES KAMPPER, GM Permit Expires: December 31, 2019 Food Fee: $125.00 License Number: RF-1 BOARD OF HEALTH MichaeCHeatey, Chairman ........ _.__................... . V\ M1V , FOR BOARD OF HEALTH USE ONLY Permit # Issued / FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: C-v,)"(-C 11� p n r����le4 �CSZo44 Establishment Address: S 'I'b9-r-t�' S)_'( ( M4A Establishment Mailing Address (if different): J M vl (K! "�' w7 r� Establishment Telephone No: 1W - rWL--- �" Nq d.b.r:�reA « EyPr r� z�sy Applicant Name &Title: P1°\ l A (�� Applicant Address: C�� f I.Yi,i S % r oy ry/ir� . Applicant Telephone No.: R i? ^ 9'37- 6 ka 24 Hour Emergency No.: t(,o 2a Applicant Email: K .ZM�rA")e' 1 P P^ \ L(" r'° M 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 O An Association partner. aA corporation ./N/�ame Title Address I-r ❑An Individual l AXE onmvpP j-- C,Fo qq___dhn(asi- 11 A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 5AMts t4 a M �2r l� Address: Sb Vjap+ra J "Rm �11Ke, �.Sitw t MA � fiL✓eu� Telephone No: 'ti6 I ' SKv - IlsS / J 24 Hour Emergency No: FAX: E-mail: J�Arh(OPGI©IloYhl a •(>DI Alt E-Mail: 3 f OC -'d IfpMl,Ci r oorA District Or Regional Supervisor (if applicable) Name & Title: ls_pccu� eot(_ DM(� Address: \\3 ��L� D ✓V'r DS ( 1, -Pm- k ll Telephone No: 1 7r - -/ 6 U -Y@ ZU 24 Hour Emergency No: 7 G 0 `'qA 2-b FAX: E-mail: ga" CJVFj,,� r,i &oPn 'TOWN OF MANSFIELD PAID__ -- APR 992019 - OQ mfy.DI}t Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: t DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Establishment Type: ❑ Caterer $35.00 Location: 1114ermanent Location Moblie Moblie Start Date: R: Retail -NO FOOD PREP ( Sq. Ft) $125 Q Milk & Cream $10.00 Moblie End Date: El Food Service up to 100 seats Mobile Food Moblie Comments: INCLUDING FOOD TRUCKS $175.00 ON NO PHF PREPARED ON SITE $100.00 Length of Permit: Food Service far 101 -200 seats $250,00 Q Manufacture Frozen Desserts/Ice Cream $25.00/freezer W-')Gnual --- -------------------- ❑ Food Service for 201+ seats $300.00 E] Pushcart $50.00 # of Pushcarts: Seasonal 0 Residential Kitchen 000 Seasonal Dates: Supermarkets $400 Q Tobacco Products $150.00 Temporary Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definilions PHF-Potentially hazardous food pime/temperature controls required) Non-PHFs - non -potentially hazardous tradition lime/temperature controls required) �(Check all that apply): RTE -ready-to-eat foods (Ex. sandw/ches, salads, muffins which need no furtherprocessing) _ _ '. sale of Commercially Pre -Packaged Non-PHFs 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 E] PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service --- --- Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Q Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Q Customer Self -Service of Non PHF and Non- 0 Customer Self -Service Perishable Perishable Foods Only - - contact alternative, time as a public health n Ice Manufactured and Packaged for ❑ Preparation of Non-PHFs Retail Sale control Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for E] Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service _ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health I Total Permit Fee: - - Payment is due with application 0 waived I, the undersigned, attest to the accuracy of the information establishment operation will ly with 105 CMR 590.000 board of health on how [o fain pies of 105 CMR.590.gfi Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. Social Security Number or Federal ID: 09 — )2 Signature of Individual or Corporate Name: L P M its application and affirm that the food applicable law. I have been instructed by the eral Food Code. of perjury that I, to my best knowledge and belief, have filed all state tax returns S ud 161A't� 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 tinder law. Signature of Individual orporate Name By: Corporate Officer (Mmldatol I Applicable) e9 - P1356v "*Social Security No. (Vohintnry) 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:\Users\sleite\Desktop\Scoffs Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassrrchusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 k1ri www. nrnss.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: a4 me#: Gi$ �S9'? -0>66 Are you an employer? Check the appropriate box: Business Type (required): LR I am a employer with �employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Iistablishment 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. