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HomeMy WebLinkAboutAlberto's (Taste of Tri-town) - 10/1/2019FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Applic w. (Application must be submitted at least 7 business days before the plan pe gle) 1) Establishment Name: 2) Establishment Address: dH l M czy)Sgsle (A 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: EC'lCS 5) Applicant/Owner Name&TitletlGy_ s I lQ1_1'1•�jIC�.�i �(. It'1`j� t�iC-C�-r/" 6) Applicant/Owner Address: e-)"j m a-n Ekte `d !-Tc�o / jc--r j p m a, 7) Applicant/Owner Telephone No: S) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name&Title,-�VU- L' - nqc Cvjj'C:�Cy-) a Tr1Sv11 �n Address: al+ I mot ��iL`C� n1�.(2 Or- \Cf,) Nq n Dc3_7 Telephone No: 50�6- C)�SS -SQ.I I Fax: Emergency Telephone No: -7 G I - (-C,(-o 4 - C-:>a Ct t f 10) Event Attending Ft - TCX V11 Date(s): 1 C:>e1 t `-QoU ( Event Name: u -T—(-t Lzn Event Location: h c, , ' -, 0 -p- ,S�rc Event time: 5 P _ ~1 P 11) Check one Food Truck Caterer Other: A -e-'Z- Q-- 12) Solid waste disposal plan: -T—V-C"h (?3e..r PY 13) Water Source: tAR 14) Sew a a disposal plan: 15 ) Please give a brief description of the food to be served: -0) Z�c!'- Food Protection Questionnaire for Catered Events Date of Event: 10� � I g-yq Event Time: 5 �3 — -1 P Location of Event: Mca-,G�i a Cx� a�6O 6ck)cxA MR List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheatingold�r Ptz-Z-c Food Manager Certification Person Trained On Site? a Yes m No Allergen Awareness Menu Label Present? Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: Pt2?0� I(C's`' How will the PHF be kept at or below 41 OF? How will the PHF be kept at or above 140°F? ny� 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. PI-z7-a- wa-rwva� 51 r A-k" )AP- ke j- 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�k2rVC;-, Pwb11 pi �6h�edcamcLcpkoa-� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) '8aa -14 "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. C:\Users\sleite\Desktop\Seotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Tit eCommon nveolth of Massach usetts Department of Industrial Accidents Office ofbtvestigations 600 Washington Street Boston, MA 02111 tvtvoi ntas's.go vIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/OrganizationNalne: n� ���' 5� �( -A Address: OW I rnco Y15�1�� C� [-rv-tc. �i City/State/Zip: NBC c Z 1 MR U dI UP Phone #: 501�s ` alv S^ S QD I Are you an employer? Check the appropriate box: Business Type (required): E ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. [&estaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no y. El Office and/or Sales (incl. real estate, auto, e(c.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. Fj Entertainment their right of exemption per c. 152, § 1(4), and we have 10.[:] Manufacturing no employees. [No workers' comp. insurance required]** 4,n We are a non-profit organization, staffed by volunteers, I Ln Health Care with no employees. [No workers' connp. insurance req.] 12.Ej Other *Any applicant lhat checks box # I most also fill out die section below showing their workers' compensation policy infomwlion. **Irlhe corporate officers have exempled nrenrselves, but the corporation has other employees, a workers' compensation policy is required and such an orgarnmdon should check box H I. I rnu an etnp/Dyer tort is providing workers' connpensniiou bnsnrmnce for tnr engloyees. Below is file policy information. Insurance Company Nanne _(-� Insurer's Address: SCI L [ City/State/Zip: Iwc� CJAAA_o__bCx'C-_) YY1R ��11pb Policy # or Self -ins. Lic. # t Lo C U q,-j sq Expiration Date: as 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 innposition ofcriminal 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 berebp certify, under the pains anal penaties of penji ny that the information provided above is n•ne and correct. Signature �� C xYl G�c Q R� Date: Phone 9:5C�_ - ass- 5Lot Official use only. Do not write in this area, to be completed by city or town offfc/aL 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: phole 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 fisted below. Self -insured companies should enter their self-insurance license number on the appropriate fine. 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 permittlicense 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 or commercial venture (i.e. 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 Fenn Revised 5-26.05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date -6 1 a5 I I'9 We, Wb(2�-V6s PuzA-,) 1 tzzc�i� (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, Signature Si 1 �w-�'Jc Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: ALBEPUB-01 AKAHANOWIT7 A�oRo., CERTIFICATE OF LIABILITY INSURANCE DATE6/3/3/2/2019 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO ACT R. S. Gilmore Insurance 27 Elm St North Attleboro, MA 02760 (PA HCNN , Ext (508) 699.7511 wc, No :(508) 695-3597 E-MAIL D s INSURERS AFFORDING COVERAGE NAIC # INSURER A: Republic Franklin Insurance Company 12475 INSURED INSURERS: Utica Mutual Insurance Co. 25976 INSURER C: AMGuard 42390 Alberto's Pub & Pizza, Inc. INSURER 0: 241 Mansfield Ave Norton, MA 02766 INSURER E 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 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. INSR LTH TYPE OF INSURANCE ADDLSUBR INSD O POLICY NUMBER POLICY EFF O POLICY EXP O LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FIX71 OCCUR 5068302 8/14/2018 8/14/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ed rcrurance!t MED EXP Ary oneperson) $ 10,000 PERSONAL &ADV INJURY $ 1,000,009 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ PR LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT BODILY INJURY Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS 0 BODILY INJURY Peraccidenl $ Pert acad n� AMAGE $ AUTOS ONLY AUUTOS ONLY B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAB CLAIMS -MADE 5068304 8/14/2018 8/14/2019 DED )( RETENTION$ 10,000 C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory nNH) Ryes, describe FF OPERATIONS below DESCRIPTION underOO N/A ALWC097899 4/25/2019 4/25/2020 PER OTH- S E.L. EACH ACCIDENT $ SOO,OOp E1 DISEASE - EA EMPLOYEE $ 500,000 EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Includes liquor liability, Re: Norton Founders Day Event, Town of Norton is listed as addidional insured with respects to general liability as required per written contract. Town of Norton 70 East Main St Norton, MA 02766 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 ACUHU 25 (ZU15/U3) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 5 \ \ I\\ ^ \9}« ( a2\\ , \ { ,[ - } ■ t \ r 2 \ w P / f rD \ / ) \ / 0 / \ ( \ ( ,PA I I I � � I