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HomeMy WebLinkAboutKona Ice (Rotary Vintage Show) - 8/17/2019f2, Commonwealth 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: TEMPORARY 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:. DAVID SOUZA Whose place of business is: KONA ICE CUMBERLAND RI, INC. - THE ROTARY VINTAGE SHOW 265 FRUIT STREET PERSON(S) IN CHARGE: DAVID SOUZA, VICE PRESIDENT Permit Expires: August 17, 2019 Food Fee: $50.00 License Number: T-30 BOARD OF HEALTH 34ichaeCHeaCey, Chairman CiG FOR BOARD OF HEALTH USE ONLY EDaleeceived 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: ) Establishment Address: as") \ ✓different): Establishment Mailing Address (if Establishment Telephone No: 2-10 I- qC C 2) Applicant/Owner Name & Title: y U i y } V 1 / ` e� v Applicant/OwnerAddress: 7 , knnL_ MA 04WI Applicant/Owner Telephone No: ' o l _ Applicant/Owner Email address: -- ` 3) Person In Charge of Onsite Operations & Title: ,- "' `. do f C C A k PIC Address: S 3U-00-114S+ k- 1 PIC Telephone No: qo`-q _ Emergency/onsite Telephone No: 6-1 01 -C1 Q - L7q `'1 J PIC Email Address: 7 _' A C 4) Event Attending: �,d - Date(s): ' To - Event Name:' % r` Event Event Location: F Event time: 3•,?oam 00 5) Check one ft Food Truck o Caterer O Other: 6) Solid waste disposal plan: MA 7) Water Source: 'lI 8) Sewage disposal plan: 9 ) Please give a brief description of the food to be served: S1)0,1)ed :Cc( , Food Protection Questionnaire for Catered Events Date of Event: ) Qfq Event Time:y>1 Location of Event: a /Jp,'j �A 1 bffabe W';� q 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? Yes o No Allergen Awareness Menu Label Present? qhYes m No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: A lwn - List the required temperature for each food as it leaves your preparation site: A-1 /A How will the PHF be kept at or below 41°F? _ How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed 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. 1 6. l � O( - 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, ifApplicabie) ` 5 50 Y( "Social Security No. (Voluntanj) 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. 10) Food will be prepared: Onsite for immediate consumption E3 Onsite and held at proper hot/ cold holding temperatures o Offsite and held at proper hot/ cold holding temperatures I--] Offsite, cooled and reheated on site El Other: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: �-b(\L Food Safely Manager.16 Allergen Awareness: l )t 12) Please describe on site hand washing facilities that will be utilized: Hp�6,,,� �8)"unc `D; k- f�V rflVJ,t Aeci0 L`�Ccl� l�> , `itx-0el6 13) Please list all sanitizing solutions that will be on site: 14) If applicable, please describe your FOG management plan or attach the written plan: NIA 15) For caterers: Cfty/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: �F 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 t"btain copies of 105 CMR 590.000 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 ffled all state tax returns an)i paid /state taxes required under law. 20) Social Security Number or Federal ID:.1,j 1 J (`l 16, idf 21) Signature of Individual or Corporate Name: ryYA— a- r -j 1p l P_ yl. i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: @M +)VL )V� r— Phone #: Lar) l- `A50 - TASS ) Are you an employer? Check the appropriate box: Business Type (required): 1. E�, I am a employer with-3—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. 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, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.E] We are a non-profit organization, staffed by volunteers, �t�� 12.�Other \Ci � `4Y),Q6 3_C,(y with no employees. [No workers' comp. insurance req.] \ l . . .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 #t. I am an emplover that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Cot Insurer's Add City/State/Zip Policy # or Self -ins. Lie. # A)_SNt;90 (12512(e9 Expiration Date: ', '' ' _ao 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. �MWW Phone #: �� �`Cli�" ���� l� 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 Person: Phone ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMmorvvyY) `� 06/01/2019 THIS CERTIFICATE IS ISSUED ASA 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(les) 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 rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Amle