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Home My WebLink AboutCBS Sporting Club (Taste of Tri-town) - 10/1/2019FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Temporary Food establishment Permit Ap (Application must be submitted at least 7 business clays before the F ®.v on d 2679 pening date) 1) Establishment Name �S Srpc){.- .-ITr ___a � 2) Establishment Address .- ' f 3) Establishment Mailing Address (if different) 7-)."� -- •�,�- 't --- � 1{tt1.�, �'r�� LiAr'+` `I,p�j _tir•Yi`u_ 1 \r"�\t:C�� A) Establishment Telephone No: 6) PPlica U wner Name & Title: ',l., '� -f I` 6) A/pplicantJQwner Address: C _-.:-- �j 7) ApplicanNOwner Telephone No: t , 7�I ,) _ t�t_ti—r- 8) Applicant/Owner Email address/ <' 9) Person Directly Responsible For Onsits Operations: Name & Title: ��. Address: ')N—) TY L \VF.L-Vct V � r]ti"a Telephone No: a Fax; ,—r ;c Emergency Telephone No: -_ 10) Event Attending--'i� 1 \tTut \ Oats(s): I �� ) q 1 Event Name: EventLocation; i�1� '\-L (. \l't�XYti�� .n�tJ �\�! v'� •7` Y �.i(\)\'\—l�C Event time: 11) Check one 12) Solid waste disposal plan: Food'rruck �(�: �Al ,� tluin'Y3k6 caterep, r. ` Other: 13) Water Source: 'IA) Sewage disposal plan: 15) Please give a brief description of the food to be served: }C �U Vy\)Ir. O\u u Town of Mansfield 6 Park.. Roo, blanylvU AFarsu<hurells 02048 Health Depampveln Ang L)wmair-l'alnrer, MKI, RS 1-leallb /tgenl an M To: Taste of the Tri-Town Participants From: Amy Donovan -Palmer, MPH, RS, 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: a 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, G Park Row, Mansfield, MA 02048 no later than September 20, 2019. Please contact the Health Department with any questions. Mime (508)261-7366 - t'ax (508)261.7425 Eureri!cover 16 ) Food will be prepared: Onsile for Immediate consumption Onsite and held at proper hoU cold holding temperatures Offsite and held at proper hoU, cold holding temperatures -6-iEsde cooled and reheated on site Other: 17) If PNF is being served, please list the person who has completed the following trainings and attach appropriate certificates: ,-� _ Food Safety Manager:. ew Allergen Awareness: —_____ 16) if applicable, please describe your FOG management plan or attach the written plan: NNA Vc- 19) For caterers: CityYrown 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 tlse permits: 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 500.000 and all other applicable law. I have been instructed by the board of health on how Wrobtain cophIs of 105 CMF 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 1, to my best knowledge and belief, have filed all state tax retu rns and paid state taxes required under law. 20) Social Security Number or Federal ID:I a (_q - l G r OS q 21) Signature of individual or Corporate Name Food Protection Questionnaire for Catered Events Date of F,vent:j� Location of Event: Event Time: List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Clnzzti'FtYl � Y1 ic�[�ic.A$ a. Food Manager Certification Person Trained On Site? dYes d No Allergen Awareness Menu Label Present? EV'Yes o No List all Potentially Hazardous Food PHF) and the individual intended temperature required: saakxs- List the required temperature for each food as it leaves yourpreparation site: 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 (j Removed Opm 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. -Cobw -- W I C� `ir1t�t2€1� 5 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. k.N" '6�0*k - Signature of Individual or Corporate Name tq(-e--) Us9(:)-�� **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandator/, 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:\Uscrs\slciteUJesktopVSeott's Documents\Food Establishments- Temp\' M CERTIFICATION FORM.doc The Continonwealth ofMassuchitsetts Deprtrhnent of InriristrialAccidents Office of Investigations 600 lVashington rSYreel Boston, NIA 02111 tvlvtv.raass.go v/ili(I Workers' Compensation Instirnnce Affidavit: General Businesses Applicant Information Please Print Legibly But siness/Orgy nizadon AddressA m) 10� 104 ?b u— (J Phone #fY3(a6 Are you an employer? Check the appropriate box: Business Type (required): 1,M l en a employer with employees (fill[ and/ 5• Ej Retail of part-time),* 6.: RestamaribDar/Eating Establishment 10 1 am a sole proprietor or partnership and have no 7, 0 Office and/or Sales (incl. read estate, into, etc.) employees working for me in any capacity. S. [] Non-profit. [No workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised 9. Q Entertaimnent their right of exemption per c. 152, § 1(4), and we have 10.