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Home My WebLink AboutScorpion Bar (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 days before the p date)4`. 1) Establishment Name: Q. %- -1�`\ "Wa �. �M v 2) Establishment Address: ac)\,.<Y\CcL1 09 3) Establishment Mailing Address' different). -"�� --t- \\ `v C` _\ ' ` V[.¢� 4(if 4) Establishment Telephone No: 654U.. ��_I\�\l) �S (oo '3,)-^aL' 5) pplicant/ wner Name & Titl" 1�f -i(Ascko yv�,, ` ,0-;� 6j pplicant/ wner Address: N`:sA U t , tVC` i 0L [ Y G 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address:,.®bne 9) Person Directly Responsible For Onsite Operations: Name & Title:. , I"P— �( k01, 3 a` n-r�fC'L G n tx.•fJ Cu Address: 55b rYjj"-Q.c. U Vivid 'rt U YA7- Telephone No: Sj _ LICIA Fax: Emergency Telephone No: 10) Event Attendin Date(s): lo) ) Event Name: Event Location: ..��,tC�(-X<sifu ac) Event time: P\ „ yn 11) Check one Food Truck catere Othj;I Other: ` 1l 12) Solid waste disposal plan: 13) Water Source: b0� 14) Sewage disposal plan: �UeYw4 cIY�Yted 15) Please give a brief description of the food to be served:le Y Y \ nl i ko S\�--VA- C&Y\ t Sys- 41\-Qub Tomn o f Mansfield GPm;h. Rom, Maur%telyd, Alemadjusetlr 02048 Heakb Dc amwent Amry Dououau-Palmer, AVI-1, RS Health Agent r To: Taste of the Tri-Town Participants From: Amy Donovan -Palmer, MPH, RS, Health Agent la)o, 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 Acopy 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. Phme (508)20.730 - [,ax (508)20-7425 Ew* d1 e1#afiiie)@1vamfieltHma.coin 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hoU cold holding temperatures Offsite and held at proper ho�U cold holding temperatures Offsite coo a 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:,, Allergen Awareness: 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: 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 106 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how t(rgbtain copies of 108 CMR 590.000 and the federal Food Code. 19) Signature of Applies 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 returns and paid state taxes required under law. 20) Social Security Number or Federal ID: — )1 U517 > 21) Signature of Individual or Corporate Name:_ 16aA 9/I Food Protection Questionnaire for Catered Events Date of Event: 10 (1 ►G Event Time: Location of Event:-6'bn-s-G-e'W C --'slact, 'gao .<5ch ( M List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Reheating �Lrti.9-., weaar�Q e�A T e�c�l Food Manager Certification Person'Frained On Site? ra/Yes m No Allergen Awareness Menu Label Present? VI<es 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: 2 1-low will the PHF be kept at or below 41 °F?yy flow will the PHF be kept at or above 140°F7�� gM�yy ptiT_ Time of PHF? Setup Served 4in moved al Dist 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. �, �'Vfvip— AXXP f-------- -.---- I - vt a'ms CC> nr- 1'7,rr -� tsLY)a� a r TAX CERTIFICATION FORM I certify wider the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required tinder law. Signature of individual or Corporate Name "Social Security No. (Voluntary) or Federal Identfficalion 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 Iicense suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Uscrstx1eitc\Desktup1&oWs DocumentsWood Establishments- Temp\'PAX CERTIPICKFION FOR.M.doc The Coraaunt Ivealth of Massachusetts Deparduent of Industrial Accidents Office of Investigations 600 Wash htgton Mreef Boston, MA 02111 )VIVIV.11tass,go Vhlia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization City/State/'Lip: Phone 49A Are you an employer? Check the appropriate box: Business Type (required): 1.0) I am a employer with employees (full and/ 5. rl Retail or part -tiro) * 6. ,M RestaurantlBar/Eating Establishnient 2. ❑ 1 am a sole proprietor or partnership and have no 7. Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. S. ❑ Non-profit [No workers' comp. insurance required] 3.Fj We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and Nye have ME Manufacturing no employees. [No workers' comp. insurance required]** I LQ I3oalth Care 4. [] We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.