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, § 1(4), and we have I 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. (No workers' comp. insurance req.] *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 # I. 7 am an employer that is providing worriers' con ensndoo insurance for my ennrployees. Below is the policy hilonnation. _ .. mac, Ct4y Insurance Company M Insurer's Address:��� S 1 ' IA, r _.._ .._ City/State/Zip: _ (U t,LfV1,)_y Policy # or Self -ins. Lie. # %n l✓ ,, 6 Q 6 y Ll �% Expiration Date: 0 I 16 1 t „ Ze 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 oMe DIA for insurance coverage verification. i do hereby �Iertify, ti�(ler ihef pins and penalties of perjury that the it formation provided hovels trite and correct. . 't0Zc) 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 A� D® CERTIFICATE OF LIABILITY INSURANCE F DATE (MMMDNWY) 04/03/2019 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 Roger Keith &Sons Insurance Agency Inc. 1575 Main Street Brockton MA 02301 CONTACT Elise FIano NAME: pIOC No Ent : (508) 583-1106 A C No): (608) 583-8478 E"MAIL ehano@rogerkeith.wm ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL II INSURERA: The Charter Oak Fire Insurance Company 25615 INSURED LPM Holding Co. Inc. dba Epicurean Feast 24 Main Street Maynard MA 01754 INSURER B: Travelers Property & Casualty Company ofAmenca 25674 INSURER C: Federal Insurance Company 20281 INSURER D: MA Retail Merchants WC Group Inc. INSURER E: 1 INSURER F: CnT/FRAr:FR CERTIFICATE NUMBER. 2019 LPM/EPICUREAN REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAGE 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 TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OFINSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYW POLICY EXP MMIDDIVYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 CLAIMS -MADE ® OCCUR R TED PREMISES Ea occurrence $ 1,000,000 MED EXP(Any one person) $ 10,000 A Y 630-6C830447 01/01/2019 01/01/2020 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 3,000,000 PRODUCTS - COMPfOP AGO $ 2,000,000 POLICY ❑ JECT LOC LIQUOR LIABILITY s 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accidents $ 1,000,000 BODILY INJURY (Perperson) $ ANYAUTO BODILY INJURY (Par acciden0 $ A OWNED SCHEDULED AUTOS ONLY AUTOS Ix HIRED NON OWNED AUTOS ONLY AUTOS ONLY 810-7C399675 01/01/2019 01/01/2020 PROPERTY DAMAGE Per accident $ S UMBRELLA LIAB v X OCCUR EACHOCCURRENCE $ 25,000,000 BEXCESS I LIAB CLAIMS -MADE ZUP-91M48908 01/01/2019 01/01/2020 AGGREGATE $ 25,000.000 DEC RETENTION $ C: EXCESS $ 35,000,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYCERIMEMBER/PARTNDED? CUTIVE ❑ Oandate in NH) EXCLUDED? (Mantlatary in NH) NIA UB-9H942545 01/01/2019 01/01/20201. OT !� STATUTE ER EL EACH ACCIDENT $ 1,000,000 EL. DIBEASE-EA EMPLOYEE $ 1,000,000 E1. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below Bl by Accident/Accident $1,000,000 D WORKERS COMP & EMP LIAB MASSACHUSETTS ONLY 01400502016119 01/01/2019 01/01/2020. el by DiseasePolicy Limit $1,000,000 BI by Disease/Employee $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: 5 HAMPSHIRE STREET MANSFIELD NIA POLICY LIMITS IN EFFECTAT POLICY INCEPTION. SNH MEDICAL OFFICE PROPERTIES TRUST, THE RMR GROUP LLC AREADDITIONAL INSUREDS AS REQUIRED IN WRITTEN CONTRACT WITH RESPECT TO GENERAL LIABILITY PER THE ATTACHED FORMS CDD2460805, CGD4670713. 30 DAYS NOTICE OF CANCELLATION TO CERTIFICATE HOLDER. r:ERTIPIr.ATF wn1 nER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The RMR Group LLC and SNH Medical Office Properties Trust ACCORDANCE WITH THE POLICY PROVISIONS. Two Newton AUTHORIZED REPRESENTATIVE 255 Washington Street Newton MA 02458 c//t,1• / ) 91988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY • •' This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended to Include any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Cover- age Part, but: a) Only with respect to liability for "bodily injury", "property damage" or "personal injury'; and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance' applies. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. 