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HomeMy WebLinkAboutNorton Country Club (Taste of Tri-town) - 10/1/2019FOR BOARD OF ,TH USE ONLY 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: 2) Establishment Address: 3) Establishment Mailing Address (if different): Telephone No: ` 4 EstablishmentTele l q' p a G' $ (i-i4 5) Applicant/Owner Name & Title: /� P 6) Applicant/OwnerAddress: 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Yti 4 Name & Title: �.. 1 z y /, Address: d G o� tilyl Telephone No: a •u�-- -Tt-)� U i sfi Fax: S',a k ''�" a 1 Yl) Emergency Telephone No: �.' y, 5 _- 10) Event Attending 't Event Name: -^""r ' , j •W'(`oE°1t`A•tw Ct, i F, 41 Event Location: I fA: S � V C�, �.�I4.T.e Event time: 11) Check one 12) Solid waste disposal plan: Food Truck / Caterer Other: f��,fJ T °`✓,J lrrnv 13) Water Source: 14) Sewagedisposalplan: I I.e�i. 1/5/) Please give a brief description of the food to be served: (Yv� • (✓�! i�.[��'4 IyAY�G•'P6L /%%'s p V MN.'6Q�/i� �YYtf/� ��jiih'i/v/ Jn.{yam , o 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hot( cold holding temperatures -JOffsite and held at proper half 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: c Food Safety Manager: ✓ Gr 41AAkr'�pm D Allergen Awareness: 16) If applicable, please describe your FOG management plan or attach the written plan: 19) Fo�r/cy�terers: Cityrrown where food establishment permit is held. Please attach a copy of the caterer's permit: df0'r�u), MA 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 comp with 105 QMR 590.00Ond all other applicable law. I have been instructed by the board of health on how to o in cc rg of 105CM/g 590 00 and the federal Food Code. 19) Signature of Applicant:1 fie! Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, 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 21) Signatureof Individual orCorporat Food Protection Questionnaire for Catered Events Date of Event: 1 1 Event Time: f N j i oi —1c, lnfdl Location of Event: P)l t' O K IN') List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating 0l7.ncnln+t' 97a3:ta'Se, 04iC1^ua: irla/ra4v. - cldrnT MMoe- Food Manager Certification Person Trained On Site? rw Yes m No Allergen Awareness Menu Label Present? �i Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: ck,cktik A-eA ids o List the required temperature for each food as it leaves your preparation site: ("ilt,t;6h Bru 1 f Grv.n awe✓ ChAAA-' ;a r2 r' y9n How will the PHF be kept at or below 41 °F? /�•iar� •'c How will the PHF be kept at or above 140°F? A( -t Time of PHF? Setup -2 , Served S . Removed v-- 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. 0�� G'�evn,na R•rd; �o�r i'.(•Lrm•, iw Div r slF2.fyr c,.% 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. ignaturedIndivoual qfflorporateName 0g-- 3< <`!7v 1 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) '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. CdUserslsleitetDesktop&otfs DocamentsWaod Establishments- Temp1TAX CERTIFICATION FORM doc The Common wealth ofMassaehusetis Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02.1.11 IN www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Dj Address: i et I" 001,jr lll,4 City/State/Zip: o S 1m-A 0-31 k'6 Phone #: (50%) 315-:- 04 v &Al, id i Are��°a an employer? Cheek the appropriate box: Business Type (required): I. © I am a employer with '7 ' employees (full and/ 5. ❑� /Retail or part-time).* 6. Restaurant/Bar/Eating Establishment [,g 2. ❑ 1 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4). and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I In Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Aviv applicant that checks box 01 mast also fill out the section below shaving their workers' compensation policy infermmion. **If the corporate officers have exempted themselves, hui the corporation has other employees, aworkers' corpensation policy is required and Stroh a orgairwitat should check box Nl. I oni an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:_ �.r-a'p©nCltn.-i' .fr;���anct Co-!.Qq,--j Insurer's Address: vC:.-AC74 jr7li11,Ktot Jo;.rf.ZvarA.- City/StateiZip: f;; t l Pr Yt r MA -?c`I i Policy 9 or Self -ins. Lic. 4 iiy_ .1.i I I IS ?r 3 % 6 ki Expiration Date: ] 4; d ;el 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eed I colder to pahis and pen/ali/rt'�s of perjury that the information provided ab ve it trite and correct Sien`tlure / -- Date: 47� Phone;;: l.��Y� r f 0 dC f iol Ojficlal me only. Do not write in this area, to be completed by city or town offcial. City or Town: Permit(License Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone M JANCOIN-01 LSOUZA1 l 'ate CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9123120119 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. A statement on this certificate does not confer ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER License# 1780062 co T cT Lucia Mantles PHONE Ne Eaq; (508) 235-2210 lac, No: HUB International New England 222 Milliken Boulevard Fall River, MA 02721 �fA OD'Es Lucia.Mendes hubinternational.com_ INSURERS AFFORDING COVERAGE NAIC b INSURERA:Ar Dnaut Insurance Com an 19801 INSURED INSURER B : INSURERC: Northeast Golf Properties 35 Sockanosset Cross Road P.O. Box $819 INSURER D : INSURER E: Cranston, RI 02920-8819 INSURER F: �_..-. CnvERAGFS CFRTIFICATF NIIMRFR- 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 CONTRACTOR 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. INSRR TYPEOFINSURANCE IAgO $DO POLICYNUMBER PMIDIYE PODD[YYY LIMITS COMMERCIAL GENERAL 41ABIIJTY CLAIMS -MADE a OCCUR EACH OCCURRENCE _ DAMAGE TO RENTED PREMISESEa occurrence) $ MED EXP oneperson) GEN-L PERSONAL &ADV INJURY AGGREGATE LqIIMpIT. APPLIES PER POLICY za E]LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMPIOP AGO $ S AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED ALTOS ONLY AUTOpS _.. RHOS ONLY ROJTNOS ONLY COMBINED SINGLE LIMIT $ BODILY INJURY Per ereon BODILY INJURY Per accitlent PROPERTY DAMAGE Perawident 3 UMBRELLA LIAB EXCESS LUIS OCCUR CLAIMS -MADE EACH OCCURRENCE 3 AGGREGATE OEO RETENTION $ $ A WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY OFFICRWM�MBOREXRTNERIFLUDED? ECUTIVE YIN (Mandatory m NH) Ityes, describe under DESCRIPTION OF OPERATIONS below N/A C928438363864 101112018 10/112019 X PER UTE ETH- E.L EACH ACCIDENT 1,000,000 $ E.L DISEASE - EA EMPLOYE 11000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD I01, Additional Remarks Schedule, may be allached if more space is required) CERTIFICATE HOLDER CANCFLLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 280 School Street Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE fa�11 ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Mansfield Board of Health Request for Fee Waiver for Food Permit Date I 1�) i ~' We, a, organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: ❑ We are a 501(c)(3) organization and ALL pr ceeds earned will go directly to the organization. ❑ We are donating ALL proceeds earned direc'ly to a 501(c)(3) organization. Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization ✓ Other: TASTE OF THE TRI-TOWN Thank you, &4141 Si ture "N bt yn w, R I Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: ■ } ; � § B § / \ \ \ a ) ( ) j 7\ \ § \ § / u �? #tom\ \ oez/?] k§§;2> A22)(§ 2 2 CL M0 ;«2)\ 30 ®jm00 §=2`\{ a@z\ww ti 0 l u Mai W U W7 erg e"Y",t1 P4 z W Wryl W K a kN N N O O V O 14. 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