[) Other *tiny applicant that checks box 01 must also till out the section below showing their workers' compensation policy inf numtion. **lithe corptvotcotFeers have exempted atemselves, but the coipomtionhns othcrempioyecs, aworkeri compansationpolicy is required tmdsuch wit orgy intion should check box NI. turn art employer tbrtl is propleibtg nvlrkers' conyreres(ttfolt itrstirentee for niy employees. Beloip ts„iliepolley information. Insurance Company Insurer's Address: 25 li.i e Lu C tTrr)1n City/State/Zip: 9_-)Z:)3ttO 1✓1 jN 01114 ,- 1-1�Z2-' Policy#orSelt=ins. Lie.# W Ci� Oa5-53l o-4, _Expiration Date: Zs- dC) Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). raiture to secure coverage as required) under Section 25A of MGL c, 152 can lead to the imposition of critninal 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 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations orate DtA ror insurance coverage verification. under provided above is trite and correct OfflclttI oxe only. Do Ito Ivrrte In tit Is area, to be eongdeterl by Illy or it) bon tolehil, City or Town: Permit/License Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone A� " CERTIFICATE OF LIABILITY INSURANCE OATE�1i14/1f8YYY) 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 Bolder 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 ON C NAME: T Scott Handorff lWinbrook insurance Brokerage 400A Franklin Street Braintree, MA 02184 ac°Nro Exl: 781.843-7000 VC. No: 781.848.6100 E-MAIL s: shandorff@twinbrook.com -- -- ----- INSURER())AFFORDING COVERAGE NAIC If INSURERA: Flremans Fund INSURED INSURER B: Atlantic Charter INSURER C: Big Night Venues Foxboro, LLC Scorpion Bar 253 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 RDULSUISKI IN$D WVD POLICY NUMBER POLICY EFF POLICYYYY POLIO EXP MMIDD EXP LIMITS A x COMMERCIAL GENERAL LIABILITY v CLAIMS -MADE OCCUR MZX 80988485 10/31/18 10/31119 EACH OCCURRENCE $ 1,000,000 iTRENTE6— PREMISES IEa occurrence $ 100,000 MEDEXP An on.mnnbn S 6,000 PERSONAL B ADV INJURY _ $ 1,000,000 GENT, AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEOT LOC OTHER: GENERALAGGREGATE $ 2,600,000 PRODUCTS - COMPIOPAGG $ 2,000,000 S AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea occident) $ BODILY INJURY (Per person) S BODILY INJURY (Peraccidenl) 5 PROPERTY DAMAGE Per necideni $ $ A x UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE XA000015363054 10/31/18 10/31/19 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DEC) I I RETENTION$ S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERIMEM ER EXCLU ED?ECUTIVE F— IMandetary in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WCA00553004 01/25/19 01/25120 PER X STATUTE EROTH- E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 A Liquor Liability MZX 80988485 10/31/18 10/31/19 Each Comm Cause Aggregate $1,000,000 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD lei, Additional Remarks Schodule, maybe attached if more space is reguIred) 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 Rizzolsh 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (201&103) The ACORD name and logo are registered marks of ACORD Information and Instructions Massachusetts General Laws chapter t52 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:' Air 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." [vIGL 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 perfomnance 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 acid 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 LI.P 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 listed below. Self -insured companies should enter their 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 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 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 0211 t Tel, # 617-727-4900 ext 406 or t-877-MASSAFE Fax # 617-727-7749 wwwanass.gov/dia Fenn Revised 5-26-05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date 'A q 119 We, rant/ 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. ease list the organization: We are not charging a fee far food/drink being served. ❑ We area religious organization ✓ Other: TASTE OF THE TRI-TOWN Thank you, AMA Signature s _ Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: