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Home My WebLink AboutWingate at Norton (Taste of Tri-town) - 10/1/2019FOR 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: Wingate at Norton 2) Establishment Address: 184 Mansfield Ave, Norton, MA 02766 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 508-285-7745 5) Applicant/Owner Name & Title: Healthcare Services Group 6) Applicant/Owner Address: 3220 Tillman Dr., Bensalem, PA 19020 7) Applicant(Owner Telephone No: 800-363-4274 8) Applicant/Owner Email address: H4X@hcsgops.com 9) Person Directly Responsible For Onsite Operations: Name & Title: David Silverstein, Food Service Director Address: 184 Mansfield Ave., Norton, MA 02766 Telephone No: 508-285-7745 Fax: Emergency Telephone No: 774-634-6028 10) Event Attending Date(s): 10/1/2019 Event Name: Taste of Tri Town Event Location: Mansfield Crossing, 280 School St., Mansfield, MA Event time: 5-7 PM 11) Check one Food Truck Caterer Other: Assisted Living Facilty 12) Solid waste disposal plan: We will dispose of any solid waste via the trash cans provided for the event and we will bring our own trash linders 13) Water Source: Event provided and we will bring bottled water 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: Korean BBQ Pulled Pork Slider with Honey Siracha Slaw 16 ) Food will be prepared: Onsite for immediate consumption Onsile and held at proper hott cold holding temperatures Offsite and held at proper hot/ cold holding temperatures X 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: Food Safety Manager: Up'�) t� Allergen Awareness: b" 18) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: Cityrrown 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 106,CMR 690.000 and all other applicable law. 1 have been instructed by the board of health o ow o co ie of 105 MR 590.000 and the federal Food Code. 19) Signature of Applicant: ��r—" Pursuant to MGM 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 ID:-2— —3 2 0 ( L 9 in 21) Signature of Individual or Corporate Name: AzAL UK1ex,-- SZYLUIC4 L aav-12 Food Protection Questionnaire for Catered Events Date of Event: 10/1/2019 Event Time: 5-7 PM Location of Event: Mansfield Crossing List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Cole Slaw Pulled Pork Food Manager Certification Person Trained On Site? t2� Yes o No Allergen Awareness Menu Label Present? [::� Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: Pulled Pork 40 F holding List the required temperature for each food as it leaves your preparation site: Cole Slaw 40 F Pulled Pork 40 F How will the PHF be kept at or below 41 °F? Ice How will the PHF be kept at or above 140°F? Heating pork to order in small batches with an induction pan Time of PHF? Setup 0430 pm Served 5-7 pm Removed 7 pm 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. Bowls Induction Burner and Pan Hotel Pans Gloves Tongs Towels Bi stem thermometer Sanitizing Wipes Chafing Dish 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. laCAI -t H (l,)a.0 a2:x,� Signature of Individual or Corporate Name 320 f g3b5' **Social Security No. (Voluntary) or Federal Identoeation 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. C:\Usem\sleite\Desktop\Scolt's Dmuments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Continonntealth of'Mnssachnsetts Department of lndnstHal Accidents Office of lit testigations 600 Washington Street Boston, MA 02111 wstiv. niass'.gov/din Workers' Compensation Insm•ance Affidavit: General Businesses Applicant Infof'mation Please Print Legibly Business/Organization Name: Healthcare Services Group A.I r1,•acc• 3220 Tillman Dr., Suite 300 City/State/Zip: Bensalem, PA 19020 Phone #: 800-363-4274 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 30 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inel. real estate, auto, etc.) employees working for me in any capacity. g. ❑ Non-profit workers' comp. insurance required] In 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]** 1 I.® Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12•❑ Other *Any applic:nLthat checks box 111 most also fill out am section below showing dreir workers' compensation policy Infomtation. **If the cogtomteolncers have. exempted Ihnnselves, but the corporation has other employees, a workers' compensation policy is required:nd such an organization should check box 91. I air an employer that is providing workers' compensation his'itrunce fir cop employees. Below Is (lie policy infrn'nmNon. Insurance Company Name: ECBM Insurer's City/State/Zip: 1400 North Providence Rd Media, PA 19063 Policy # or Self -ins. Lie. fl GL 5425884 Expiration Date: 1/1/2020 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dale). Failure to secure coverage as required touter Section 25A of MOL c. 152 can lead to the imposition ofcriminal penalties 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 it title 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. do her eerd y, n r the nln. oud renal(/es of peijrrrp that the information provider/ oimre is tare and eorivel. s Sinnaoa Date,- ��t ti12DlCi Phone9: -7`ILi `(01q—%Oi—& Officln! use only. Do not Ivrile in liiis area, (o be canple(ed k1 city or town nflicial. City or Town: Permit/License iq Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone N: 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 commomvealth 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 fisted below. Self -insured companies should enter thew 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 licenses. 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 orcommercial venture (i.e. a dog license or permit to bum 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 Revised 5-26-05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date 9/11/2019 We Healthcare Services Group (restaurant/ 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 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 Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: �Ro® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMONYYY) 01/04/2019 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 INS URER(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 NAME Kyle Chien ECBM, LP PxoNE E (610)668-7100 AID Ne: (610)667.2238 AODREes; kchlw@ecbm.00m 1400 N. Providence Road, INSURER(S)AFFORDING COVERAGE NAIC p Suite 5025 INSURERAI National Union Fire Ins Goof Pittsburgh PA 19445 Media PA 19063 INSURED INSURER B: Now Hampshire Ins CD 23841 Healthcare SONICOS Group, Inc. INSURER C: 3220 Tlliman Drive INSURER D: INSURER E: SURE 300 Bensalem PA 19020 INBUReRP: ' COVERAGES CERTIFICATE NUMBER: Dummy 19 M Standard REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWWAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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, LTH TYPE OF INSURANCE IN9D VND POLICY NUMBER E F MWDD/YVVV PO ICY E%P MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR SIR: GL 6426884 01/01/2019 01/01/2020 EACH OCCURRENCE $ 1,000,000 X PREMISES Ee c u re $ 10,000 MED E%P (Anyone arson) § 100,000 I PERSONAL BADV INJURY $ 1.000.000 GENLAGGREGATE LIMITAPPLIES PER: X POLICY jECT LOG OTHER: GENERALAGGREOATE $ 10,000,000 PRODUCTS - COMPIOPAGO § 2,000,000 It A AUTOMOBILE X X LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY XAUTOS ONLY CA9767454 01/0112019 01/01/2020 COM81 ED IINGLEUMIT Eee ltlan $ 1,000,000 BODILY INJURY (Per pemon) $ BODILY INJURY (Per accident) $ AGE PROPERTY DAMAGE Peracddeni $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACHOCCURRENCE $ AOOREGATE E DEB RETENTION $ E B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUOVE OFFICEWMEMBER EXCLUDED? (Mandatory In NH) If Yes describe under DESGIRIPTION OF OPERATIONS below NIA WC 012717043 01/01/2010 01/01/2020 SPEAR X PER OTH- TUTE ER E.L. EACHACCIDENT ,§ L0001000 E.L. DISEASE - EA EMPLOYEE E 1,000,000 E.L. DISEASE -POLICY LIMIT I, 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace le required) 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 LOO] ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD I W U w H W U •Tcn !�1 z P4 .10 W 2 CO WK J pM N o c�•'a U q 0 sex o a g Y L d y� \, �Y b + . lti 4� O ~ l S � E I Town of Mansfield 6 Park Rom, Nlausfielel, Ma.rmchusells 02048 Heclllh Depar/rraerll /lniy Oonorau-Pabner, AVI1, 1' Heallh /19ov Memo To: Taste of the Tri-Town Participants From: Amy Donovan -Palmer, MPH, IRS, Health Agent , Date: July 18, 2019 Re: Permitting Requirements Dear Taste of the Tri-Town Participants, 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 (30b')261-7366 I'ax (508)261-7425 E'olail ad/�aGucl(i�liraurfiokluin.ram