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Home My WebLink AboutPalm's Catering (Fall Fest) - 10/5/2019r 11-2 ; i FOR BOARD OF HEALTH USE ONLY ec}d S ; Permit Fee Approved By Permit # Issued - ' �ry Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: pa, ✓ Establishment Address: /t�� ,.e,�{— �f f+�i1 Yl Z. 02i99S GP Establishment Mailing Address (if different): Establishment Telephone No: 00 1— 2AS — 710 `L 2) Applicant/Owner Name & Title: 7Oo, \ ,et o. ( m /c�k-J�- II ApplicantlOwnerAddress; 140 Nti(.0 ( ,S c)3 JC bio Applicant/Owner Telephone No: I0 ( — 2- _I j — q O Applicant/Owner Email address: 00 t ..`. Cd 3) Person In Charge of Onsite Operations & Title: w f c, I k el- o / e n Ci/'� PIC Address; /'v y / c) �I4C) PIC Telephone No: (— 2,qj — w q o Emergency/onsite Telephone No: �t � PIC Email Address: (/ �__ � . IS, .,el-�`% vac. C'�. �S F CiM 4) Event Attending: rv, l _6 hI ✓ ', " )00/7d1 Date(s): V ION Event Name: �t..7 + Fu (t n l Event Location: &I o n A - Event time: 5) Check one a Food Truck aa--16aterer O Other: 6) Solid waste disposal plan: lam/ 7) Water Source: C�I�rn (tib,{-P,G 6) Sewage disposal plan: IL1114- 9 ) Please give a brief description of the food to be served: 10 ) Food will be prepared: ED Onsite for immediate consumption *Onsite and held at proper hot/ cold holding temperatures El Offsite and held at proper hot/ cold holding temperatures = Offsite, cooled and reheated on site I--] Other: 11) If PHF is being served, please list the person who has completed the following tralnings and attach appropriate certificates: .,(� Food Safety Manager: jr` \ "r w Allergen Awareness: � k� 12) Please describe on site hand washing facilities that will be utilized: 1J%SQe�Se�� >ll -e -r to e-�S� S �a((c)n 13) Please list all sanitizing solutions that will be on site: / l-c�� S�1 / �(nSc'_/ _�cf �, il-; Z�- , W�S�i `�/c�rS%1 d•C,{��'e�2 14) If applicable, please describe your FOG management plan or attach the written plan: �esa (! 1 15) For caterers: City/rown where food establishment permit is held. Please attach copy of the caterer's permit: i � f f� , AZ 9 S7fm-f e oC � Ao-41SA T For food trucks, please list additional communities where a food permit is held and attach copies of the Base of Operations or Commissary permit: 1, 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 obta�)s; oM95 CMR 590."Ogd 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: 0 %' ��K 1 (O p 7 211 Signature of Individual or Goroorate Name: S(fIOS Food Protection Questionnaire for Catered Events Date of Event: &j • S7."2,0 f 61 Event Time: lZi'nl V -S Location of Event: FU' Yon Pd/1 __ , AansP e.l<&i /1 LA_ List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location: On ice/Refrigerated Cooking yr-qej&kte S R (�'ce' Reheating Food Manager Certification Person Trained On Site? <Yes o No Allergen Awareness Menu Label Present? Yes o No List all Potentially Hazardous Food (PHF2 and the individual intended temperature required: s6 ( 65' F List threquired temperature for each food as it leaves your preparation site: �cAvll 'F V!e- Xbe 044) 9/°F _ cJ I/1 GF elo4J µ(°F n How will the PHF be kept at or below 41 F. !-I- -?- Y� C C'C') lc' /' How will the PHF be kept at or above 140°F? S f enevm i s kk irvt r / Time of PHF? Setup 11 Awl Served I2Z 10/vM Removed Please describe hand washing and sanitizing supplies that will be provided on S W. 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. Fcvd- j 1 e��to.v �FtrS 1�'� Gil e/ S +uo/1-1�j�X iole5 O�cche-s L04111'.N�krhs I�j LaF� (Jje�Sii—� TshIZCoV 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. A- ��igna'ftfreVf dividual or C rporate Name By: Corporate Officer (Mandatory, if Applicable) q 7 - 399 l e8 4 *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 fall 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street -- Boston, MA 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization S lrx:f-��in Address: GC. ( %1 o'ill � i (-&b- U City/State/Zip: LAfie,fF,e11 / X L O& Phone#: cf(f) Are you an employer? Check the appropriate box: Business Type (required): L ® 1 am a employer with --_L('-) employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/EatingEstablishment 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, § 1(4), and we have 100 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.K[Other *Any applicant that checks box #1 must also 811 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 #1. I am an employer that is providing workers' compensatipn insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: �> � �� Lo il�tptco Al_lfc� City/State/Zip: Policy # or Self -ins. Lic. # o Z— �j LC_ A A Z _Y— 6i' 1 Expiration Date: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' . , n �rVg pains and,geltalties of perjury that the information provided above is true and correct Phone #: lto t— Z l f—/ o l o Oficial 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 (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: The Hartford Insurance Co of the Midwest ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 20605 Company Code: G POLICY NUMBER: Previous Policy Number: 7 . ,g C -THF MiTFORD Suffix LARS RENEWAL 02 WEC AA2ZG1 F ---j 3 02 WEC AA2ZG1 1. Named Insured and Mailing Address: PALM'S CATERING SAUCES AND BETTER DRESSINGS LLC (No., Street, Town, State, Zip Code) 140 NEW RD MOOSUP CT 06354 FEIN Number: 47-3861684 State Identification Number(s): TIN : RI 0000000002 The Named Insured is: LLC Business of Named Insured: Caterers Other workplaces not shown above: 691 MAIN STREET WARREN RI 02885 2. Policy Period: From 05/05/19 To 05/05/20 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: JOHN ANDRADE INSURANCE AGENCY INC PO BOX 8 BRISTOL RI 02809 Producer's Code: 02090178 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877)853-2582 Total Estimated Annual Premium: $454 Deposit Premium: Policy Minimum Premium: $419 RI Audit Period: ANNUAL Installment Term: Four Pay (30%Down+2@25%+1 @20%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 03/26/19 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 03/26/19 Policy Expiration Date: 05/05/20 INFORMATION PAGE (Continued) Policy Number: 02 WEC AA2ZG1 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: RI B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Pians. All information required below is subiect to verification and chance by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe (Other Than Certified Acts Of Terrorism) Estimated Annual Premium (before Surcharges) *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $454 Deposit Premium: Policy Minimum Premium: $419 RI Interstate/Intrastate Identification Number: Refer to Schedule of Operations Labor Contractors Policy Number: NAICS: 722320 SIC: 5812 $237 $215 $1 $1 $454 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 03/26/19 Policy Expiration Date: 05/05/20 n EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number: 02 WEC AA2ZG1 Endorsement Number: Effective Date: 05/05/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PALM'S CATERING SAUCES AND BETTER DRESSINGS LLC 140 NEW RD MOOSUP CT 06354 Item 3.D. of the Information Page is completed to include the following endorsements WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1 INFORMATION PAGE WC000001A.2 INFORMATION PAGE WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC000414A 90 -DAY REPORTING REQUIREMENT- NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC000419 PREMIUM DUE DATE ENDORSEMENT WC000421 D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC000425 EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT WC380401 B RHODE ISLAND SHORT RATE CANCELLATION ENDORSEMENT WC380601 RHODE ISLAND DIRECT LIABILITY STATUTE ENDORSEMENT WC9900011 Signature/ Copyright WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY WC990005 SCHEDULE OF OPERATIONS WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS Form WC 99 03 68 Printed in U.S.A. Process Date: 03/26/19 Policy Expiration Date: 05/05/20 7.40 This is to certify that license is hereby granted to Palm Is Catering, aI a /' Sauces and Dressings of said Warren, to keep a Victualling House at This license is issued subject to Rules and Regulations established by the :hate Health Department BUREAU OF LICENSES License Expires Bunchy, December 01, 2013 Unless sooner revoke of cause. Issued by order of the Town Council of said WARREN Tuesday, November 13, 2018 Attest: Julie A. Coelho, CIVIC Town Clerk N M V N O O ul A WE CE 0 w I ❑ O 0 0 a W J 0 OWE] c .0 W E Lm mumom o � (V� T O cV T L N V a W J 0 OWE] O O N LU r a U N LL a m LU U &L w Ola6ot ��/cJ.�ag2 ManS�ield Application for Standard Permit (Rev.i1 2otJ] Return Completed application to: 10 Plymouth St, Nans0eld MA 02048 4, Permit Number: DIG SAFE NUMBER City orTown: Mansfield q/lC�/�I Start Date; pate: In accordance with the provisions of M.G.L Chapter 140, as provided in section 10A applloation Is hereby made by f�2a�LS At -(m ef Pb-Im `S Ce(,+er. ('txq L/Ot -zsf l — /0 90 If (F 7 f 0 Zfi for permission to (state clearly purpose for which permit Is requested) ft,,,P2',.ery Pbc�_-L s" t th,-Y7 1` ' F'-el'anr`f Name of Competent Opendor (If applicable)LL Cort, No, ��pp Date Issued -rejected By r cw� �{Yit�vt (Slanatae orApplloami Date of expiration Fee Amount Paid$ .L Vl2P l(JD??7//72Lt%2lfJP.GbGGIZ D��/�GG74Q�?.LGOP.�6 /cV.wnq° Mansfield FP -006 (Rev. 1.1.2015) PERMIT CltyorTown: Mansfield D(GSAFENUMBER Date: Start Date: 'Permit Number (If applicable): In acoordanca with the provisions of M.G.L Chapter 148, as provided to (FIA Name of Person, FRrn or rbrpomur mi for Restrictions: at (&teat and #or Du 1111 eLowtlon forAdequate ItlerdfioatlC Fee Paid $ This pertnitwlll expire on Signature of Official Granting Permit: this permit Is granted This permit must be conspicuously posted upon the premises