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HomeMy WebLinkAboutCreedon & Co., Inc. (Youth Soccer Tourney) - 10/13/2019tA P' FOR BOARD OF HEALTH USE ONLY Zulu 71, Date Received hPermit 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: C re f> d o r) a n d C o• I n c, Establishment Address: 3 C, r C� . �,)� r� ,/ LS -�.�, M C 0 I (J,) C, Establishment Mailing Address (if different): Establishment Telephone No: 2) Applicant/Owner Name & Title: Pe'l_ ._, 7 �• (r'C' �� iC� f1h� nne C:; lI Ci'ot-ccn � Applicant/OwnerAddress: Ci4 : - Applicant/Owner Telephone No: Applicant/Owner Email address: CtIm \ F(O- C (^ 6(1, n C, C' 0 , n 0 M 3) Person In Charge of Onsite Operations & Title: 7 , h,) C re.e I e n .+. `'t a l ({ 2 1-e(d � F ti PIC Address: ,3 � -j(%I t"))(� � U CCc� (? �-L es t c � F1 c j le o PIC Telephone No: sC; �6- - � F (� �) Emergency/onsite Telephone No: 2,0 0 -9 H f -1 a 3 b PIC Email Address: I-O l e CL; C 's' -{ �, Cj C r) Ck. r1 I C L ' ( o ty-I 4) Event Attending: rn �� i1 U� j l C� �� Cy't L �� l 1 .r n Date(s): ! q C) n 1 D ! .3 j Event Name: S C o C rl I utl-n Q ill v n --(-- Event Location: (C d Event time: Y, �' �� } - rJ y Erb •4',a ( i1 dog f 5) Check one O Food Truck Pid Caterer = Other: pp 6) Solid waste disposal plan: Bret uQ i-)f- ID Ct C k f`0 C_j'f'r d C,,1 t.i.. tl 1 u l' I- 7) Wafer Source: Lp 8) Sewage disposal plan: f 9 ) Please give a brief description of the food to be served: 10) Food will be prepared: Onsite for Immediate consumption Onsite and held at proper hott cold holding temperatures Offsite and held at proper hot/ cold holding temperatures = ffsite, cooled and reheated on site = Other: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: 4 y Food Safety Manager: nKt.tICI) tw i q, / ( n j ••� ii \ Allergen Awareness', 12) Please describe on site hand washing facilities that will be utilized: c"{/-� 1-i C + 13) Please list all sanitizing solutions that will be on site: , c 3C f= cl 14) If applicable, please describe your FOG management plan or attach the written plan: 15) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit: { For food trucks, please list additional communities where a food permit is held and attach copies of the Base of Operations or Commissary permit: 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 CMR 59,0.000 and the federal Food Code. 19) Signature of 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: O t ` C11 C>✓_.__ j 21) Signature of Individual or Corporate Name: �� , W Food {Protection Questionnaire for Catered Events Date of Event: ti i U' �% 7 i j Event Time: R, 0 rfi - P nl� Location of Event: _ 1 60 r N m o t.l I h F? i. List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location: On ice/Refrigerated Cooking i! .i vt"1-P1/ ` Reheating � JI Food Manager Certification Person Trained On Site? � Yes o No Allergen Awareness Menu Label Present? fKYes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: \ r 1 _ O-cc a f ^,Ail ' ` z^C'y, TVif.. .0 t k c i r� t 11 Q j CC'Ct tom, l t,i.r ; I v 1} List the required temperature for each food as it leaves your preparation site: f G r=VC1. Lt c I I —'if' �m C� ''- a How will the PHF be kept at or below 41 °F? C� 1. �i.� 4 ci-eya How will the PHF be kept at or above 140°F? ('I Ct. h-\ d'>i'l i l'U 0 tr r')-P 1% Time of PHF? Setup i C f ; C KYl Served C t-NRemoved C7, 0 tQ ) t Please describe hand washing and sanitizing supplies that will be provided on site: 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. a;l 1"l i+f 1 h-0 l 6UIj' -N..'(� ) V-, TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. S .- Si tore of Individual. or Corporate Name By; Corporate Officer (Mandatory, if Applicable) `1 - goQo51-(3 **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 subj eet to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. U—\ ..................wa. .....,,��.,..».,.,... Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip: �UTC�6 n Cl,- P6 f' i iq., I___ :. Phone #: 5 b� q - 5 I L�' Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. [] Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no q, ❑ 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.I YI We are a corporation and its officers have exercised 9. ❑ Entertainment 7i) 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 area non-profit organization, staffed by volunteers, 7 with no employees. [No workers' comp. insurance req.] 12.[ Other �r. *Any applicant that checks box #1 must also GII 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 #t. [ant an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: f �%,Cl,l ii 1/ Rcu<.e i it,,kycur\C-e_ (;�';h_( Insurer's City/State/Zip: Policy # or Self -ins. Lic. # �� 9 7 �1 3 — ( I — �, l Expiration Date: t J' 3 t / 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 ofMGL e. 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi , under thepains and penalties ofperjury that provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Contact 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office C-. to L.,{a.on and Co. Packcing List y k 4 -�s29��59'�i 43 YSY f.s#a 1`E='-: 25 ail:€i 7:00 am ("De:%('O!:I Event Date Rookmq Contact Site Contact Sales Rep Irt�r rourmmment 10.) 2;2019 ($at) John C reedon John Anlc Penney f ,ei � r, Bodkin Tel y Site Cell Guests C'oncCssinn, (508) 793-31000 (Ms)791 S101: 3000(11I11) Site Name \4anslirl i '" h Sarar Fields Date 'I 10 11 Delivery Location Site Address 50 Phvmouth Road. Mansfield. \ALA Delivery Date and -i ime Delivery Start 7:00 am 5:00 am Food & Beverage FoodiSorwee, lOnls "Concc,6,11 `ysuuP Culler-1 an}e CIII) 1X itll LAI. Iltermos I lot Chocolate t2 l'heriooscs) 25 Cases Assorted Soda &'..i0 Cases Bottle Water per t);n C;e;rs T\;rN HK hie'Cs l d Cases \>,•'eld ,luictt {t�,¢ �,:s -> i.amQ N,hip"ins.2d Raacls Cigg. Racou. C hccsr Sandm Mies-60 per Day Yoti, rt kith Vmil and Granola-50 per Day Assorted Sand+cich Wraps 50 per Day. "Chicken C'aesal" i (nnl6urv1cii,Chresebm g s- 10 Cases per Day ,lumhu i llq�4'�c.5 C'ascs per Dny 6 ( asc> I'rt64h Fries -per Day' I''owrrh:u:� Pr�iwill .I C-airs Total Sausagc. Pppvis Onion Grinders- 5 per lily Cast Chips Lnntc Pruh (-np<.50 per Dad Chick. n (;wC iu Salads-. 5 petDay I Cases lianunns Total 10 Case, Chlckcn Firwet:s a. ith Frcnch Fries Chick,ll linc,i,"> only t Qty I I GU 50 50 400 �110 6 100 75 2 50 5 1 Last koaised: 91612111') (12:35 pus) Site l elephone (50S 'M (10; 1 I nd :00 pill Padyl rack order i5929 Page 1 of 2 I MLW� ClicnVorganualion Mitlisfi0d soccar Fournallicill F vc,lt Desci Itibon Concessions S: [It Ma tsllelllrr, Date 10 13 20 1 9-Surl Delivery 7:00 ant Packing List Sunday, Octobor 13, 2019 41'06109 7:00 ain Event Date Reeking Contact I ()1 13 '20 19 (Still) John crocclon Reeking let (>()S) low) Delivery Location Site Address ;O 111%niouth Road. Milnsf--cld. MA Delivery Date and Time Start 8:00 all Food & Beverage Food/sn'-VIR,�,015 Qly (11 1 lik, thermos 3 I lot Chilcol f lici mo."o) 2 )S Cosr,; A:ttoi IQ(l Soda K 30 Cases Bottle wilicr par I Dn\ 5 Vr\ jjjCVS ('aseN M�,,JCJ) .Juice 11,,dki0I its "I., Limit! Mull'jiis.2 4 Bzwels I g!!. kilcoll. SaIldN\ ichcs-00 per Du) Gil Yo,--urt It J, Fruit and Gjllnolzl-5O per Day 50 A tsort ed Wrill's SO per Dfly tO C I t-cwlhnrtms- 10 Gases per Oir, •100 I I'll CiIscs per I)kly 200 6 Cries Pfeil CJ) Fj.jCS_j)Cl- J)d 6 powellmis Pri)(611-1 Cases Twill too Sausage. Peppers,'Onion Grinders-75 per Day 75 CaSL, C111, is 2 " l'itC 1:1 ;O per !):I\ Chicktn) tlalnils I ; par Dap 2 ;n,os Buli4ws I (lull I 1U Cases