TUmer Northern Kentucky Insurance PHONE (859)586-8580 Fax (859)586-8616 A1C NoiExg; IAIC. No): PO Box 357 AODRI:sS: Amie@comerstoneinslic.com INSURER(S) AFFORDING COVERAGE NAIC0 INSURERA: Ohio Security Insurance Company 24082 Hebron KY 41048 INSURED INSURERS: Kona Ice Cumberland Ri INSURERC: 255 York Ave INSURER D : INSURERS: MED EXP (Any one person) $ 15,000 Pawtucket RI 02860 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019-2020 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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILm TYPE OF INSURANCE INSO WVD POLICY NUMBER MMIDD Y EFF MWDD/YYCYY LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 2,000,000 v CLAIMS -MADE OCCUR E'S4SNEN7 2,000,000 PREMISES Ea occumm. $ MED EXP (Any one person) $ 15,000 PERSONAL B ADV INJURY $ A Y BZS56116566 05/16/2019 05/16/2020 GEN'L AGGREGATE LIMIT APPUES PER: GENERALAGGREGATE $ 4,000,000 POLICY ❑ JECOT F LOC PRODUCTS-COMP/OPAGG $ ERPL $ 50,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea.Wdenk) BODILY INJURY(Perperson) $ X ANYAUTO A OWNED SCHEDULED AUTOS ONLYAUTOS BAS56116566 05/16/2019 05/16/2020 BODILY INJURY(Peracck1srC $ PROPERTY DAMAGE $ Peraccident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BACEE $ UMBRELLAUAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) If yes, describe under DE6CRIPTION OF OPERATIONS below NIA XWS56116566 05/1912019 05/19/2020 PER OTH- STATUTE ER _ EACHACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Addiflonal Romari s Schedule, maybe aftached if more space is required) Certificate holder is listed as an additional insured With regards to the operations of the named insured. Town of Mansfield, MA 6 Park Row Mansfield MA 02408 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 ©1988-2015 ACORD CORPORATION, All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD N H Ill Ot N N N H N a ii t) � 43 U U tp � a) 1Z ! �3 G� U (. U1 w C1Ij V] �L p V � til £A lk „ T Lo u x--• :E CN T m 3 , , 7 .L p T N J'3Pu-u[¢�T MASSACHUSETTS DEPARTMENT OF REVENUE Letter ID: L1506444288 m ,,-,qT--�.; r PO BOX 7044 Notice Date: May 16, 2016 „. ;' ;`' BOSTON, MA 02204-7044 Account ID: MLS -10180562-004 ” 'y g' 'liF,.,� CONTACT CENTER OqY'�' (617) 887-6367 SALES TAX ON MEALS. AND BEVERAGES REGISTRATION CERTIFICATE 11111111,11,,,11 I'll III i4,11III ,i,11,I1f1IP,111,h1Ill. [III III o KONA ICE CUMBERLAND RI INC — KONA ICE CUMBERLAND RI, INC. 255 YORK AVE PAWTUCKETRI 02860-5827 Attached below is your Sales Tax on Meals and Beverages Registration Certificate (Form MT -1). Cut along the dotted line and display at your place of business. You must report any change of name or address to us so that a correct MT -1 can be issued. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re- print a copy of this certificate. DETACH HERE y5s` 's^r MASSACHUSETTS DEPARTMENT OF REVENUE Form MT -1 �' ( f > Sales Tax on Meals and Beverages Registration Certificate y� t/r N r,F `, � tam This registration must be posted and visible at all times. KONA ICE CUMBERLAND RI INC Account ID: MLS -10180562-004 KONA ICE CUMBERLAND RI, INC. Certificate Number: 1120100352 255 YORK AVE PAWTUCKET RI 02860-5827 This certifies that the taxpayer named above is registered under Chapters 62C and 64H of the Massachusetts General Laws to sell meals and beverages at the address shown above. This registration is non -transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: May 1, 2015 COMMONWEALTH OF MASSACHUSETTS NUMBER BHP -2019-0894 Town of Foxboro Board of Health Fr:E $100.00 ,Kona Ice Cumberland RI, INC. . " ." "_.- unTElssueD a' NAME May 25, 2019 255 York Ave Pawtucket, RI 02860 ADDRESS IS HEREBY GRANTED A MOBILE ICE CREAM TRUCK VENDOR PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2019 unless sooner suspended or revoked. Board of _........ Health Health Director COMMONWEALTH OF MASSACHUSETTS NUMBER BHP -2019-0894 Town of Foxboro -- Board of Health FEE $100.00 Kona Ice Cumberland RI. INC. ones ISSUED NAME May 25, 2019 255 York Ave Pawtucket, RI 02860 ADDRESS IS HEREBY GRANTED A MOBILE ICE CREAM TRUCK VENDOR PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2019 unless sooner suspended or revoked. Board of Health Health Director w O W wJ 0 z h-� z FOP, J W z z W4 P4 W Ci lV 0 0 O w � O O N N b ti CO M � y N N Q h cz �G� v w�q T 71 h Q ln\ " testi h v � � 0 W U � O 0 V n V q§ 0 w � w H � y N N Q h �G� v w�q 71 h Q ln\ " testi h v \ C V n V q§