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HomeMy WebLinkAboutFireflys BBQ @ XFinity (Summer Jam) - 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: XFINITY FOOD PERMIT 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:. STEVEN A. ULISS Whose place of business is: Q CAFE LLC DBA FIREFLY'S BBQ @ THE XFINITY CENTER - SUMMER JAM 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: STEVEN A. ULISS, OWNER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-19 BOARD OF HEALTH MichaeCHeaCey, Chairman ��6- 11 1 1 FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: 0. CA(b LL6 A/8 r2l-FJV� CM 2) Establishment Address: Mo EJOA-11,4�T-WLeORWA #%['00 3) Establishment Mailing Address (if different): W 4) Establishment Telephone No: �6 0 '3, 5 7 5) Applicant/Owner Name & Title: 6) Applicant/Owner Address: 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: a V -212W, Ntt 9) Person Directly Responsible For Onsite Operations: Name & Title: coWm k V I I 6e�t 06-feA Address: io C*m a-, kkitW Mh oilo% If Telephone No: 5(* 2617- bb,61� Fax: 267, Mt+ Emergency Telephone NO: 10) Event Attending Date(s): -,Tune- 15 j 20 19 X Event Name: Sw6t6 (3m� Event Location:ctr,�cy- Event time: 11) Check one Food Truck X Caterer Other: 12) Solid waste disposal plan: 13) Water Source; TOW 14) Sewage disposal plan: TOW 15 ) Please give a brief description of the food to be served: eRtChAti, 8 ; 4 � . 16 ) Food will be prepared: Onsite for immediate consumption 91 Onsite and held at proper hot/ cold holding temperatures Offsite and held at proper hot/ cold holding temperatures Offsite, cooled and reheated on site Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: p� Food Safety Manager: fVtddym lNCIA ,� Allergen Awareness: M i i ( I \ ttw 18) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: Cityfrown where food establishment permit is held. Please attach a copy of the caterer's permit: MAS LoP.'t uw I /VSA OIasi For food trucks, please list additional communities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the accuracy of the information provided in this application and I 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 9"0.000 and the federal Food Code. 19) Signature of Appl 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. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: �� 3AU^ AV -h' T" Food Protection Questionnaire for Catered Events Date of Event: Location of Event: Event Time: 'I a M — ►/N List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating �+'ivLrf 7b,.+.yp, pn./rte "Ovty/V, /error✓ Po///.l P/i.<rl,.)/ Cij CYJ! �i /!<i! C'ti/L /!LN S.a.�r,,� t ✓�2� 1�.k.,✓J �— !'vC!/ MJ✓ IA ✓A1N-/ . TOJ//w/-L/<it� ,iw ✓if P.�»r-s / `�/fi fY1,aa l/O/✓✓/q�✓ i7'/✓7+ S? L VIVI Food Manager Certification Person Trained On Site? o No Allergen Awareness Menu Label Present? dyes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: y/v> do y✓ � 61' po rrrrJ.rr.zs y u List the required temperature for each food as it leaves your preparation site: �/.A,f,///J /�� PGC.✓/,b.... ✓j/d How will the PHF be kept at or below 41 °F? CV How will the PHF be kept at or above 140°F? Time ofPHF? Setup Served 7 sZo elnoved 2.to List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. CY///1. wlnJ �9AJ,S/e% /?irALM Ph ni .4, 4,, Pj/ /✓ Ali /A� 14(.,raciari..ii G/yin-,�f �v/�'✓% 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. /�! /hq-'�fi'> //[��✓�v-ate ��/� /+f aa-,dj.�.y /✓/.er'�L�.2 e of individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) �7yZ 2 2 - "Social "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\slehc\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 Applicant Information Please Print Legibly Business/Organization N Address: Mo �, , fiwtj �f City/State/Zip ,j�Y�1 t-; v (i�J}�/� 017 Phone #: Are you an employer? Check the appropriate box: Business Type (required): LN N I am a employer with ---!50 .