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HomeMy WebLinkAboutFirefly's BBQ (Kiss Concert) - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: XFINITY FOOD PERMIT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. STEVEN A. ULISS Whose place of business is: Q CAFE LLC DBA FIREFLY'S BBQ THE XFINITY CENTER - KISS CONCERT 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: STEVEN A. ULISS, OWNER Permit Expires: December31,2019 Food Fee: $175.00 License Number: XFS-4 BOARD OF HEALTH AichaeCHeaCey, Chairman WIF.5 Co FOR BOARD OF HEALTH USE ONLY Date Received Permit 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: JOA U� fi 2) Establishment Address: , t '31T, ft0aW-&0(A-iMft 01151 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 15011� '1 cJ rps 5) ApplicantlOwner Neme &Title: If�r� `-MAY I %01_9 6) ApplicantlOwner Address: t. (`o �� I v 7) Applicant/Owner Telephone No: /— (ob /1 r 8) ApplicantlOwner Email address: -IyJ-1 t� ( ^ y / ( — 9) Person Directly Responsible For Onsite Operations: Name & Title: l I Address: ,1. 17 Telephone No: 3br1 g Fax: 7 V Emergency Telephone No: ZV r IGUL 10) Event Attending Date(s): 5 n R/y 1� 2D Event Name: Event Location: X, Event time: I, 11) Check one Food Truck ACaterer Other: 12) Solid waste disposal plan: 01� r 13) Water Source: --ravio 14) Sewage disposal plan: T � 15 ) Please give a brief description of the food to be served: Chi cltt ,k4 ?wYtffs,t t 1 r C&-"S"3.Q 16 ) Food will be prepared: Onsite for immediate consumption .S(Onsite and held at proper hob cold holding temperatures Offsite and held at proper hob cold holding temperatures Offsite, cooled 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: ��1�,,,.���'t��T,t ( � OL> Allergen Awareness: iijlt cil Kn.l� 18) 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: M AP100901L) X11 M Ol'7 it For food trucks, please list additional communities where a food permit is held and attach copies of the permits: I, 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 obtain copies 914X CMR 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 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: 21) Signature of Individual or Corporate Name: i1 7J n Food Protection Questionnaire for Catered Events Date of Event:-�A Location of Event: Event Time: r7 ,Da dj-n — $. am List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating AlY/>f.lE IA✓i /rOif✓ /pm 11{// P/i.l�-/,J/ Cq 4Y✓I �Oi!<<Ir (iJ/c llJ.v S.P+rJwN �L /314-i 1r.f -AYJ �_ �!/Cii N.✓11A ✓.0?if.I Te.f//(-431�y..7 �i✓Yff P/1XT8 TliT9r+ rgL/yy/ Food Manager Certification Person Trained On Site? ei'Yes o No Allergen Awareness Menu Label Present?' dYes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: �U/✓J/ijs✓ 'Ye List the required temperature for each food as it leaves your preparation site: 'Oak <<I.!`sL / 6 How will the PHF be kept at or below 41'F? C.y �� !(Si y s How will the PHF be kept at or above 140°F? y Time of PHF? Setup v✓ Served 7 � <.� emoved , 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. 421/1, py/nJ efV4 .JIc✓/ //Hn b -d d� fl �fy�n5 (/i/HrU i G� ./✓ .Wi <Arj 7iiNnt+r�lsii /f.4or in/!f '/1iy /f �i3tr<�s 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. /�1 /�i.P.-,q�/,�y /�t�.y/,�.��e s>�Q�t.�—/� /H,�..25•.�i /r/.�..76�,2 �eof or—Corporate Name By: Corporate Officer (Mandatory, if Applicable) G/- �3yzz - 1'142 "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\Dcsktop\Scott's Documents\Food Establishments- Tcmp\TAX CERTIFICATION FORM,dec ss 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 Name: UL Address: 11 wM GJT City/State/Zip: MA 0 E71,52., Phone #: 506 T, ?0'62) Are you an employer? Check the appropriate box: Business Type (required): l.� I am a employer with�O employees (full and/ 5. ❑ Retail or part-time).* 6. �0 Restaurant/Bar/Eating Establishment 2.0 I 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. [No workers' comp. insurance required] 8. ❑ Non-profit 3. F-1 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also fill 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 out an employer that is providing workers, compensation insurance for my employees. Below is the policy information. Insurance Company Name: IYO p�5A l � ycNisndL ffyorl/1ifCyu-') VV(/ (2rl')t/I° Nx C ' Insurer's Address: ppPo L- I✓ ;iC City/State/Zip: IN�(i IIV,y V.& o�Jb�l - o0oo `� Policy # or Self -ins. Lie. # 0' 0��11 ✓`iCJ�J (� �� Expiration Date: i 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 certify, under theins and penalties ofperjury that the information provided above is true and correct. %3 �/ Official 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 Contact Person: Phone A� �® CERTIFICATE OF LIABILITY INSURANCE TE DA1/17/2019YYY) 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(les) must 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 Association Members Insurance Agency 200 Broadway Suite 207 Lynnfield, MA 01940 CONTACT PHONE FAX A1C Nor EXt: AIC No: E-MAIL ADDRESS: - INSURERS) AFFORDING COVERAGE NAIC# wsURERA: MA Retail Merchants WC Group Inc. PERSONAL & ADV INJURY $ INSURED INSURER B: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO - ECT LOC Q Cafe LLC d/b/a Firefly's BBQ 350 E Main Street INSURER C: — INSURER D: INSURER E: Marlborough, MA 01752 INSURER F: COMBINED SINGLE LIMIT Ea accident _ _$ BODILY INJURY (Per person) $ COVERAGES CERTIFICATE NUMBER: 00002 REVISION NUMBER: 00000 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 LTR TYPE OF INSURANCE ADDL INSR SUBR MO POLICY NUMBER POLICY EFF (MMIDDYYYYI POLICY EXP IMMIDDIYYYY)LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE DOCCUR - EACH OCCURRENCE $ bA61A=OR TED PREMISES Ea occurrenp� $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO - ECT LOC PRODUCTS COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident _ _$ BODILY INJURY (Per person) $ BODILY INJURY (Per amitlenn $ PROPERTY DAMAGE $ Per accitlenl $ UMBRELLA LIAB EXCESS UAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATIONWC ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (M andatoNIA ryin NH) If yyes, describe under DESCRIPTIONOFOPERATIONS below 014005034631119 1/01/2019 1/01/2020 STATU - X - OTH TORVLIMITS ER E.L. EACH ACCIDENT $ 1A00,000 _ E.L DISEASE - EA EMPLOYE $ 1,000,000 "-- E.L. DISEASE POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION Q Cafe LLC Firefly s BBQ E Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mar arlbOroUgh, MA 01752 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTICE TO EMPLOYEES A_ NOTICE ' TO EMPLOYEEI The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222, Braintree, MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005034631119 01/01/19 - 01/01/20 POLICY NUMBER EFFECTIVE DATES Association Members Insurance Agency 200 Broadway Suite 207, Lynnfield, MA 01940 (781) 771-0009 NAME OF INSURANCE AGENT ADDRESS PHONE # Firefly's BBQ 350 E Main Street, Marlborough, MA 01752-0000 EMPLOYER ADDRESS 01/08/2019 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222.9222 Braintree, MA 02185.0000 Information Page and Q Cafe LLC Firefly's BBQ 350 F. Main Street Marlborough, MA 01752 Workers Compensation and Employers Liability Insurance Policy Carrier Polic #: Policy Period 014005034631119 01/01/2019 to 01/01/2020 Association Members Insurance Agency 200 Broadway Suite 207 Lynnfield, MA 01940 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named insureds if Appiicalbe r of Business: Limited Liability Co Federal ID#: 043422462 D: NCCI / Bureau #: 34355 ployment ID #: File #: 014005034631119 Renewal Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2019 to 12:01AM on 01/01/2020 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA 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: C Other States Insurance: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $ 1,000,000.00 each accident $ 1,000,000.00 policy limit $ 1,000,000.00 each employee D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000308(04/84), WC000406(�, WC000414(07/90), WC000422B(01/15), NOE(01/01), WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13), WC200405(06/01), WC200601A(07108) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Minimum Premium $ 290.00 Form # WC 00 00 01 C (Ed,) Code # Premium Basis Rate Per $100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Prorated Premium Estimated Annual Premium Expense Constant De osit $ 10,895.00 $ 10,895.00 $ 0.00 $ 0.00 :) Copyright 2013 National Cnunc0 ,.,, Countersigned by: Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185-0000 Information Page Q Cafe LLC Firefly's BBQ 350 E Main Street Marlborough, MA 01752 Workers Compensation and Employers Liability Insurance Policy Carrier Policy #: Policy Period 014005034631119 01/01/2019 to 01/01/2020 Association Members Insurance Agency 200 Broadway Suite 207 Lynnfield, MA 01940 Schedule of Classifications : MA Renewal Agreement Code No. Classification 8810 Clerical Office Employees Noc 01/01/19-01/01/20 9079 Restaurant Noc 01/01/19 Payroll $148,818.00 $1,254,360.00 Rate 0.07 1.03 Premium $ 104.00 $ 12,920.00 Description Manual Premium Percentage Factor Amount Rate Deviation (9037) 20.0000% $ 13,024.00 Increased Employers Liability Limits (9812) 2.0000% $ 2,605.00 Experience Modification - Listed below (9898)$208.00 Standard Premium 0.9900 $ 10,521.00 Volume Discount (0063) 0.4500% $ 10,521.00 Normal Premium $ 47.00 Expense Constant (0001) $10,474.00 Domestic Terrorism (9740) $ 0.00 Annual Premium 0.0300 $ 421.00 DIA Assessment 1.4700%/ $ 10,895.00 1.4700% $ 190.00 Total $11,085.00 Experience Modifiers Effective Date 9900 08/01/2018 Domestic Terrorism Payrpll Rate Ch,rge: 1,403,178.00 0.0300 421.00 Form # WC 00 00 01 C (Ed. ) J Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE PO BOX 7010 BOSTON, MA- 02204 . Q CAFE LLC N� 350 E MAIN ST MARLBOROUGH MA 01752-5422 Dear Taxpayer, Notice Date: 08/09/13 Taxpayer i6 Number; 043.422 462 Below please find your Siales Tax on Meals and All Beverages Registration Certificate (Form MT -1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept, of Revenue Massachusetts Department of Revenue MT -1 Customer Service Bureau PO Box 7010 Boston, MA 02204 The vendor herein named is registered to sell meals and beverages pursuant to the General Laws, Chapters 62C and 64H. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct MT -1 can be issued. IDENVICA71014 Q CAFE LLC NUMBER DBA FIREFLY'S 043-422462 318 SEVEN BRIDGE ROAD LANCASTER MA 01523 ISSUE DATE 08/09/13 MARLBOROUGH HEALTH DEPARTMENT THE MARLBOROUGH HEALTH DEPARTMENT HAS ISSUED THIS FOOD PERMIT TO: NAME: Firefly's ADDRESS: 350 East Main Street ISSUED: November 1, 2015 PERMIT TYPE: Annual PERMIT CATEGORY: Food Service On- and Off --site Catering HAS BEEN ISSUED PERMIT ## FF 19-50 5 TO CONDUCT BUSINESS WITHIN THE CITY OF MARLBOROUGH, IN ACCORDANCE WITH FEDERAL FOOD CODE 105 CMR 590.000 AND THE 1999 FOOD CODE AND ALL RULES AND REGULATIONS SET FORTH BY THE CITY OF MARLBOROUGH, HEALTH DEPARTMENT. I UNDERSTAND THIS PERMIT MAY BE REVOKED AT ANY TIME, IF COMPLIANCE OF TOWN RULES AND REGULATIONS ARE NOT MET. THIS PERMIT WILL EXPIRE ON: DECEMBER 31, 2019 DIRECTOR OF PUBLIC HEALTH BOARD OF HEALTH Robin Williams, Chair +m-�• _' James Griffin, Vice Cheur Cathleen Liberty Joseph Tennyson, MD, Member 4/23/2019 Yahoo Mail - Mansfield Xfnity Temporary Food Permit Mansfield Xfinity Temporary Food Permit From: Jane Doucette (Jdoucette@mansfieldma.com) To: amy@fireflysbbq.com Date: Tuesday, April 23, 2019, 11:02 AM EDT Hi Amy, here is the temporary food permit for the Kiss Concerts and Summer Jam at the Xfinity Center. Please include Sery-Safe and Allergen Certificates and, if required to have Workers' Comp, include an insurance certificate from your insurance carrier. The fee will be $175.00 per application. If you have any questions, please let us know. And thank you for applying early; most people wait until the last minute. Jane Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (Sass) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. 1/1 <.»� ��� \\��d /� < .. » �� . � � � � �� � \� � �� \ »<. ?� ����\/�� »� �\\ � � w ©.� - \?2 :«§ � � � � ~�� \ � � ©° �� .���� . � � a��/%\§�\:��� . � \� � � . � ! � ; �� r . � \ � ¢ y<w« . FSI w U V z z 3 d z W-4 w W a N a 0 J V � 0 z w a;� m Qoi a o o � o U a w U yam.. " Q cd W a a a 0 g V � 0 a;� Qoi a o a 0 d 4 � n •a L � ~ R42 A