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HomeMy WebLinkAboutEpicurean Feast/Tyco (100 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: 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 @ TYCOXENDALL 100 HAMPSHIRE STREET PERSON(S) IN CHARGE: BRIAN CLOUGHERTY, MANAGER Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS -23 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream 0 rs FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: f. f a j Co Cdr 11 Establishment Address: Establishment Mailing Address(if different): Establishment Telephone No.: Applicant Name & Title: i -e , Applicant Address: Applicant Telephone No.: 7`ly - yCi U U, C 24 Hour Emergency No.: Applicant E-mail: Ed z ($a' (kc` CGS Owner Name & Title (If different from applicant): = IV L - 1t L' c r A'.° e - OwnerAddress: -Jt Owner Telephone No.: eq (,2Lc Owner E-mail:�} a IiQ f', CC, tit it Qc1�l �- �o� Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. �A Corporation Name Title Address O An Individualk r ;E>si�1 4 i +_hS G �� �F tYI� C_ fV � ( tyd C t O A Partnership }lid.{Sc r t)�Wi i IL 11 s V El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: tI€} bLt4iI�.f Address: ,% Telephone No:: v ; - r_� I P 6'G 24 Hour Emergency No: FAX: r i ` 3 E-mail: C~C1( 'fuI a C C s^c n E23�f cec� Alt E -Mail: f..) titikf�' lY (fCs�• �� �� District Or Regional Supervisor (if applicable) Name & Title: R+i A'e (l (A u.e'et oN c__' Address: 1, t' G e r fi y tT-t— CI Telephone No: qqV - 4116-- qMt 24 Hour Emergency No: FAX: C(q f , k qj -, i i � E-mail: r E tFeeti3r, l 1 fv� t�.� . �C to yt Food Establishment Information WATER SOURCE: rF SEWAGE DISPOSAL: tvb DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS:(V� �ri nk — Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Pja" -tom' Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: ': Permanent Location Establishment Type E] Caterer $35.00 Q Moblie Moblie Start Date: Q Retail ( Sq. Ft) 94ilk & Cream $10.00 Moblie End Date: Food Service up to 100 INCLUDING Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 9 -food Service up to 101 -200 $250.00 E] Food Service up to 201 + $300.00 I3 Supermarkets $400 Frozen Desserts/Ice Cream $25.00/freezer Q Pushcart $50.00 # of Pushcarts: I� Residential Kitchen $100.00 Retail Food $125.00 Length of Permit:EiManufacture [gnnual -- - -- Q Seasonal Seasonal Dates: 0 -Temporary Temporary Start Date: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food(timeRempereture controls required) Non-PHFs - non -potentially hazardous food(no time/temperatum controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads muffins which need no furfherprocessing) aale of Commercially Pre -Packaged Non-PHFs U-15HFCooked 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 Cold Holding For Single Meal Service �HF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs Q Sale of Raw Animal Foods Intended to be Prepared by Consumer �Reheatmg of Commercially Processed Foods for Service Within 4 Hours EJ Vacuum Packaging / Cook Chill ice- Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ E] Customer Self -Service of Non PHF and Non- Perishable Foods Only y (] Customer Self -Service Ice Manufactured and Packaged for Retail Safe Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin _ (] Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: C��+ _ L C Payment is due with application El 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 knovrledge and belief, have fled all state tax returns and paid state taxes required under law. i ) Signature of Individual or Corporate Name: :J\ { .� Social Security Number or Federal ID: �_ 6 fbL 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. t Signature of Individual r Corporate Name By: Corp rate Office Mandatory, if Applicable) **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scot`s Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: 24 City/State/Zip: Phone#: V+q)`6-(,ec r - Are you an employer? Check the appropriate box: Business Type (required): 1. [9/I am a employer with 1�0 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] $• ❑ 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.[31 Other( a k 4-p r= i 1 - Fe, 6,(t S P p_i ` . k e_ *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: U 7 { � 1 � � rl ilt S I LI Lk n u p .i �—,C Insurer's Address: City/State/Zip: I�f ( �y Policy # or Self -ins. Lic. # 0 1 �t ti O .'/ b o �� (� Expiration Date:III f 1 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. Phone #: I t� — Lcm - o GGG- 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: www.mass.gov/dia Phone N M O P' E ti �V � V O O _ p .o_ m a ?c o CD `a o N s u v m ® N U c w O � N V O N G O O Q V V � � o Z v v N 3 G N aaaass��� O N r �Q O s c v w N v C h p z io S C�9Ti � 2 V c u Q Y a s u w a a v u Im Ln u p u o as P' ti to y V O O _ W \F F T CD Q V V N s u v ® N W n o� � N Q Q V Gl v A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 11/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ctRtrIFPCA'i E 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 Roger Keith & Sone 1575 Main Street Brockton MA 02301 CONTACT Janelle Litto NAME: PNFpCCo (5087503-8470 San, o: E-MAIL ADDRESS: jlitto@rogerkeith.com INSURERS AFFORDING COVERAGE NAICP INSURER A:TRAVELERS 25623 INSURED LPN Holding Co. Inc. dba Epicurean Feast Food Service 24 Main Street Maynard ; MA 01754 INSURERB:MA Retail Merchants WC Grou INSURER C:FFEDERAL INSURANCE 20281 INSURERD:NH ASSOCIATION MEMBERS WCT INSURER E: INSURER F: 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 1 POLICY NUMBER MMIDDY� MhUDDYIYVYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE X OCCUR DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ MED UP (Any one person) $ 10,000 63060830447 1/1/2018 1/1/2019 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 0 PECT RO- ❑ LOC J PRODUCTS - COMP/OP AGO $ 2,000,000 Liquor Liability $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea aocident BODILY INJURY (Per person) $ A X ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS 81070399675 1/1/2018 1/1/2019 BODILY INJURY (Per accident) $ DAMAGE Poraaident $ NONOWNEDPROPERTY HIRED AUTOS AUTOS $1,000 DEDUCTIBLES A X UMBRELLA LIABX OCCUR ZUP93M4890816 1/1/2018 1/1/2019 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 L, X EXCESSLIAB CLAIMS -MADE DED X RETENTIONS 10,000 1 35,000,000 $ 35,000,000 79882528 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY OFFICER/MEIMBER EXCLUDED? ETORIPARTNERJEXECUTIVE ry] (Mandatory in NH) N / A PJOB 6C87139-8-16 1/1/2018 1/1/2019.} X STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYE $ 1,000,000 If describunder DESCRIPTION O OFOPERATIONS below MZAZ,CT,,NJ,=,PA,RI,VT E.L. DISEASE -POLICY LIMIT $ 1,000.000 B WORERES COMP. MA ONLY 014000502016118 1/1/2018 1/1/2019 1,000,00011,000,00011,000,000 WORKERS COME. US ONLY 030009100240118 1/1/2018 1/1/2019 1,000,00011,000,000/1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) POLICY LIMITS IN EFFECT AT POLICY INCEPTION CFRTIFICATF HOLDER CANCELLATION ACORD 25 (2014101) INS026 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF MANSFIELD 6 PARK ROW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE DONOVAN DUNN/KEIJJI ACORD 25 (2014101) INS026 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD