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HomeMy WebLinkAboutNew England Ice Cream (Taste of Tri-town) - 10/1/2019FOR BOARD OF 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: Nei �&LQ (Pf\ 2) Establishment Address: 2�-�. I r `fl1S1tlp A-,FA\K wwt,, 3) Estabilshment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant/Owner Name & Title: 6) Applicant/Owner Address: Aye 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: L A (r o S«, (Nry\ 9) person Directly Responsible For Onsite Operations: --- Name & Title: V� Address: Telephone No: ht)�_ (��\ _�pp'1., Fax: Emergency Telephone No; O 10) Event Attending Date(s): -RSkC 1' Event Name: Event Location:SI- Eventtime: 11) Check one Food Truck Caterer Other: 12) Solid waste disposal plan: O[A 13) Water Source: 14) Sewage disposal plan: NSA 16 ) Please give a brief description of the food to be served: SCt CA(LQANM 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hoU cold holding temperatures Offsite and held at proper hoU cold holding temperatures Offsite, cooled and reheated on site Other: SC2 C.CCAM 17) If PHr is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: Allergen Awareness: 1"5V,a NJ1i+li 18) If applicable, please describe your FOG management plan or attach the written plan: 19) 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 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�eo-toes of -105 CMR 690.000 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 ret urns and paid state taxes required under law. 20) Social Security Number or Federal ID: J1L 21) Signature of Individual or Corporate Name:(sN^a Town of Mansfield 6 Part; Rmn, Mansfield, Afasraebnsellt 02048 To: Taste of the Tri -Town Participants From: Amy Donovan -Palmer, MPH, RS, Health Agent t-r'104I Date: July 18, 2019 Re: Permitting Requirements Dear Taste of the Tri -Town Participants, I fecath Department /Jury Donovan -Palm¢; bLP1-9, RS I-(ecrllb /(fan! Since the last Taste of the Tri -town event, there have been several changes made to the Food Code with regards to permitting. Please review the following requirements to determine necessary documentation based on your operation, No permit is needed if your establishment: • Currently holds a Mansfield Food Establishment permit. • Serves only pre-packaged food that does not require time or temperature control. • Currently holds a CATERER permit in another town. Caterers must submit the following: o A copy of the current Food Establishment/ Caterer permit. o Food Protection Questionnaire for Catered Events. (attached) For all other vendors, please submit ALL of the following completed documentation: • Temporary Food Establishment Permit Application. (attached) • Food Protection Questionnaire for Caterer Events. (attached) • The Tax Certification Form. (attached) • The Worker's Compensation Insurance Affidavit: General Business. (attached) • The Worker's Compensation declaration page. • Fee waiver form. (attached) • Food Protection Manager Certificate. • Allergen Training Certificate. In order to obtain a permit, all documents must be filled out and returned to the Health Department, 6 Park Row, Mansfield, MA 02048 no later than September 20, 2019. Please contact the Health Department with any questions. Phone (508)209-7366' Pax (508)2/!-7425 - Emailud/xrGner@nunficlrhia.corr,l TAX CERTIFICATION FORM 1 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. NV, AAOV� (,mm W Yoz I Signature of Individual or Corporate Name By: Corporate Officer (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. C1Uscrs\s1aito\Desktop\S00h's Uacumcntsftod 6siab1i5hmen1s-1'eMPVrAX CER•r111CA'110N MRM.dac The Connamawealtli of Massachusetts Department of Iudush•iat Accidents Office of IliVestigations 600 Wasllington Street Boston, MA 02111 tvtwamass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant information``-- Please Print Legibly Business/Organization Name: 1 `rCA J &N Ala 10- (nm Address: k'A Mkrvsko. NCAA City/State/Zip: WoN` &� NA o1 ibd Phone Are you an employer? Check the appropriate box: Business Type (required): I.® 1 am a employer with 11-00 employees (full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Gating Establishment 2.0 1 am a sole proprietor or partnership and have no ?• 0 Office and/or Sales (f icl. real estate, auto, etc.) employees working for me in any capacity. $• (] Non-profit (No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised 9. [] Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** I t.0 Health Care 4.0 Weare a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.© Other NsliAl N May applicant thin checks box 1; I must also fill out to section beluwshouving theiruvorkers' compens Ilion policy f alo(mmion. **I rthe corporate officers haveexempted themselves, but are touroralion has otlter employees, a trorkcrs' compensation policy is required imd such an organi'rdion should check box 91, i ant an employer Mat is providing workers' insarauce for n;y employees'. Below is the policy information. Insurance Company Insurer's Address: s� City/State/Zip: • MM -2&"N 111N > Policy # or Self -ins. Lic. It ��O' ��� �i�SC _ Expiration k 1 Attach a copy of the workers' compensation policy declaration page (showing the poliey another mut expiration (late). Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penallies of a tine 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 tip to $250.00 u day against the violator. Be advised Ura a copy of this statement may be forwarded to the Office of Investigations or Ilse DiA for insurance coverage verification I (lo hereby eerltjp;Jaute(• the pains and penalties of perjrny 11+at the iajarmalia+ provided above is a'ae mut correct. Phone ft: V «�)Ax) Qjfrc•ial use only. Do not write in this area, to be completed by ciq, or lmvn official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Contact 3. Cfty/Town Clerk 4, Lleensing Board 5. Selectmen's Office Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or Iicenses, A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revisut 5-26-05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date N.`lo w We, W Q,,J S organization ) request a waiver of the ,Good 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 proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly 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, Signatu n �Xcc VS1a, lte4��en� Title *Please provide proof of valid 501(c)(3) status BON Use Only Approved Denied Reason: Signature: Date: II.Y1;lU1zgaTil IHOGAN ACORO" CERTIFICATE OF LIABILITY INSURANCE DATEt110112018MM12018 Y) 1 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 certiflcate holder is an ADDITIONAL INSURED, the pollcy(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 an this certificate does not confer rights to the certificate holder in ilau of such endorsement s - PRODUCER ANCT go Robiln Insurance Aggency 144Gould Street Suite100 PIH FAX ----T -- (Ac,No,ExIU(789)456.0700 __LAIO,Nel;(781) 449-8976 Needham, MA 02494s: E-MAtL certificates@roblininsurance.com _AOPSEsT _ INSURERIS)AFFOROING COVERAGE NAIC q`_ INsuasRA;Acac is insurance Comply 31325 11/0112019 INSURED INSRRER B: Travelers Insurance CO j( _36161 INsuRmc:A1M Mutual, Insurance Co 33758___ New England Ice Cream Corporation _ INSURER D; 222 Mansfield Avenue Norton, MA 02766"— _ �—_—_ INSURER INSURER F: COVERAGES CERTIFICATE NUMBER: 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 OP SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRType Jim GPINSVRANCB —A AOOL SUBR PO UCYNUMBER MOLICYEFF POLIOY E%E P LIMITS X COMMERCIAL GENERAL LIABILITY nculMsMAOE I OCCUR EBL AI MIL CPA5116109-15 11!01/2018 11/0112019 EACHCCCURRENCE___ 3 1'000,000 j( DAMAGETORENTED PREMLSES_tEa Nrre0ca)__. MEDEXP 300,000 3 '--10,000 3 _...—.__—�. PERSONAL S ACV INJURY _ �—_—_ AGGREGATE LIMIT APPLIES PER: POLICY El JEC, n LOC ,._81,000,000 GENERAL AGGREGATE_ S 2,000,000 GENL X --- PRODUCTS •COMPIOP AGO 3 2,00000 S OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea.aWdenlL 1,000,000 X ANY AUTO OWNED SCHEDULED AIUpT�O�S ONLY AUpTX�OpByyNpp MAA5115111-15 11/01/2016 11/0112019 8001LY INJURY, IF.,person) BODILY INJURY (Per a¢IEpnl), 1,000,000 5___._ X X AUTOS ONLY X AUTOB OF1LV Collision X Comprehensive ('acEGR� AMAOE — " $ D¢duCtible S 1,000 B X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIM ZUP-15828829.18-NF 11/01/2018 11/01/2019 EACH OCCURRENCE 3 15,000,000 AGGREGATE $ 15,000,000 DEO RNNETENTION$ ANO EMPLOY RS L]ABILIIT• YIN ANY PROPRIETOR/PARTNER/EXECUTIVE �FDICEpPM Meep EXCLUOE07 `N� (Mandatory In NH) H yyes, desofibe udder OE CR O OF OPERATIONS beimv T. ER x 1STATMTE 1ELTI _ EACH ACCIDENT S C NIA WMZ-800.8005864-2018A 11/0112018 11101/2019 3 500,000 _E_L. E.L. DISEASE-EAEMPLOYE 5_-_ 500,000 S 500,000 E.L. DISEASE• POLICY LIMIT A Property CPA 5115109-15 11101!2018 11101!2019 1BUilding 19,382,781 A Property CPA 5115109.15 11/0112018 1110112019 BPP 7,268,381 DESCRIPTION OF OPERATIONS ILOCATIONS /VEHICLES (ACOR0107. Atltlltional RomaBe Schsdulo, mny ho attachetl if mom apace ie requlretll Issued as evidence of Insurance. Tri -Town Chamber of Commerce 280 School Street Mansfield, MA 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. AUTTHHOORMED REPRESENTATIVE AGUKD Z5 (2015/031 U 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Q N r, z w l u 1 J 0 sed oo " a a Cd U Q Q 0 sed oo " a a Food Protection Questionnaire for Catered Events Date of Event: 1k�A1 I u)), Event Time: Location of Event: MNNS UA 1.10 U& S b.a>A List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? 'Kyes m No Allergen Awareness Menu Label Present? � Yes o No List all Potentially Hazardous Food(PHF)and the individual intended temperature required: y= CcfAM — lri List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? See, ( .'t, bur CI szm+ How will the PHF be kept at or above 1407? Time of PHF? Setup Served Removed 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.