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HomeMy WebLinkAboutMark Fanelli's Traveling Amusements - 12/31/20190 Commonwealth 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 - ELKS CARNIVAL 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:. MARK FANELLIIJOSEPH FANELLI Whose place of business is: MARK FANELLI'S TRAVELING AMUSEMENTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOSEPHFANELLI Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-21 BOARD OF HEALTH MichaeCHeaCey, Chairman 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: '[``¢ Y t � 'v , � _�,: t i @ ��_r, i h 1 Pam. -"` 1 t 2) Establishment Address: j 3) Establishment Mailing Address (if different): J� 4) Establishment Telephone No: R 5) Applicant/Owner Name & Title: f .Tj i 6) Applicant(Owner Address: 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address:, 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: :yv .. , t=.' F h r Telephone No: Emergency Telephone NO:t"',,.2, 10) Event Attending Date(s): ice, .. i r iX Event Name Event Location:`' 4 Event time:,= 11) Check one 12) Solid waste disposal plan: Food Truck Caterer „ Other: J d 13) Water Source: � 4 11 8 ~ ' 7`_} ` i CN T`r 7 15) Please give a brief description of the food to be served: ' k �J t PAID APR 3 0 2090 350 ,v-ti Food Protection Questionnaire for Catered Events Date of Evenf Event Location of Event: 5 < (}C c C List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating 3 �\ ! aa del Food Manager Certification Person Trained On Site? 1 Yes Allergen Awareness Menu Label Present? t2Xes � ►. w we List all Potentially Hazardous Food (PHF) and the individual intended temperature required: ,4, Ti tv � C�_ t. . List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 OF? Flow 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. 16) Food -u aillb"reparedr.....---...._ ...........--__....� , Onsite for immediate consumption } `'Onsite-andtretd atpitoper-hoUsold-holdi�g temperatures Offsite and held at proper hot/ 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: I Food Safety Manager y Allergen Awareness �'� ti ,%P, `t cC. ',� j 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: 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copiesRf 1,Q8 CMR 690.000 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 stM taxes required under law. f�11� 20) Social Security Number or Federal ID: iOi _4L `7 1 1 21) Signature of Individual or Corporate Name: ( �()V Y `v� �� `ter tr 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. Signature of Individual or Corporate Name By: Corporate Officer (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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massaeltusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/State/Zip:u'1t I -'hone#: rjC1 C 1 `k �� Are you an employer? Check the appropriate box: Business Type (required): I�qI am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (me], real estate, auto, etc.) 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. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box # I 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 4I. I am an employer that is prov!t n# Torker ' ctgaapensation insurattfe fol my employees. Below is the policy information. Insurance Company Name: Insurer's Address: I r i l `W c_t t.. , City/State/Zip .. t CC r k yr } ;+ i I b (L j Policy # or Self -ins. Lic. #ji 4 } =fat .C� t r f Expiration Date: <_S l i 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 (he pains and penalties of perjury that the inforrnation provided above is trite and correct. cv-r" of C,✓. Official use only. Do not write in this area, to be completer/ by chy or town City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone 1 ® A� o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODrfYYY) 04/26/2019 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 t0 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 Allied Specialty Insurance, Inc. 10451 Gulf Blvd CONTACT Carol A. Serra NAME: ANC NN Ex : 727-647-3090 FAX No: 727-367-1407 ADDRESS: caserra@alliedspecialty.com Treasure Island, FL 33706-4814 INSURERS AFFORDING COVERAGE NAIC It INSURER A: T.H.E. Insurance Company 12866 INSURED Mark Fanelli s Traveling Amusement Park INSURER B: P O Box 249 INSURER C: INSURER D: Rindge, NH 03461 INSURER E : INSURER F: !`OVERAGES r.PPTIFIr.ATF NIfMRFR• 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 R rypE OFINSURANCE DDL MID POLICY NUMBER MMDI DNYYY mpOm Yl'YY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR CPP0100529-09 03/02/2019 03/02/2020 EACH OCCURRENCE $ 1,000,000 PREMISES Fa occurrence) $ 100,000 MED EXP (Anyone person) $ PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE It 10,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 PRO- POLICY D JECT El LOC OTHER: A AUTOMOBILE LIABILITY CPP0100529-09 03/02/2019 03/02/2020 EOeBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED NON -OWNED AUTOS ONLY X AUTOSONLY Ix PROPERTY DAMAGE Peraccidenl $ 8 A UMBRELLALIAS OCCUR ELP0010141-09 03/02/2019 03/02/2020 EACH OCCURRENCE $ 4,000,000 X AGGREGATE $ 4,000,000 EXCESS LIAB CLAIMS -MADE OED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN IPARTN RVE WCP0004451-016 04/16/2019 0310212020 XN �/nACCIDENT E.L$ 1,000,000 ELVEE $ 1,000,000 OFFICERPRHETO OFFICE IMEMB RE EXCLUDED? ❑ (Mandatory in NH)f NIA E.LIMIT $ 1,000,000 yes,describe antler DESCRIPTION OF OPERATIONS below *WC Coverage is afforded in the State(s) of: CT, MA, NH & RI DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) EVENT DATES: 04/29/19 through 05/06/2019 to include set up and tear down ADDITIONAL INSURED: Town of Mansfield, MA and Xfnity Center, 885 S Main St, Mansfield, MA as respects to the negligence of the named insured. Town of Mansfield, MA 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATIVE / n ©1 ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD I ?\\ � \ � » ^ \ \ }\ \/ \/ }} : M, < wl� 0 � � u 0--� � � :� _ L5 Q� z *M-� z � � � � � z P4 � � � \ e ± @ \ \\\\ \ ®&[ \ � / � 12 .� � - % \ ® k § LL C \ § L « / § k $ ( CL k CL 0 0 w \ k k ° )}\y \ \ \\\ \ . / Commonwealth 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 PERMIT - ELKS CARNIVAL 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:. MARK FANELLI/JOSEPH FANELLI Whose place of business is: MARK FANELLI 'S TRAVELING AMUSEMENTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOSEPH FANELLI Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-22 BOARD OF HEALTH NichaeCHeaCey, Chairman U!S ' aN -- 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: .M y 1 a el Y 1fa i t t k �,C�J _ 2) Establishment Address: -�-- - 3) Establishment Mailing Address (if different): ,P - 4) Establishment Telephone No: � q � c� > / h , � ` J 5) Applicant/Owner Name & Title: n 6) Applicant/Owner Address: 7) Applicant(Owner Telephone No: , ( ` w� -� 9—(D-7(t/ 3 mo 8) Applicant/Owner Email address: e k- /I 9) Person Directly Responsible For Onsite Operations: Name & Title: h nJ Address: III Telephone No: - IFa Emergency Telephone No: U 10) Event Attending Date(s): Event Name: C Event Location: Event time. )� - 11) Check one 12) Solid waste disposal plan: Food Truck Caterer ��--� Other. ( ��C� 1 �O ✓ 13) Water Source: 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: RM �'i(kr�TNr Food Protection Questionnaire for Catered Events Date of Event; 5 ' � Event Time: Location of Event =kS List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? es o No Allergen Awareness Menu Label Present? toes o No List all Potentially Hazardous ood�(PHF) and the e 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? 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. 16 ) Food-wWAh_-prep Onsite for immediate consumption diretd aTprdperi3eU-csld-h g temperatures Offsite and held at proper hot/ 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' � —'(', 11QQ \ Allergen Awareness: k�t--{�lQ �t 18) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: Cityfrown 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: 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies (?f 1R5 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 ,t,#. taxed raguired under law. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: PO(, Vt '(� i 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. C4�y,Vv �,�_I11 ,��� _I��, . ��� ��Weni� Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0,�-44q ('13gf) "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\Scott's Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc 4 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 Business/Organization I 4�- Are y u an employer? Check the appropriate box: Business Type (required): I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 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. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11 ❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req j 12.❑ Other *Any applicant that checks box 91 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 91. / an: an employer that is prove ng arker ' c°tttRensation insurtmf a fof my employees, Below is the policy information. Insurance Company Name: 1 f I 1�� O�) Ccl 1 t �1 11 S Insurer's Address: ((" �J [ V L j _ (—�r � j t City/State/Zip: l 1 PCB �j u V� /1 1 6 f I �J �t 148 J� Policy # or Self -ins. Lie. #Lw (� { ( ��C� ` ( Expiration Date: Z ' ()�Q 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, undexFhe pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town 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 � § p- :)} - aa- ,v \® (\ ©C\l C\j 2 ; . � 3"_ 7 � ® ° \} w W-4 0 � � � 1; ctm� z *04 z � � W z P4 � � � z W4 Q� � � � � o o�o \ ƒ \ \ . 2 % \ z / % \ Lqlg ) )i\\§ „) ( ;® 2 /®\ \o \ \� \ \ � / #� � — t \ ® R @ L £ 2 k / @ / O $ A) ( § ca CL CL 0 e 00 w z _ a) Bank #: Packet #: Town of Mansfield SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER _ _ Department. Board of Health FOOD PERMIT __ Schedule #: JED 43019 _ Date: 04130119 Source Account Number Amount Description of Acccount 01512 445006 MARK FANELLI TRAVELING AMUSEMENT $ 350.00 I -__--_-.- _i-____ Cash $ 350.00 Checks Total $ 350.00 - - h'Credit Card - I TOTAL: $ 350.00 i Mansfield MA 04/30/19i To The Officer Making the Payments The above_ Is a detailed Est of moneys collected b me amounting m the a regate to: $ 350.00 for the period ending which I have paid to the Town Treasurer whose receipt I hold, therefor -. --- Jane Doucette I UWN OF MANSFIELD PAID APR 3 0 2010 CHECK# MT.�`-- .... .� _."