2. The insurance provided to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability re- quired by that "written contract requiring in- surance'. This endorsement shall not in- crease the limits of insurance described in Section III — Limits Of Insurance. b) The insurance provided to the additional in- sured does not apply to "bodily injury', "prop- erty damage' or "personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: I. The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and IL Supervisory, inspection, architectural or engineering activities. c) The Insurance provided to the additional in- sured does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products -completed op- erations hazard" unless the "written contract requiring insurance' specifically requires you to provide such coverage for that additional insured, and then the Insurance provided to the additional insured applies only to such "bodily injury" or "property damage' that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 1 The insurance provided to the additional insured by this endorsement is excess over any valid and collectible 'other insurance', whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply on a primary basis or a primary and non-contributory basis, this insurance is primary to 'other insurance' available to the additional insured which covers that person or organization as a named Insured for such loss; and we will not share with that 'other insurance'. But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible 'other In- surance', whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured when that person or organization is an additional insured under such 'other insur- ance'. 4. As a condition of coverage provided to the additional Insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an 'occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY 1. How, when and where the "occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and Ill. The nature and location of any injury or damage arising out of the "occurrence" or offense. b) If a claim is made or "suit" Is brought against the additional insured, the additional insured must: 1. Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c) The additional insured must Immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us In the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. d) The additional insured must tender the de- fense and indemnity of any claim or "suit" to any provider of "other Insurance" which would cover the additional Insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement Is primary to "other Insur- ance" available to the additional insured which covers that person or organization as a named Insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. — DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 46 06 05 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. !•. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE —This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage Is excluded or limited by such an endorsement. The following listing Is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Broadened Named Insured B. Blanket Additional Insured — Broad Form Vendors C. Damage To Premises Rented To You • Perils of fire, explosion, lightning, smoke, water • Limit increased to $300,000 D. Blanket Waiver Of Subrogation E. Blanket Additional Insured — Owners, Managers Or Lessors Of Premises F. Blanket Additional Insured —.Lessors Of Leased Equipment G. Incidental Medical Malpractice H. Personal Injury —Assumed By Contract PROVISIONS A, BROADENED NAMED INSURED 1. The following is added to SECTION 11— WHO IS AN INSURED: Any organization, other than a partnership or joint venture, over which you maintain owner- ship or majority interest on the effective date of the policy qualifies as a Named Insured. However, coverage for any such organization will cease as of the date during the policy pe- riod that you no longer maintain ownership of, or majority Interest in, such organization. 2. The following replaces Paragraph 4.a, of SECTION 11—WHO IS AN INSURED: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier, unless reported in writing to us within 180 days. 1. Amended Bodily Injury Definition J. Bodily Injury To Co -Employees And Co -Volunteer Workers K. Aircraft Chartered With Crew L. Non -Owned Watercraft — Increased From 25 Feet To 50 Feet M. Increased Supplementary Payments • Cost of bail bonds increased to $2,500 • Loss of earnings increased to $500 per day N. Knowledge And Notice Of Occurrence Or Offense 0. Unintentional Omission P. Reasonable Force — Bodily Injury Or Property Damage B. BLANKET ADDITIONAL INSURED — BROAD FORM VENDORS The following Is added to SECTION 11 — WHO IS AN INSURED: Any person or organization that is a vendor and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part Is an insured, but only with re- spect to liability for "bodily injury" or "property damage" that: a. Is caused by an "occurrence" that takes place after you have signed and executed that con- tract or agreement; and b. Arises out of "your products" which are dis- tributed or sold in the regular course of such vendor's business. The insurance provided to such vendor is subject to the following provisions: a. The limits of Insurance provided to such ven- dor will be the limits which you agreed to pro- CG D4 67 07 13 © 2013 The Travelers Indemnity Company, All right reserved. Page 1 of 7 Includes copyrighted material of Insurance Services Office, Inc. with Its permission. COMMERCIAL GENERAL LIABILITY vide in the written contract or agreement, or the limits shown in the Declarations of this Coverage Part, whichever are less. b. The insurance provided to such vendor does not apply to: (1) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (2) Any express warranty unauthorized by you; (3) Any physical or chemical change in "your products" made intentionally by such vendor; (4) Repackaging, unless unpacked solely for the purpose of Inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; (5) Any failure to make such inspections, ad- justments, tests or servicing as vendors agree to perform or normally undertake to perform in the regular course of business, in connection with the distribution or sale of "your products' (6) Demonstration, installation, servicing or repair operations, except such operations performed at such vendor's premises in connection with the sale of "your prod- ucts"; or (7) "Your products" which, after distribution or sale by you, have been labeled or re- labeled or used as a container, part or in- gredient of any other thing or substance by or for such vendor. Coverage under this provision does not apply to: a. Any person or organization from whom you have acquired "your products", or any ingre- dient, part or container entering into, accom- panying or containing such products; or b. Any vendor for which coverage as an addi- tional Insured specifically is scheduled by en- dorsement. Exclusions c. through In. do not apply to dam- age to premises while rented to you, or tem- porarily occupied by you with permission of the owner, caused by: a. Fire; b. Explosion; c. Lightning; d. Smoke resulting from such fire, explosion, or lightning; or e. Water. A separate limit of insurance applies to such damage to premises as described in Para- graph 6. of Section III — Limits Of Insurance. This insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with permission of the owner, caused by: a. Rupture, bursting, or operation of pres- sure relief devices; b. Rupture or bursting due to expansion or swelling of the contents of any building or structure, caused by or resulting from wa- ter; c. Explosion of steam boilers, steam pipes, steam engines, or steam turbines. 2. The following replaces Paragraph 6, of SEC- TION III— LIMITS OF INSURANCE: Subject to 5, above, the Damage To Prem- ises Rented To You Limit is the most we will pay under Coverage A for damages because of "property damage" to any one premises while rented to you, or temporarily occupied by you with permission of the owner, caused by fire; explosion; lightning; smoke resulting from such fire, explosion, or lightning; or wa- ter. The Damage To Premises Rented To You Limit will apply to all damage proximately caused by the same "occurrence", whether such damage results from fire; explosion; lightning; smoke resulting from such fire, ex- plosion, or lightning; water; or any combina- tion of any of these. The Damage To Premises Rented To You Limit will be the higher of: C. DAMAGE TO PREMISES RENTED TO YOU a. $300,000; or 1. The following replaces the last paragraph of b. The amount shown on the Declarations of Paragraph 2., Exclusions, of SECTION I — this Coverage Part for Damage To Prem- COVERAGES — COVERAGE A BODILY IN- ises Rented To You Limit. JURY AND PROPERTY DAMAGE LIABIL- ITY: Page 2 of 7 © 2013 The Travelers Indemnity company. All right reserved. CG D4 67 07 13 Includes copyrighted material of Insurance Services Office, Inc. with Its permission. 