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.❑ Other *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 out an employer that is providing workers' compensation insurance for sty employees. Below is the policy information. Insurance Company Insurer's Address: V/y0, Lt X B59.)_120.- 122:1- nn City/State/Zip: �7 kil ✓�r 22 QM -1255 - 0900 Policy # or Self -ins. Lic. # 01400 50346) J 1119 Expiration Dater %a 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, aM�L_� he pains and penalties ofperjury that the information provided above is true and correct Signature: Date: //1 Phone #' r' -T — 3n- e"3 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 #: °+�Ku CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 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 the terms and conditionrt ADDITIONAL INSURED, the policy(ies) moat be endorsed. If SUBROGATION IS WAIVED, subject to s 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 endorsementiei. PRODUCER Association Members Insurance Agency 200 Broadway Suite 207 Lynnfleld, MA 01940 INSURED Q Cafe LLC d/b/a Firefly's BBQ 350 E Main Street Marlborough, MA 01752 Uv CWAUt:b CERTIFICATE NUMBER: 000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELO INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONIC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AF EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY T- C_OMMERCIAL GENERAL LIABILITY CLAIMS -MADE 11 OCCUR GEN'L AGGREGATE LIMIT APPLIES PER; POLICY PRC LOC AUTOMOBILE LIABILITY _ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION l` WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YiN AANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) 014005034531119 MA Retail Merchants WC OF ANY CONTRACT OR OTHER DOCUMENT I 'D BY THE POLICIES DESCRIBED HEREIN IS BEEN REDUCED BY PAID CLAIMS. 1/01/2019 11/01/2020 OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additlonel Remarks Schedule, If Inure space Is ragUIMd) ) Cafe LLC dba Firefly's BBQ 50 E Main Street larlborough, MA 01752 :ORD 25 (2010/05) S SPECT TO WHICH THIS IT TO ALL THE TERMS. BODILY INJURY (Par person) IS BODILY INJURY (Par accident) $ P e0accldentDAMAG $Is 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 REPRESENTATIVa The ACORD name and logo are registered CORPORATIO marks of ACORDORD N. All rights reserved, NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222, Braintree, MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005034631119 01/01/19 - 01/01/20 POLICY NUMBER EFFECTIVE DATES Association Members Insurance Agency 200 Broadway Suite 207, Lynnfield, MA 01940 (781) 771-0009 NAME OF INSURANCE AGENT ADDRESS PHONE # Firefly's BBQ 350 E Main Street, Marlborough, MA 01752-0000 EMPLOYER ADDRESS 01/08/2019 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222.9222 Braintree, MA 02185.0000 Information Page Q Cafe LLC Firefly's BBQ 350 E Main Street Marlborough, MA 01752 Workers Compensation and Employers Liability Insurance Policy Carrier Policy #: Policy Period 01 '+UU0VJ4fjJ 1119 1 01/01/2019 to 01/01/2020 j ociation Members Insurance Agency Broadway Suite 207 ifield, MA 01940 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named insureds if Applicalbe Type of Business: Limited Liability Cc Federal ID#: 043422462 Risk ID: NCCI /Bureau #: 34355 Unemployment ID #: File #: 014005034631119 Renewal #: 01400E Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2019 to 12:01AM on 01/01/2020 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: C• Other States Insurance: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $ 1,000,000.00 each accident $ 