[] Manufacturing no employees. [No workers' comp, insurance required]** 1 L� Health Care 4.n We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.El Other _ May appliurntlhst checks box Bt must also fill ant the section below slowing their workers' compensation policy inl'omun[an. **If the corporate officers have cxenipicd IheniseNes, hilt the corporation pus other employees, a workers' compensation policy is required mid such no on miinrtion should check box Sl. 1 ant art eaplayer teat ispravldhtg u'ortte,•s•' conrliensaiJatr insrrrrmcrfnrrrty eugrfnyees, 6eloiv is Ikepottep trrfornrrrflat. Insurance Company Insurer's Address: CitylStalelZip:�Y n_M 4_� I i LT -Jc27 Policy # or Solf ins. Lie. #�J�k,°r% _[ (p 7 } Expiration Date: _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration hate). Failure to secure coverage as required under Section 25A of MGL c. 152 call 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 tip to $250.00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ror insurance coverage verification. I do hereby certify, mider the pubis rind penahles of perfiny that U7 4? Of flelal Ilse 0111y. Do not write In this area, to he caapleted by city or iloon affletal, City or Town: Permit/License above Is true and correct. fssubrg Authority (circle ore): 1. Board of Health I Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone AC'"RL7 CERTIFICATE OF LIABILITY INSURANCE DATE (MMroorcyvY) 09/09/19 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFfiRS 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 endomement(s). PRODUCER CONTACT NAME: Scott Handorff _.._ Twinbrook Insurance Brokerage 400A Franklin Street Braintree, MA 02184 PHON o, Ext _781.843-7000 _ ac No: 781.848.6100 Aonaess:. shandorff@twinbrook.com INSURER(S) AFFORDING COVERAGE NAIL If INSURER A: Atlantic Charter INSURED INSURER B : INSURER C : Big Night Management Group, LLC DBA CBS Sporting Club 200 Patriot Place INSURER D: INSURER E: Foxborough, MA 02035 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. ILTR TYPE OF INSURANCE INSD SUB POLICY NUMBER POLICY EFF POLIO YYYY POLICY EXP POLIO YYYY LIMBS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE ❑ OCCUR EACH OCCURRENCE $ TERTMT— PREMISES Ea occurrence $ MED EXP An one arson $ PERSONAL B ADV INJURY $ /IES PER: GEN'L AGGREGATE LIMIT APPLIES POLICYOJECOT ❑I LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea acNdenl $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY —DAMAGE Permcidera $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS40ADE EACH OCCURRENCE $ AGGREGATE $ DIED I I RETENTION$ S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERIMEM ER EXCLUDED? ANY EGUTIVE Y� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WCA00567201 07/02/19 07102/20 PER OTH- X STATUTE ER EL. EACH ACCIDENT $ 1,000,000 71, DISEASE - EA EMPLOYEE S 1,000,000 E.L, DISEASE -POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Foxborough ACCORDANCE WITH THE POLICY PROVISIONS, Foxborough, MA 02035 _ AUTHORIZED REPRESENTATIVE Joseph P Rizzo / SIT @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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 trader 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 suchdwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be all 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 he 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 fine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at die bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding die applicant. Please be sure to fill in the pennit/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 die 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 its a call. `the Department's address, telephone and fax number: The CotnnionWealth of Massachusetts Department oHodustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 wwwanass,gov(dia Form Reviscd 5-26-05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date S19ri 119_ We, 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 601(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: -2/We are not charging a fee for food/drink being served, ❑ We are a religious organization ✓ Other: TASTE OF THE TRI-TOWN Thank you, ig5 natu e (t Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: