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HomeMy WebLinkAboutEpicurean Feast/Tyco (West St.) - 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: 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:. LPM HOLDINGS CO., INC. Whose place of business is: EPICUREAN FEAST @ TYCOIKENDALL 777 WEST STREET PERSON(S) IN CHARGE: SHEILA WOOD, MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-24 BOARD OF HEALTH MichaeCHealey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLI`CATIUN (Application must be submitted at least 30 days before the planned opening date) hment NameSE jCG hment Address: ( e S {- hment Mailing Address(if different): <� { (Ili A.? Pi- F Yeavr a Cr��s�t hment Telephone No.: ���6 - %�tG i - �v cC Applicant Name & Title:dt Applicant Address: 1p��1e ¢� S f Yf444 dY ci l tom- C t`(.g"v Applicant Telephone No.: CW _ Pill -Uf L c, 24 Hour Emergency No.: -c (C" Applicant E-mail: K A jk be A Lk C[ f Mc Owner Name & Title (If different from applicant): Owner Address: -)y Ad'� e(-e Owner Telephone No.: Ct i `7 ` -o G (k C Owner E-mail: Kim b o Lk c I CA,, /10,', C c e✓t Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. U-A-corporation Name Title Address An Individual C i' f Y I. L',�L _El w O �C ( dr „Sr, fltt I A Partnership O Other legal Entity -- Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: %e i h W o o h�-f Address: 9111 � A- i�'+' I K u T 0 f- - ' s cti Telephone No: rj r7 `F - C F " 24 Hour Emergency No: FAX: l i - fcl-I - `11 I c( E-mail: t-e)C�n&, (D C 0 o ; CoftA AltE-Mail: IF deer-D ej C LN t District Or Regional Supervisor (if applicable) Name & Title: I\`t f E C I Q ur e f� Ee' tom- ^ Address: t e f F y Si • C[ i 0 f-' t� Telephone No: CI rjV - -61 6 - Lf a del 24 EmergencyHour No: e 1r�'G=LC. FAX: c(f1 C� i^ ..� �iC( E-mail: R uce V �r Z � &�C i. c E n i Food Establishment Information WATER SOURCE: U)ii-) SEWAGE DISPOSAL: TC L p� DEP Public Water Supply No: (If applicable) No. of Food Employees: I DAYS/HOURS: W�_ C- rlhIlk- 3` f (VA Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. G�l� �a iL'1t`d Person Trained in Anti -Choking Procedures (If 25 Seats or more): E Location: Permanent Location Establishment Type El Caterer $35.00 QMoblie Mobile Start Date: E Retail ( Sq. Ft) Q-tdlilk & Cream $10.00 Mobile End Date: Q'Food Service up to 100 INCLUDING ❑ Mobile Food Consessicn Mobile Comments: FOOD TRUCKS $176.00 Food Service up to 101 -200 $250.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length Of Permit: Annual E Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Seasonal Seasonal Dates: Supermarkets $400 ElSu P Residential Kitchen $100.00 E Retail Food $125.00 Temporary Temporary Start Date: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF- Potentially hazardous food(timeRemperature controls required) Non-PHF's - non -potentially hazardous tood(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat roods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs [J.PHFCooked To Order of 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 Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly 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- ustomer SeIfService LI Use of Process Requiring A Variance Perishable Foods Only - and/or HACCP Plan (including bare hand El Ice Manufactured and Packaged for contact alternative, time as a public health L,rPreparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for Ej Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for El Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: % 3 J ' C z� Payment is due with application E 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 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. Signature of Individual or Corporate Name: fro`_ ['t G-_& n =( Social Security Number or Federal ID: )- ) I7 f> 0 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. ^� 1 Signature of Individual or Grporate Name By: Co porate Of or ( andatory, if Applicable) U`t -A,�1 .),I C,C *"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:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc i The Commonwealth ofMassaehusetts Department oflndustrial 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 J-Pim , L-EGt=e bW e4f-i- Business/Organization Name: d-t - Cc (KNutd a ti fivt i43eSt- .St - Address: � -I KA t L > -_( I+ Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with S'&Ci employees (full and/ 5. ❑ Retail 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. [No workers' comp. insurance required] 8. ❑ Non-profit 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 no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. ❑ Other C',�_ Fe te- L *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 isproviding workers' compensation insurance for• my employees. Below is the policy information. Insurance Company Name: Insurer's Address: V (} , k (y k J, L4 City/State/Zip: A�64j r Policy # or Self -ins. Lic. #1 �� (o [ ( Expiration 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 cerfifY, under the pains and penalties of perjury that the information provided above is true and correct. —6i-,uo 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 ACORb® CERTIFICATE OF LIABILITY INSURANCE 11..% DArE(MMbonvyv) 1 11/20/2018 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(ies) 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 NAME: T Jenell0 Litto (508)583-1106 p/C N0:(508)583-8478 Roger Keith a Sons 1575 Main Street MoErl. EMAIL jlitto@rog erkeith.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A:TRAVELERS 25623 Brockton MA 02301 INSURED INSURERB:MA Retail Merchants WC Group INSURER C:FFEDERAL INSURANCE 20281 LPN Holding Co. inc. INSURERD:NH ASSOCIATION MEMBERS NOT dba Epicurean Feast Food Service INSURER E: 24 Main Street 1 INSURER F: Maynard NA 01754 COVERAGES CERTIFICATE NUMBER:2018 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 AOD SUER POLICY NUMBER MMIDD� EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE OCCUR PREMISES Ea=.AMAGE TO menca $ 1,000,000 MEO EXP(Any one person) $ 10,000 6306CS30447 1/1/2018 1/l/2019 PERSONAL &ADV INJURY $ 1,000,000 included liquor liability GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 $1,000,000 limit X POLICY [:] RI- JEC 1-1OC PRODUCTS - COMPIOPAGG $ 2,000,000 Liquor Liability $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS 8107C399675 1/1/2018 1/1/2019 BODILY INJURY (Per accident) $ PROPER-r.colden DAMAGE $ HIRED AUTOS NON-OWNED $1,000 DEDUCT1eLES A X UMBRELLA LIAB OCCUR ZUP91N4890816 1/l/2018 1/1/2019 EACH OCCURRENCE $ 25,000,000 X N AGGREGATE $ 25.000 000 L, EXCESS LIAB CLAIMS -MADE DEC) I X I RETENTION$ 10,000 35,000,000 $ 35,000,000 1 79082528 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OT - X STATUTE ER A ANY I OFFICERIMEMBER EXCLUDED?]N/A (Mandatory In NH) P,TUS6C87139-8-16 1/1/2018 1/1/2019 E.L. EACH ACCIDENT $ 1,000,000 E.L. E.L. DISEASE - EA EMPLOYEE $ 1.000,000 Oyes,Ounder DESCRIPTION OF OPERATIONS below AZ,CT,NEYYT ,NT,N,PA,RI, E.L. DISEASE -POLICY LIMIT $ 1,000,000 B WORKRRS COMP. MA ONLY 014000502016118 1/l/2018 1/1/2019 1,000,000/1,000,000/1,000,000 WORKERS COMP. NH ONLY 030009100240118 1/1/2018 1/1/2019 1,000,000/1'W0,0W/1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) POLICY LINITS IN EFFECT AT POLICY INCEPTION TOWN OF MANSFIELD 6 PARK ROW MANSFIELD, INA 02048 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 DUNN/KEIJJ1 5�J L - C.y��__ ACORD 25 (2014/01) INS025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD In M rn 00 IT Ln 0 n O rl .a O Z LU h C U LL H 1- C W V