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Home My WebLink AboutCovidien - 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 HOLDING CO., INC. Whose place of business is: COVIDIEN 15 HAMPSHIRE STREET PERSON(S) IN CHARGE: GERALD PACE, MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -14 BOARD OF HEALTH MichaeCHeatey, Chairman Milk & Cream �aetr a 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: et L& c �.�.✓ Establishment Address: )1 HktwOafpo Establishment Mailing Address(if different): A4 Establishment Telephone No.: ;� _ `{ l l t Applicant Name & Title: Ka i e�> % t't tl; Ai f Ak-__4 , Applicant Address: cz`h $)'fid i t, zsf ju p�� `-Ai old � O I q S Applicant Telephone No.: eq '1 �GC C� 24 Hour Emergency No.: -t']d 40f 1 'C; C (' C' Applicant E-mail: i t ptb Cd�-< ( Ak C G Owner Name & Title (If different from applicant): �J aW 40L� ri d P -7- E-' C " Owner Address: 0�4 Ill? f Owner Telephone No.: q'jP-- d i) GCv p Owner E-mail: e4w_ ('rice_ Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. L4 Corporation El An individual Name Title Address El A Partnership �a� tai C� +tSor �i it " " It it u Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: [tilt) 1 Ct(L vz` f�ei`i��_ i itl Address: I1 ,J kc 'S ° Telephone No: �5 u 1-`� 1 7 24 Hour Emergency No: 4'C FAX: `i 1 V �q `� - :3 r1 I q E-mail C cuCo r��%hey, CCrA Alt E -Mail: rc,�-rL a t 4 District Or Regional Supervisor (if applicable) Name & Title: C( G�kt* e k.l (_� 1" k) e r -t Sr- - C'. I i i T -,:,r (VIA b t 6 r Address: -)-i Telephone No: 24 Hour Emergency No:P1 FAX: CI FIV 3 �A (tl E-mail: ( iL C_ ' I-- Q C i , C G vrc Food Establishment Information WATER SOURCE: v;- SEWAGE DISPOSAL: iz / No. of Food Employees: DEP Public Water Supply No: (if applicable) DAYS/HOURS:, til _ Pht Name of Person In Charge Certified in Food Protection Management �^ individuals list is file. If more than 3 are certified, complete on Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: `. Permanent Location Establishment Type Caterer $35.00 ❑Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) [b 41k & Cream $10.00 Mobile End Date: [J'Food Service up to 100 INCLUDING ❑ Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Q Food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/ice Cream $25.00/freezer Len th of Permit: �: - Annual Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts-, ❑ Residential Kitchen $100.00 Seasonal Seasonal Dates: E] Supermarkets $400 Retail Food $125.00 E] Retail Snack Food $50.00 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain. Date: Food Operations Definitions:PHF- Potentiallyhezardous food(timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches,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 Sate of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And I] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer IE] Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Vaba and/or HACCP Plan (including barere hand Customer Self -Service of Non PHF and Non- Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Q Offers Raw Or Undercooked Food Of Retail Sale Origin ,Animal El/prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Foode by the Board of Health obcompleted 4 Total Permit Fee: �' l .j, Payment is due with application ❑ 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 59,p.000 and tjre 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: V: r a Social Security Number or Federal ID: � C�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 under law. �i r r' ( } � 1t4, -,, )_ -1 ,- Signature of Individual Corporate Name By: Co orate Offi, (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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of, Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Address: Phone #: 14- I`1J� Are you an employer? Check the appropriate box: Business Type (required): 1. M I am a employer with ,j i%c 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. E] Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care with no employees. [No workers' comp. insurance req.] 12.S -Other eclft' ' 3 -f3< t11.0 *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 nolicv information. Insurance Compal Insurer's Address: City/State/Zip: C? Policy # or Self -ins. Lic. # i'11 l /) Lw ✓�o io i 1, P 1 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. — (%(,^(4-1C Official use only. Do not write in this area, to he 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 ACORH CERTIFICATE OF LIABILITY INSURANCE `„/ DATE(MNVDD/YYYY) 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 CONTACT Janelle Litto NAME: Roger Keith & Sons PHONE (508)583-1106 Fac NAIC,o: (50e)5e3-e47e AD E-MAILSS' jlitto@rogerkeith.com E 1575 Main Street INSURERS AFFORDING COVERAGE NAICN INSURER A:TRAVELERS 25623 Brockton MA 02301 INSURED INSURERBRA Retail Merchants WC Group INSURER C:FFEDERAL INSURANCE 20281 LPN Holding Co. Inc. INSURERDWH ASSOCIATION MEMBERS WCT dba Epicurean Feast Food Service INSURERS: 24 Main Street 1 INSURER F: Maynard MA 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 rypE OFADDL SUER POLICY NUMBER POLICY EFF MMIDDIYYYYI POLICY UP fMMIDDNYYYILIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2_000,000 A CLAIMS -MADE ❑X OCCUR DAM GET RE TED 1,000,000 PREMISESSEa occurrence $ MED UP (My oneperson) $ 10,000 63060830449 1/1/2018 1/1/2019 PERSONAL &ADV INJURY $ 1,000,000 included liquor liability GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 $1,000,000 limit X POLICY 0 PRO-JECT r_1 LOG PRODUCTS -COMP/OPAGG $ 2,000,000 Liquor Liability $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ A X ANY AUTO ALL OSCHEDULED AUUTOSS AUTOS 8107C399675 1/1/2018 1/1/2019 BODILY INJURY (Per accident) $ PeOP.ER- nDAMAGE $ HIRED AUTOS AAUTOSWNED $1,000 DEDUCTIBLES 8 A X I UMBRELLA LIAR X OCCUR ZU1,91144890816 1/1/2018 1/1/2019 EACH OCCURRENCE $ 25,000,000 AGGREGATE It 25,000 000 C X EXCESS LIAR CLAIMS -MADE DED I X I RETENTION$ 10,000 1 35,000,000 I $ 35,000,000 1 79882528 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICER MEIMBOER PROPRRIPARTNEWEXEXCLUDED? ECUTIVE (Mandatory In NH) N /A PJUB6C87139-8-16 1/l/201B 1/1/2019 X PER OTH- STATUTE ER E L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000 000 If yes, Fer DESCRIPTIONIPTION Oun OPERATIONS below F AS, CT, ME, NJ, W, PA, RI, VT E.L. DISEASE -POLICY LIMIT $ 11000,000 B WORKRES COUP. NA ONLY 014000502016118 1/1/2018 1/1/2019 1,000,000/1,000,000/1,000,000 WORKERS COMP. NH ONLY 030009100240118 1/1/2018 1/1/2019 1,000,000/1,000,00011,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) POLICY LIMITS IN EFFECT AT POLICY INCEPTION TOWN OF MANSFIELD 6 PARK ROW MANSFIELD, 61A 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 � G - y. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) W14 O w U w W U V z *-.4 z q h w z w P4 z w co� W M s, m 3 U c 0 a y n O a rn r u O N jot � m 00 .� za 0W o U 0 z N V cz ^ H S s, m 3 a c 0 y n O p r u � jot a v O „•woo I aF a g 3} M y o M O 0 � jot a v O 42 o v d O Cep O � N 0 o t+ Wh N a p