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Home My WebLink AboutEdible Arrangements (Taste of Tri-town) - 10/1/2019Permit 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: �_' j 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No:�.J 5) Applicant/Owner Name & Title: t 6) ApplicantlOwner Address: JXA,v7 7) ApplicantlOwner Telephone No: -- 8) ApplicantfOwner Email address: } `` 9) Person Directly Responsible For Onsite Operations: -)� r r , Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 10) Event Attending Date(s): Event Name: Event Location: r-, Event time: 11) Check one 12) Solid waste disposal plan: _Food -Truck Other: ^� r 13) Water Source: 14) Sewage disposal plan: t 15) Please give a brief description of the food to be served: �. 0C. '�'— 16) Food will be prepared: Onsite for immediate consumption Onsite and heldat proper-bnt1 cold holfttemperalures Offsite and held at proper hot/ cold holding temperatures Offsite, cooled an re este 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: _ 19) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit: Via.':✓ 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 105 CMR fi90.000 and all other applicable law. I have been instructed by the board of health on how, to obtain copies of 1b5 CMR 590.000 and the federal Food Code. 19) Signature of Applicant: 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 retums and paid state taxes required under law. 20) Social Security Number or Federal ID: '2f'; S 5 ?iS 21) Signature of Individual or Corporate Name:-, Food Protection Questionnaire for Catered Events Date of Event:[( 7 % — _ Event Time: 4 — 79rb Location of Event. /9)q'v° ""r if rig 5Sf ,u5 List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating �G7rr' Food Manager Certification Person Trained On Site? Yes ® No Allergen Awareness Menu Label Present? uT'Vcs m No List all Potentially Hazardous Food (PHP) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? 7-c < / 214, 2�slf How will the PHF be kept at or above 140°F? 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. NSr= r«kfl a TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Q Signature of Individual or Corporate Name :Corporate Office (Mandatory, if Applicable) %°'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:\IlseB\sleile\Desklop\Scoll's Dmumenls\I'ood Esmblishments-Temp\TAX CERTR'ICS(ION PORM.doc The Cotmtionneealth ofMassuchtisetts Depen trimitt of Industrial Accidents Office of Investigations 600 I'Vashington Street Boston, MA 02111 n mv.Inass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Natnc ) 1d)�lP✓!)3 ' S AX- 9 ✓ -Ml-,-; vVy0 Address: AD 6. ❑ Restaurant/Bar/Eating Establishment 2.0 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. S. ❑ Non-profit [No workers' comp. insurance required] Phone #: 5—L 14 5-y-3 `L93e� .y Are you an employer? Check the appropriate box: Business Type (required): 1.9 1 am a employer with L_ inployees (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 (incl. real estate, auto, 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. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I I ❑Health Care 4, F] We are a non-profit organization, staffed by volunteers, _! C 44'—L' with no employees. [No workers' comp. insurance req.] lIff Other *Any applicant rhat checks box 41 must also fill out the section below shoving their workers' compensation policy information. **If rhe corporate officers have exempted themselves, but (lie corporal ion has other employees, a workers' compensation policy is required mid such .m orgard/inion should check box IfL con an employer that is providing workers' compensation htsuroncefor my, employees. Below Is the policy hrforermtion. Insurance Company A - Insurer's Address: f a.1a 4,,r," "AA 2- r`, City/State/Zip: Y/ -{do C:�/\,� Policy # or Self -ins. Lia # ZA tufo (- vii Expiration Date: mj/ f-,�—_ 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 lnvestigations of the DIA for insurance coverage verification. do herel{y certify, tinder the pinus mtd penaldes rf petjoig than the information provided above Is true and correct. Official ase ontp. Do not uvrite in this area, to be completed by city or lova 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 Contact Person: Phone illansfield Board • Date We, (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 601(c)(3) organization. Please list the organization: ❑ GVe are not charging a fee for food/drink being served. ❑ We are a religious organization ✓ Other: TASTE OF THE TRI -TOWN I Thank you,�� Signature� CtW k-'V�— Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: (Policy Provisions: WCOOOOOOC) INFORMATION INSURER: The Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number. 14974 Company Code: 7 POLICY NUMBER: 76 WEG NG9633 Previous Policy Number. 176 WEG NG9633 1. Named Insured and Mailing Address: MJM ENTERPRISES INC (No., Street, Town, State, Zip Code) 375 CENTRAL ST FOXBORO MA 02035 FEIN Number: 20-5658561 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Florists Other workplaces not shown above: 2. Policy Period: From 10/02/18 To 10/02/19 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. ` Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY 71 HANOVER ROAD FLORHAM PARK NJ 07932 Producer's Code: 76250717 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $1,767 Deposit Premium: Policy Minimum Premium: $288 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Tenn: The policy is not binding unless countersigned by our authorized representative. Suffix LABSLARS RENEWAL 8 Countersigned by 08/23/18 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date:'08/23/18 Policy Expiration Date:. 10/02/19 le-q90, 2|\ 0 �< ■ . LL 2 0 2 7 rA § 2 k /k�ID §\ 2 § - Mr W Q 09 a