3. The following replaces Paragraph a. of the definition of "insured contract" In the DEFINI- TIONS Section: a. A contract for a lease of premises. How- ever, that portion of the contract for a lease of premises that indemnifies any person or organization for damage to premises while rented to you, or tempo- rarily occupied by you with permission of the owner; caused by: (1) Fire; (2) Explosion; (3) Lightning; (4) Smoke resulting from such fire, ex- plosion, or lightning; or (5) Water. is not an "insured contract' 4. The following replaces Paragraph 4.b.(1)(b) of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: (b) That is insurance for premises rented to you, or temporarily occupied by you with the permission of the owner; D. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8„ Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LI- ABILITY CONDITIONS; We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of premises owned or occupied by or rented or loaned to you; ongoing operations performed by you or on your behalf, done under a contract with that person or organization; "your work; or "your products", We waive this right where you have agreed to do so as part of a written contract, executed by you prior to loss. E. BLANKET ADDITIONAL INSURED — OWNERS, MANAGERS OR LESSORS OF PREMISES The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that is a premises owner, manager or lessor and that you have agreed in a written contract or agreement to name as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily Injury", "property damage", "personal injury' or"advertising injury" that: COMMERCIAL GENERAL LIABILITY a, Is "bodily injury" or "property damage" caused by an 'occurrence" that takes place, or "per- sonal injury' or "advertising injury' caused by an offense that is committed, after you have signed and executed that contract or agree- ment; and b. Arises out of the ownership, maintenance or use of that part of any premises leased to you. The insurance provided to such premises owner, manager or lessor is subject to the following pro- visions: a. The limits of insurance provided to such premises owner, manager or lessor will be the limits which you agreed to provide in the written contract or agreement, or the limits shown on the Declarations of this Coverage Part, whichever are less. b. The Insurance provided to such premises owner, manager or lessor does not apply to: (1) "Bodily injury' or "property damage" caused by an "occurrence" that takes place, or "personal injury' or "advertising Injury' caused by an offense that is com- mitted, after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such premises owner, manager or lessor. c. The insurance provided to such premises owner, manager or lessor is excess over any valid and collectible other insurance available to such premises owner, manager or lessor, unless you have agreed in a written contract for this Insurance to apply on a primary or contributory basis. F. BLANKET ADDITIONAL INSURED — LESSORS OF LEASED EQUIPMENT The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that Is an equipment lessor and that you have agreed in a written con- tract or agreement to include as an additional in- sured on this Coverage Part is an Insured, but only with respect to liability for "bodily injury", "property damage", "personal injury' or "advertis- ing injury" that: a. Is "bodily injury' or "property damage" caused by an 'occurrence" that takes place, or "per- sonal injury" or "advertising Injury' caused by an offense that Is committed, after you have CG D4 67 07 13 @ 2013 The Travelers Indemnity Company. All right reserved. Page 3 of 7 Includes copyrighted material of Insurance Services office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY signed and executed that contract or agree- "Good Samaritan services" means any emer- ment; and gency medical services for which no compen- b. Is caused, In whole or in part, by your acts or sation is demanded or received. omissions in the maintenance, operation or 3. The following is added to Paragraph 2.a.