1,000,000.00 policy limit $ 1,000,000.00 each employee D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000308(04/84), WC000406(n, WC000414(07/90), WC000422B(01/15), NOE(01/01), WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13), WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Minimum Premium $ 290.00 Form # WC 00 00 01 C (Ed. ) Code # Premium Basis Rate Per $100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Prorated Premium Estimated Annual Premium Expense Constant De osit $10,895.00 $ 10,895.00 $ 0.00 $ 0.00 :n) Copvright 2013 National Cmn,ii oo rt�,.�o..��.,n.... �.......____ .., ... ._ Countersigned by: Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222.9222 Braintree, MA 02185-0000 Information Page Workers Compensation and Employers Liability Insurance Policy Carrier Polic #: Policy Period 014005034631119 1 01/01/2019 to 01/01/2020 Renewal Agreement rv. VYJ9LLyOL Carrier Prior Polic #: 014005034631115 Item 1: Named Insured and Address Agency Fi Cafe LLC Association Members Insurance Agency Firefly's BBQ 200 Broadway Suite 207 Marlborough, MA 01752 E Main Street Lynnfield, MA 01940 Ma Schedule of Classifications : MA Code No. Classification Payroll Rate Premium 8810 Clerical Office Employees Noe $ 148,818.00 0.07 $ 104.00 01/01/19 - 01/01/20 9079 Restaurant Noe $ 1,254,360.00 1.03 $ 12,920.00 01/01/19 - 01/01/20 Description Manual Premium Rate Deviation (9037) Increased Employers Liability Limits (9812) Experience Modification - Listed below (9898) Standard Premium Volume Discount (0063) Normal Premium Expense constant (0001) Domestic Terrorism (9740) Annual Premium DIA Assessment Total Experience Modifiers Effective Date .9900 08/01/2018 Form # WC 00 00 01 C (Ed.) Percentage Factor 20.0000% 2.0000% 0.9900 0.4500% Amount $ 13,024.00 $ 2,605.00 $ 208.00 $ 10,521.00 $ 10,521.00 $ 47.00 $ 10,474.00 $ 0.00 0.0300 $ 421.00 1.4700%/ $ 10,895.00 1.4700% $ 190.00 $11,085.00 Pad roll Rate ;Charge Domestic Terrorism 1,403,178.00 0.0300 421.00 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. 11111 O���'�����'d�lllll COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE PO BOX 7010 BOSTON, MA. 02204 o Q CAFE LLC 4030 .® 350 E MAIN ST ' MARLBOROUGH MA 01752-5422 Dear Taxpayer, r . Notice Date: 08/09/18 Taxpayer Ill .Number 048 422 482 Below please find your Stiles Tax on Meals and All Beverages Registration Certificate (Form MT -1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of Revenue Massachusetts Department of Revenue Customer service Bureau MT -1 PO Box 7010 Boston, MA 02204 The vendor herein named Is registered to sell meals and beverages pursuant to the General Laws, Chapters 62C and 64H. This registration is effective only for the registrant at the location Specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct MT.1 can be Issued, Q CAFE LLC IDENTIFICATION DBA FIREFLY'S MWORR 318 SEVEN BRIDGE ROAD 043-422462 LANCASTER MA 01523 ' ISSUE DATE 08/09/13 V w U N 0 J J W N m N � i4 Q% z a o u U w z � U q Q 0 ti O V V � w O y :1 1 THE MARLBOROUGH HEALTH DEPARTMENT HAS ISSUED THIS FOOD PERMIT TO: NAME: firefly's ADDREss: 350 East Main Street IssuED: November 1, 2018 PERMIT TYPE: Annual PERMIT CATEGORY: Food Service On- and Off-site Catering HAS BEEN ISSUED PERMIT ## FP 19-50 TO CONDUCT BUSINESS WITHIN THE CITY OF MARLBOROUGH, IN ACCORDANCE WITH FEDERAL FOOD CODE 105 CMR 590.000 AND THE 1999 FOOD CODE AND ALL RULES AND REGULATIONS SET FORTH BY THE CITY OF MARLBOROUGH, HEALTH DEPARTMENT. I UNDERSTAND THIS PERMIT MAY BE REVOKED AT ANY TIME, IF COMPLIANCE OF TOWN RULES AND REGULATIONS ARE NOT MET. THIS PERMIT WILL EXPIRE ON: DECEMBER 31, 2019 DIRECTOR OF PUBLIC HEALTH BOARD OF HEALTH Robin Williams, Chair jmiies GiiFhn, Vice Chair Cathleen Liberty Joseph Tem yson, MD, Member