Pries Chicken finvcr, unit 9ilr0oig ) 1., PIPM Last Rc-, kvd! li) ( 12:36 pill) 1N H: k"'F S I ilc Conoc! John crcvdon Site Cell (50S) 70- ? I W Site I le lone 'SOS i 1" 00 End 5:00 Pill Sales Rep I'cillne, Guests ,OOO (Illn) Parytrack Order# Page 1 of P CITY OF WORCESTER, IAA, Department of Inspectional Services 25 Meade Street, Worcester, MA 01610 Phone:(508)-799-8539 FOOD ESTABLISHMENT PERMIT PIN: FM-18.1399 EFFECTIVE DATE: Tuesday, January 01 2019 M PERMIT EXPIRES: PERMIT FEE: Tuesday December 31, 2019 $250.00 In accordance with Regularions promulgated under authority of M.G.L. c. 94, ss 305A: c. 111, ss. 5 123A, 105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder JOHN W.S. CREEDON Address of Permit Holder 39 JOLMA RD, Name of Food Establishment CREEDON AND CO., INC. Address of Food Establishment 39 JOLMA RD OPERATIONS PERMITTED Food and Drink Establishment 1 - 100 Occupancy Comments: Restrictions: Common Notes: Renewal of Permit: DURATION OF PERMIT Annual An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the expiration of the permit. Notification of Changes: This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior to closing and this permit must be returned to the DIS. Director of Housing and Health Inspections Post Conspicuously A`QRV CERTIFICATE OF LIABILITY INSURANCE DA 0502/2019 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 INSURER(S), 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. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER No.,T Joseph Zemaitis Zemaitis/Baker Insurance Agency PHONE (50B) 752-7777 FAX (508) 752-8580 A/C No E_t1: (AID No); 108 Shrewsbury Street E-MAR- : jzemaitis@zemaitisbakeccom Suite 201 INSURER(S) AFFORDING COVERAGE NAIC9 Worcester MA 01604 INSURERA: Ohio Casualty Insurance Co 24074 INSURED INSURER B: Ohio Security Insurance Co 24082 Creedon And Company Inc It Vending Express IN$URERC: Continental Indemnity Co. 28258 39 Jolma Rd - -� INSURERA INSURER E: Worcester MA 01604 INSURER F: COVERAGES CERTIFICATE NUMBER: CLI98202208 - REVISION NUMBER: THIS ISTO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTPNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD MD POLICYNUMBER POLICYEFF MMIDD POLICYEXP MMIDD/YYYY UNITS A x COMMERCULL GENERAL LIABILITY CLAIMS -MADE Fx-1 OCCUR SK055313020 10/11/2018 10/11/2019 EACH OCCURRENCE S 1,000,000 PREMISES E� ao c nce S 300,000 MED ExP (Any one person) S 15,000 PERSONALeAOV INJURY S 1,000,000 GENLAGGREGATE LIMITAPPUES PER: PO- X POLICY 0 JET LOC OTHER: GENERALAGGREGATE S 2,000,000 PRODUCTS-COMPIOPAGG s 2,000,000 Liquor Liability 5 1,000,000 g AUTOMOBILE LIABILITY ANY AUTO OWNED v SCHEDULED AUTOS ONLY /� AUTOS HIRED NON -OWNED XI AUTOS ONLY x AUTOS ONLY BA855313020 11/1112018 _ -I �I 10/11/2019 COMBINED SINGLE LIMIT ati imt s 1,000,000 BODILY INJURY(P., poison) $ BODILY INJURY (Peracdd rci S PROPERTY DAMAGE Per ecddent $ Medical payments S 5,000 A x UMBRELLA LIAR EXCESS LIAR v X OCCUR CLAIMS -MADE 6SO56313020 :�)/11/2018 10/11/2019 EACH OCCURRENCE g 10,000,000 AGGREGATE s 10,000,000 . DEC)0,000 RETENTIONS $ C WORKERSCOMPENSrATON ANDEMPLOYERSLIABILITY OFFICERIEANY IMBER EXCLUDED ECUTVE YF tMandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 37-833436,01.01 05/03/2019 06/03/2020 PER OTH- %� STATUTE ER E.L. EACH ACCIDENT g 1,000,000 E.L. DISEASE -EA EMPLOYEE S 1,000,000 E.L. DISEASE -POLICY LIMIT g 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1qi, Additional Remarks Schedule, may tee attached if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CREEDON AND COMPANY, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 39 JOLMA ROAD AUTHORIZED REPRESENTATVE WORCESTER MA 01604 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ell m E T u� m±s ac, R-0 egg 7-34 17� Z. I R --Zc Will Z5 r �