(1) of use by you of equipment leased to you by SECTION 11— WHO IS AN INSURED: such equipment lessor. Unless you are in the business or occupation The Insurance provided to such equipment lessor of providing professional health care services, is subject to the following provisions: Paragraphs (1)(a), (b), (c) and, (d) above do a. The limits of insurance provided to such not apply to any "bodily injury" arising out of equipment lessor will be the limits which you any providing or failing to provide "incidental agreed to provide in the written contract or medical services" by any of your "employ - agreement, or the limits shown on the Decla- ees", other than an employed doctor. Any rations of this Coverage Part, whichever are such "employees" providing or failing to pro - less. vide "incidental medical services" during their work hours for you will be deemed to be act- b. The insurance provided to such equipment ing within the scope of their employment by lessor does not apply to any "bodily injury" or you or performing duties related to the con - "property damage" caused by an "occur- duct of your business. rence" that takes place, or "personal Injury" or "advertising 4. The following exclusion Is added to Para - injury" caused by an offense that is committed, after the equipment lease ex- graph 2., Exclusions, of SECTION I — COW pires. ERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: c, The insurance provided to such equipment lessor is excess over any valid and collectible Sale Of Pharmaceuticals other insurance available to such equipment "Bodily injury" or "property damage" arising lessor, unless you have agreed in a written out of the willful violation of a penal statute or contract for this insurance to apply on a pri- ordinance relating to the sale of pharmaceuti- mary or contributory basis. cats committed by, or with the knowledge or G. INCIDENTAL MEDICAL MALPRACTICE consent of, the insured. 1. The following is added to the definition of "oc- 5. The following Is added to Paragraph 5. of currence" in the DEFINITIONS Section: SECTION III — LIMITS OF INSURANCE: Unless you are in the business or occupation For the purposes of determining the applica- of providing professional health care services, ble Each Occurrence Limit, all related acts or "occurrence" also means an act or omission omissions committed in the providing or fail - committed in providing or failing to provide ing to provide "incidental medical services" to "incidental medical services" to a person. any one person will be considered one "oc- currence". 2. The following is added to the DEFINITIONS Section: 6. The following is added to Paragraph 4.b., Ex - cess Insurance, of SECTION IV — COM- "Incidental medical services" means: MERCIAL GENERAL LIABILITY CONDI- a. Medical, surgical, dental, laboratory, x-ray TIONS: or nursing service or treatment, advice or This insurance is excess over any valid and instruction, or the related furnishing of collectible other Insurance, whether primary, food or beverages; excess, contingent or on any other basis, that b. The furnishing or dispensing of drugs or is available to any of your "employees" for medical, dental, or surgical supplies or "bodily injury" that arises out of providing or appliances; failing to provide "Incidental medical services" c. First aid; or to any person to the extent not subject to Paragraph 2.a.(1) of SECTION It — WHO IS d. "Good Samaritan services". AN INSURED. Page 4 of 7 © 2013 The Travelers Indemnity Company. All right reserved. CG 04 67 07 13 Includes copyrighted material of Insurance Services Office, Inc. with its permission. H. PERSONAL INJURY — ASSUMED BY CON- TRACT 1. The following replaces Exclusion a., Contrac- tual Liability, in Paragraph 2, of SECTION I — COVERAGES — COVERAGE B PER- SONAL AND ADVERTISING INJURY LI- ABILITY: e, Contractual Liability "Personal injury" or "advertising Injury" for which the insured is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to: (1) Liability for damages that the insured would have in the absence of the contract or agreement; or (2) Liability for damages because of "personal Injury" assumed in a con- tract or agreement that is an "insured contract", provided that the "personal injury" is caused by an offense com- mitted subsequent to the execution of the contract or agreement. Solely for the purposes of liability assumed In an "insured contract", reasonable at- torneys fees and necessary litigation expenses incurred by or for a party other than an Insured will be deemed to be damages because of "personal injury", provided that: (a) Liability to such party for, or for the cost of, that party's defense has also been assumed in the same "Insured contract'; and (b) Such attorney fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this In- surance applies are alleged. 2. The following replaces the third sentence of Paragraph 2, of SUPPLEMENTARY PAY- MENTS — COVERAGES A AND B: Notwithstanding the provisions of Paragraph 2,b.(2) of Section I — Coverage A — Bodily In- jury And Property Damage Liability or Para- graph 2,e, of Section I — Coverage B — Per- sonal and Advertising Injury Liability, such payments will not be deemed to be damages because of "bodily injury", "property damage" or "personal Injury", and will not reduce the limits of Insurance. COMMERCIAL GENERAL LIABILITY 3. The following replaces Paragraph 2.d, of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B: d. The allegations in the "suit" and the in- formation we know about the "occur- rence" or offense are such that no conflict appears to exist between the interests of the insured and the Interests of the in- demnitee; 4. The following replaces the first subparagraph of Paragraph f. of the definition of "insured contract" in the DEFINITIONS Section: f. That part of any other contract or agree- ment pertaining to your business (includ- ing an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury," "property damage" or "per- sonal injury" to a third person or organiza- tion. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. I. AMENDED BODILY INJURY DEFINITION The following replaces the definition of "bodily in- jury" in the DEFINITIONS Section: "Bodily injury" means bodily injury, mental an- guish, mental injury, shock, fright, disability, hu- miliation, sickness or disease sustained by a per- son, including death resulting from any of these at any time. J. BODILY INJURY TO CO -EMPLOYEES AND CO -VOLUNTEER WORKERS The following is added to Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: Paragraph (1)(a) above does not apply to "bodily Injury" to a co -"employee" In the course of the co - "employee's" employment by you or performing duties related to the conduct of your business, or to "bodily injury" to your other "volunteer workers" while performing duties related to the conduct of your business. K. AIRCRAFT CHARTERED WITH CREW The following is added to Exclusion g., Aircraft, Auto Or Watercraft, in Paragraph 2, of SECTION I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABILITY: This exclusion does not apply to an aircraft that is: CG D4 67 07 13 © 2013 The Travelers indemnity company. All right reserved. Page 5 of 7 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY (a) Chartered with crew to any insured; (b) Not owned by any insured; and (c) Not being used to carry any person or prop- erty fora charge. L. NON -OWNED WATERCRAFT 1. The following replaces Paragraph (2) of Ex- clusion g., Aircraft, Auto Or Watercraft, in Paragraph 2, of SECTION I - COVERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: (2) A watercraft you do not own that is: (a) Fifty feet long or less; and (b) Not being used to carry any person or property for a charge. 2. The following is added to Paragraph 2. of SECTION II — WHO IS AN INSURED: Any person or organization that, with your ex- press or implied consent, either uses or is re- sponsible for the use of a watercraft that you do not own that is: (1) Fifty feet long or less; and (2) Not being used to carry any person or property for a charge. M. INCREASED SUPPLEMENTARY PAYMENTS 1, The following replaces Paragraph 1.b. of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION I - COVER- AGES: b. Up to $2,500 for cost of bail bonds re- quired because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to fur- nish these bonds. 2. The following replaces Paragraph 1.d. of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION 1 — COVER- AGES: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. N. KNOWLEDGE AND NOTICE OF OCCUR- RENCE OR OFFENSE The following Is added to Paragraph 2., Duties In The Event of Occurrence, Offense, Claim or Suit, of SECTION IV — COMMERCIAL GEN- ERAL LIABILITY CONDITIONS: e. The following provisions apply to Paragraph a. above, but only for the purposes of the in- surance provided under this Coverage Part to you or any Insured listed in Paragraph 1. or 2. of Section 11— Who Is An insured: (1) Notice to us of such "occurrence" or of- fense must be given as soon as practica- ble only after the "occurrence" or offense is known to you (if you are an individual), any of your partners or members who is an individual (if you are a partnership or joint venture), any of your managers who is an individual (if you are a limited liability company), any of your trustees who is an individual (if you are a trust), any of your "executive officers" or directors (if you are an organization other than a partnership, joint venture, limited liability company or trust) or any "employee" authorized by you to give notice of an "occurrence" or offense, (2) If you are a partnership, joint venture, lim- ited liability company or trust, and none of your partners, joint venture members, managers or trustees are individuals, no- tice to us of such "occurrence" or offense must be given as soon as practicable only after the "occurrence" or offense is known by: (a) Any individual who is: (1) A partner or member of any part- nership or joint venture; (ii) A manager of any limited liability company; (III) A trustee of any trust; or (iv) An executive officer or director of any other organization; that is your partner, joint venture member, manager or trustee; or (b) Any "employee" authorized by such partnership, joint venture, limited li- ability company, trust or other organi- zation to give notice of an "occur- rence" or offense. (3) Notice to us of such 'occurrence" or of- fense will be deemed to be given as soon as practicable if it is given in good faith as soon as practicable to your workers' compensation insurer. This applies only if you subsequently give notice to us of the "occurrence" or offense as soon as prac- ticable after any of the persons described Page 6 of 7 © 2013 The Travelers Indemnity Company. All right reserved. CG D4 67 07 13 Includes copyrighted material of Insurance Services Office, Inc. with Its permission. in Paragraphs e.(1) or (2) above discov- ers that the 'occurrence" or offense may result in sums to which the insurance provided under this Coverage Part may apply. However, if this policy includes an endorse- ment that provides limited coverage for "bod- ily injury" or "property damage" or pollution costs arising out of a discharge, release or escape of "pollutants' which contains a re- quirement that the discharge, release or es- cape of "pollutants" must be reported to us within a specific number of days after Its abrupt commencement, this Paragraph a, does not affect that requirement. O. UNINTENTIONAL OMISSION The following is added to Paragraph 6., Repre- sentations, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: The unintentional omission of, or unintentional er- ror in, any information provided by you which we COMMERCIAL GENERAL LIABILITY relied upon In issuing this policy will not prejudice your rights under this insurance. However, this provision does not affect our right to collect addi- tional premium or to exercise our rights of cancel- lation or nonrenewal in accordance with appiica- ble insurance laws or regulations. P. REASONABLE FORCE — BODILY INJURY OR PROPERTY DAMAGE The following replaces Exclusion a., Expected Or Intended Injury, in Paragraph 2. of SECTION I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABILITY: a. Expected or Intended Injury or Damage "Bodily injury" or "property damage" expected or intended from the standpoint of the in- sured. This exclusion does not apply to "bod- ily injury" or "property damage" resulting from the use of reasonable force to protect any person or property. CG D4 67 07 13 @ 2013 The Travelers Indemnity Company. All right reserved. Page 7 of 7 Includes copyrighted material of Insurance services Office, Inc. with its permission. Q FBI, for successfully completing the standards set forth for which is accredited by the American National Stam roger Certification Examination, for Food Protection (CFP). 1 /30/2018 1/30/2023 DATE OF EX DATE OF EXPIRATION Local laws apply. Che ry for recertification requiremenls. 5o1ution6 - EliMp O uI ReYwmMAvaionomHorA Aeart deign Conlin us wilt quesnw o1233 S. W-6fa ,Svh 36A^,Uius , IL W6066383 ur ServSde@mWimrag. C Name of Recipient: JAMSS K MPPER Certificate Number: 2749420 Date of Completion: 112-17 Date of Expiration: 1120rz 2 Die above -named person is beteby issned tbis rertlfieate fa completing an allergen awareness training piogiam recognized by the Nlasawburetts Departnient ofPubGr Heald) in accordance wit)105 l 590.009(G)(1)(a). Diis rertifirate will be valid fa five (5) yeas f ranidate ofmapleBm:. Issncd By: RATIONAL`i RESTAURANT ASSOCIATION, Massachusetts Restaurmt Association 800.765,2122 333 Twnpikc Road, Su&c 102 wrvsv.rcsRnrnntorg Southharough,AIA 01772 508-303A905 www,marcstnur ntassoc.org B 25.00 the to the Town TOWN OF BOARD OF HFALTH- nllJ APR 0 9 1019 GNECKd 125.0 $ 125.00 Bank N PktN