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HomeMy WebLinkAboutNE Sportservice, Inc. - 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER LOTSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERMIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-14 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET -MAIN KITCHEN AND COMMISSARY PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December31,2019 Food Fee: $310.00 License Number: XFS-1 BOARD OF HEALTH Michae(HeaCey, Chairman Milk & Cream 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - RIGHT FIELD FOOD PERSON(S) IN CHARGE. JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-3 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER WOODSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-4 BOARD OF HEALTH Michae(HeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - COURTYARD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $310.00 License Number: XFS-5 BOARD OF HEALTH NlchaeCHeaCey, Chairman Milk & Cream Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 -- - — 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER WOODSIDE PORTABLE PERSON(S) IN CHARGE. JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-6 BOARD OF HEALTH MichaeCHealey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE,INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - WOODSIDE FRIED DOUGH PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-7 BOARD OF HEALTH NichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER WOODSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-8 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER WOODSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December31,2019 Food Fee: $300.00 License Number: XFS-9 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LEFT FIELD FOOD PERSON(S) IN CHARGE. JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee. $300.00 License Number: XFS-10 BOARD OF HEALTH MichaeCHeaCey, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER LOTSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-11 BOARD OF HEALTH MichaeCHeaCey, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER LOTSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December31,2019 Food Fee: $300.00 License Number: XFS-12 BOARD OF HEALTH Michae(HeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - GRAB & GO PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-13 BOARD OF HEALTH MichaeCHealey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER LOTSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-15 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOTSIDE FRIED DOUGH PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-16 BOARD OF HEALTH AichaeCHealey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - BOSE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-17 BOARD OF HEALTH MichaeCHeaCey, Chairman 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET -MAIN KITCHEN AND COMMISSARY PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $310.00 License Number: XFS-1 BOARD OF HEALTH Milk & Cream MichaeCHeaCey, Chairman 1306 33,- =/� y �. X p: s i FOR BOARD OF HEALTH USE ONLY FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned bpf Establishment Name: New England Sportservice, Inc. @ Xfinity Center Main Kitchen & Commissary Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com _ Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. A Corporation Name Title Address An Individual Please see the attachment. 9 A Partnership IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: )velez@delawarenorth.com Alt E -Mail: bsalansl<@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): (John Velez is working on obtaining this.) --� Location: Kil Permanent Location Establishment Type: Q Caterer $35.00 EB Mobile Mobile Start Date: - Retail -NO FOOD PREP ( Sq. Fl) $125 Milk & Cream $10.00 Moblie End Date:rj Food Service up to 100 seats 0 Mobile Food Consession Mobile Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream Length of Permit: g HFood Service for 101 -200 seats $250.00 $25.00/freezer Annual Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: ® Residential Kitchen $100.00 Q Seasonal Seasonal Dates: ® Supermarkets $400 Tobacco Products $150.00 Temporary i9 Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions: PHF- Potentially hazardous food (timallemperature controls required) Non-PHFs - non-polent ally hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly 0 Delivery of Packaged PHFs Susceptible Population Facility ❑� Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Ed Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) G Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Main Kitchen & Commissary Q Prepares FoodlSingle Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Q Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application 0 waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply w{h 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain coT of 105 CMR 59(:000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury flim I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of individual or corporate Name: New England Sportservice, Inc. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31 st of each year. NAME OF BUSINESS: New England Sportservice, Inc. @ Xfinity Center ADDRESS: 885 South Main Street, Mansfield, MA 02048 TELEPHONE AT LOCATION: (508) 261-2900 FAX NUMBER: OWNER OF BUSINESS: New England Sportservice, Inc. TELEPHONE OF OWNER: (716) 858-5162 FEDERAL ID/SS NUMBER: 04-3466949 FEE: $10.00 PERMIT NUMBER: XF-1 M&C SIGNATURE:. j DATE: i 1L) 16 Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - RIGHT FIELD FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-3 BOARD OF HEALTH AichaeCHealiey, Chairman FOR BOARD OF HEALTH USE ONLY Permit FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned X I%_ 3 APP 2G19 date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Right Vjfd Foad-- Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or Ed An Association partner. IX A Corporation Name Title Address O An Individual Please see the attachment. O A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: i.velez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establish ment,lInformation WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): [a (John Velez is working on obtaining this.) Location: N Permanent Location Establishment Type: Caterer $35.00 ❑Q Mobile Mobile Start Date: r Retail -ND FOOD PREP ( Sq. Ft) $125 F1 Milk & Cream $10.00 Mobile End Date: ( Food Service to 100 Mobile Food Mobile Comments: up seats INCLUDING FOOD TRUCKS $175.00 ON SITE $100.00 NO PHF PREPARED ON Manufacture Frozen Desserts/ice Cream Length of Permit: Food Service for 101 -200 seats $250.00 $25.00/freezer Annual Food Service for 201+ seats $300.00 ea Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 Seasonal Seasonal Dates: Supermarkets $400 _-.,__ „__,_, ,,,,_,...,. ❑^� Tobacco Products $150.00 ® Temporary Q Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food((ime/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which needno further processing) Q Sale of Commercially Pre -Packaged Non-PHFs `sU PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service r1 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer '❑'Q Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours CJ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- !a Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) -- F1 Ice Manufactured and Packaged for Retail Sale it Preparation of Non-PHFs Other Food Operations [ Juice Manufactured and Packaged for rJ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Burgers, Dogs, Bottled Beverages Prepares Food/Single Meals for 6`a Offers RTE PHF in Bulk Quantities'r❑J Catered Events or Institutional Food Service iU Retail Sale of Salvage, Out -Of -Date _--- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application GL waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 oblain,copjQs of 105 CMR $90.00,0 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, t my best knowledge and belief, have tiled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Tr_ybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER WOODSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-4 BOARD OF HEALTH Jwichae(HeaCey, Chairman � 1 -s - '-r FOR BOARD OF HEALTH USE ONLY Permit Es Issued"> a -- FOOD ESTABLISHMENT PERMIT APPLICATIO 1'w APR Z 9 2019 (Application must be submitted at least 30 days before the planned dlJe�Aft date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Upper Woodside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. Fl., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. IN A Corporation Name Title Address O An Individual Please see the attachment. 9 A Partnership ® Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert, is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more) T(John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: Caterer $35.00 Mobile Mobile Start Date: (d Retail -ND FOOD PREP ( Sq. Ft) $125 Milk & Cream $10.00 Mobile End Date: Mobile Comments: p Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Food Service for 101 -200 seats $250.00 GJ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Frozen Desserts/Ice Cream $25.00/freezer Length of Permit:Manufacture ®i Annual Food Service for 201+ seats $300.00 lr9 Supermarkets $400 i Pushcart $50.00 # of Pushcarts: ^❑'1 Residential Kitchen $100.00 Tobacco Products $150.00 Retail Snack Food $50.00 -- -- Seasonal Seasonal Dates: 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non-potentally hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) M Sale of Commercially Pre -Packaged Non-PHFsI❑'a' PHFCooked To Order [H Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service iia PHF and RTE Foods Prepared For Highly Susceptible Population Facility rn Delivery of Packaged PHFs — - Sale of Raw Animal Foods Intended to be Prepared by ConsumerI❑"3. H Reheating of Commercial) 9 y Processed Foods for Service Within 4 Hours Vacuum Packaging / Cook Chill na Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service (] Ice Manufactured and Packaged for Retail Sale _ 0 Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Animal Origin Full Menu c=1 Prepares Food/Single Meals for Catered Events or Institutional Food Service ® Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application [5 waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with05 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies Q 105 CMR 59,0.0P6 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certv under the penalties of perjury that I, ito `�y best knowledge and belief, have filed all state tax returns and paid state taxes required under law. J Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - COURTYARD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee.• $310.00 License Number: XFS-5 BOARD OF HEALTH michaeCHeaCey, Chairman Milk & Cream g r5 - FOR BOARD OF HEALTH USE ONLY Permit# IsSUd"t FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Establishment Name: New England Sportservice, Inc. @ Xfinity Center Courtyard Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansl(@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IE An Association partner. IN A Corporation Name Title Address O An Individual Please see the attachment. O A Partnership INI Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: f ..IMMIS 3ITiTa'ifino re I - er, WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): L (John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: '-"❑'1 Caterer $35.00 [] Mobile Mobile Start Date: lA Retail -NO FOOD PREP ( Sq. Ft) $125 IH Milk & Cream $10.00 Moblie End Date: Mobile Comments: Food Service to seats INCLUDING FOO TROD TRUCKS $175.00 Food Service for 101 -200 seals $250.00 ® Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: ® Annual [� Food Service for 201+ seats $300.00 Supermarkets $400 Q Pushcart $50.00 # of Pushcarts: P Kitchen $100.00 � Tobacco 0 Tobacco Products $150.00 -- Seasonal Seasonal Dates: H Temporary Temporary Start Date: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF - Potentially hazardous food(timeltemperature controls required) Non-PHFs - non -potentially hazardous lood(no timeltemperature controls required) RTE - ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no further processing) i5 Sale of Commercially Pre -Packaged Nan-PHFs PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Delivery of Packaged PHFs G3 Sale of Raw Animal Foods Intended to be Prepared by Consumer [Eii Customer Self -Service Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Perishable Foods Only i'-"1 Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) C'1 Ice Manufactured and Packaged for Retail Sale __ Q Preparation of Non-PHFs Other Food Operations iH Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin Full Menu Prepares Food/Single Meals for Catered Events or Institutional Food Service Q Offers RTE PHF in Bulk Quantities ® Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ❑m waived I, the undersigned, attest to the 1 establishment operation will com board of health on how to obtain Signature of Applicant: y of the information provided in this application and affirm that the food 105 CMR 590.00jj1and all other applicable law. I have been instructed by the of 1p5 CMf?�590.b00 and the federarFood Code. Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that%td my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: New England Sportservice, Inc. @ Xfinity Center ADDRESS: 885 South Main Street, Mansfield, MA 02048 TELEPHONE AT LOCATION: (508) 261-2900 FAX NUMBER: OWNER OF BUSINESS: New England Sportservice, Inc. TELEPHONE OF OWNER: (716) 858-5162 FEDERAL IDISS NUMBER: 04-3466949 FEE: $10.00 PERMIT NUMBER: XF-5 M&C SIGNATURE: DATE: Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER WOODSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-6 BOARD OF HEALTH MichaeCHeaCey, Chairman Y_ rs-- � FOR BOARD OF HEALTH USE ONLY Permit # 10101 WWWA = (Application must be submitted at least 30 days before the planned cpe@nn l_date)__ _— Establishment Name: New England Sportservice, Inc. @ Xfinity Center Upper Woodside Portable Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansl<@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 9 An Association partner. DQ A Corporation Name Title Address ❑a An Individual Please see the attachment. Ed A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansl<@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): [ED (John Velez is working on obtaining this.) Location: ®' Permanent Location Establishment Type: yp � Caterer $35.00 l0 Mobile Mobile Start Date: ® Retail -NO FOOD PREP ( Sq. Ft) $125 H Milk & Cream $10.00 -- Mobile End Date: Mobile Comments: >� Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 s3 Food Service for 101 -200 seats $250.00 ( Food Service for 201+ seats $300.00 §0 Supermarkets $400 ®Mobile Food Consession NO PHF PREPARED ON SITE $100.00 t=1 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 Tobacco Products $150.00 Length of Permit: W, Annual Seasonal Seasonal Dates: Q Temporary Temporary Start Date: Retail Snack Food $50.00 Temporary End Dale: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions: PHF Potentially hazardous food (tureltemperature controls required) Nan-PHFs - non -potentially hazardous food(no timellemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no turtherprocessing) ® Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service'❑1 PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs Eq Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially Processed Foods for Service Within 4 Hours Q Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ Customer Self -Service of Non PHF and Non- Perishable Foods Only Customer Self -Service _ Ice Manufactured and Packaged for Retail Sale 0 Preparation of Non-PHFs Other Food Operations [U Juice Manufactured and Packaged for Retail Sale 0 Offers Raw Or Undercooked Food Of Animal Origin Fries, Bottled Water, Fountain Soda � Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date --- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application Q waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000d all other applicable law. I have been Instructed by the board of health on how to obtain copies ofI105 CMR 590.OWIZ nd the federal Vood Code. Signature of Applicant:', Pursuant to MGL Ch.62C, sec. 49A, I certi under the penalties of perjury that ll my best knowledge and belief, have filed all slate tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE,INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - WOODSIDE FRIED DOUGH PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-7 BOARD OF HEALTH MichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY FOOD ESTABLISHMENT PERMIT APPLICA (Application must be submitted at least 30 days before the planned yrs- 7 APR 2 9 2919 date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Woocl°sifJen6Dough Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. IX A Corporation Name Title Address An Individual Please see the attachment. O A Partnership _ ® Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) NO. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. I� LPerson Trained in Anti_Choking Procedures (If 25 Seats or more): 0 (John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: yp 2i Caterer $35.00 Moblie Moblie Start Date: Retail -NO FOOD PREP ( Sq. Ft) $125 Milk & Cream $10.00 Moblie End Date: Food Service up to 100 seats Mobile Food Consession Moblie Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Ii Manufacture Frozen Desserts/Ice Cream Length of Permit: Food Service for 101 -200 seats $250.00 $25.00/freezer © Annual Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: (� Residential Kitchen $100.00 Seasonal Seasonal Dates: [] Supermarkets $400 Tobacco Products $150.00 Retail Snack Food $50.00 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions: PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muRns which needno furtherpracessing) P'7 Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery of Packaged PHFs Susceptible Population Facility - fD Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially 0 Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ® Use of Process Requiring A Variance HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- dH Customer Self -Service Perishable Foods Onlyand/or contact alternative, time as a public health control) fs Ice Manufactured and Packaged for Retail Sale IH Preparation of Non-PHFs Other Food Operations O Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Fried Dough, Bottled Beverages „1 Prepares Food/Single Meals for r7 Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Eg Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food To be completed by the Board of Health Total Permit Fee: ---- Payment is due with application lE waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply w!(1( 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copi of 105 CMff 59"00 and the federal Food Code. Signature of Applicant: \ 6 WV ` �\ Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perju at I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER WOODSIDE FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-8 BOARD OF HEALTH MichaeCHeaCey, Chairman V X- FOR BOARD OF HEALTH USE ONLY Per it"' { fred. r ^tea 4. vi FOOD ESTABLISHMENT PERMIT APPLICA � 9 2619 (Application must be submitted at least 30 days before the planned ening date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Lower Woodside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FL, Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FL, Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansl<@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or H An Association partner. IN A Corporation Name Title Address ® An Individual Please see the attachment. A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. Of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Roohn Velez is working on obtaining this.) Location: Permanent Location Establishment Type Caterer $35.00 Moblie Moblie Start Date: PU Retail -NO FOOD PREP ( Sq. Ft) $125 ® Milk & Cream $10.00 Moblie End Date: Moblie Comments: ` Food Service l0 100 seats INCLUDING FOOD TRUCKS $175.00 f1 Food Service for 101 -200 seals $250.00 Food Service for 201+ seats $300.00 Supermarkets $400 f9 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 ® Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: (] Residential Kitchen $100.00 ® Tobacco Products $150.00 Retail Snack Food $50.00 Length of Permit: X1,j Annual Seasonal SSeasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Dale: Food Operations: (Check all that apply): Dehnitions:PHF - Potentially hazardous food(time/temperature controls required) Nan-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Q Sale of Commercially Pre -Packaged Non-PHFs P PHFCooked To Order [3 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs eaPreparation of PHFs For Hot And Cold Holding For Single Meal Service PO PHF and RTE Foods Prepared For Highly Susceptible Population Facility F3 Delivery of Packaged PHFs — la Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours I=❑.°, Vacuum Packaging / Cook Chill _ l Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Animal Origin Full Menu r'd Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities _ [,9d Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application fu waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comp)yy��with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain dies of 105 CMR(690.000 and the federal Food Code. Signature of Applicant: �17v Pursuant to MGL Ch.62C, sec. 49A, certify under the penalties of perjury and paid stale taxes required under law. to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: 04-3466949 Signature of individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus 'title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER WOODSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-9 BOARD OF HEALTH Michae[HeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Perm14je6 FOOD ESTABLISHMENT PERMIT APPLICAT04. APR 2 9 2019 (Application must be submitted at least 30 days before the planned)gp6Aing date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Lower Woodside Portable Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FL, Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FL, Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. IN A Corporation Name Title Address R An Individual Please see the attachment. O A Partnership 5 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: ivelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seals or more): Lai (John Velez is working on obtaining this.) Location: N Permanent Location Establishment Type: 0 Caterer $35.00 :❑�_ Mobile Mobile Start Date: Retail -NO FOOD PREP ( Sq. Fl) $125 0 Milk &Cream $10.00 Mobile End Date: Q Food Service to 100 seats Q Mobile Food Consession Mobile Comments: up INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Dessertslice Cream Length of Permit: Q Food Service for 101 -200 seats $250.00 $25.00/freezer ® Annual Q Food Service for 201+ seats $300.00 (] Pushcart $50.00 # of Pushcarts: ®Residential Kitchen $100.00 0 Seasonal Seasonal Dates: Ed Supermarkets $400 Tobacco Products $150.00 I Temporary ® Retail Snack Food $50.00 Temporary Start Date: Temporary End Dale: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherpmcessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order'❑.' Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs �"-�. Preparation of PHFs For Hot And FlIt PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery of Packaged PHFs --- Susceptible Population Facility Q Sale of Raw Animal Foods Intended to be Prepared by Consumer [Efl Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand L;3 Customer Self -Service of Non PHF and Non- ❑- Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) [11 Ice Manufactured and Packaged for Retail Sale Intl Preparation of Non-PHFs Other Food Operations ts=1 Juice Manufactured and Packaged for []d Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Burgers, Dogs, Sausage, Bottled Water Q Offers RTE PHF in Bulk Quantities � Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: - Payment is due with application Y:J waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply Wt 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain conies f 105 CMR 590.00-0and the federal.Food Code. Signature of Applicant: l4(-�`}fr'"L-Com.-r�t.G Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I and paid state taxes required under law. best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LEFT FIELD FOOD PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-10 BOARD OF HEALTH -%1ichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permi�l$ftad FOOD ESTABLISHMENT PERMIT APPLICATION/ I .'il� Al`' �p19 (Application must be submitted of least 30 days before the planned,opgoing da eJ� Establishment Name: New England Sportservice, Inc. @ Xfinity Center Left^Meld-.Fend Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. Fl., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IN An Association partner. IN A Corporation Name Title Address O An Individual Please see the attachment. N A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: )velez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees 280 _ DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): [H (John Velez is working on obtaining this.) —� Location: Permanent Location Establishment Type: Caterer $35.00 0 Mobile Motile Start Date: Q Retail -NO FOOD PREP ( Sq. Ft) $125'❑Q Milk & Cream $10.00 Mobile End Dale: Q Food Service up to seats Q Mobile Food Consession Mobile Comments: INCLUDING FOOD TRUCKS $175.00 TR NO PHF PREPARED ON SITE $100.00 Frozen Desserts/Ice Cream Length of Permit:Manufacture rJ Food Service for 101 -200 seats $250.00 $25.00/freezer ® Annual [� Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: Seasonal Residential Kitchen $100.00 Seasonal Dates: ® Supermarkets $400 Tobacco Products $150.00 L'I Retail Snack Food $50.00 Q Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food (time/temperature controls required) Nan-PHFs - non -potentially hazardous tood(no time/temperalum controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which needno furtherprocessing) rs Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Q Hol PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs �' Susceptible Population Facility -- Sale of Raw Animal Foods Intended to be Prepared by Consumer ® Reheating of Commercially ❑'L- Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours eH Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Q Customer Self -Service of Non PHF and Non- CH Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) O Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations !% Juice Manufactured and Packaged for r=1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Burgers, Dogs, Bottled Water OffersFood/ Offers RTE PHF in Bulk Quantities Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application 12 waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 copjes of 105 CMR 590.p00, and the federal_ Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, �cartify under the penalties of perjury that`I�,r o my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER LOTSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-11 BOARD OF HEALTH NichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION �4�S ,2 ' (Application must be submitted at least 30 days before the planned cpeni(V.date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Upper Lotside Portable Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansl(@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or H An Association partner. IN A Corporation Name Title Address U An Individual Please see the attachment. ® A Partnership IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) 1 l Name & Title: f� (� Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (if 25 Seals or more): (John Velez is working on obtaining this_) Location Permanent Location Establishment Type: I] Caterer $35.00 Ia Moblie Moblie Start Date: Q Retail -NO FOOD PREP ( Sq. Ft) $125 M Milk & Cream $10.00 Moblie End Date: Moblie Comments: Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Food Service for 101 -200 seats $250.00 ® Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit:0 Annual I� Food Service for 201+ seats $300.00 0 Pushcart $50.00 # of Pushcarts: ----- Seasonal Seasonal Dates: t? Supermarkets $400 Residential Kitchen $100.00 td Tobacco Products $150.00 0 Retail Snack Food $50.00 [M Temporary Temporary Start Date: Temporary End Date: _ Temporary Time: Rain Date: Food OpefatlOnS: (Check all that apply): Definitions:PHF- Potentially hazardous food(timelfemperatufe controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls acquired) RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no rurtherprocessing) 0 Sale of Commercially Pre -Packaged Non -PRFs F PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service � PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PRFs ry - Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours I Vacuum Packaging /Cook Chill Use of Process Requiring di Variance andlor HACCP Plan (including bare hand contact alternative, time as a public health __ control) Customer Self -Service of Non PHF and Non- Perishable Foods Only J Customer Self -Service F.1 Ice Manufactured and Packaged for Retail Sale _ (] Preparation of Non-PHFs Other Food Operations Fri]Juice Manufactured and Packaged for Retail Sale I=J Offers Raw Or Undercooked Food Of Animal Origin Fries, Bottled Water, Fountain Soda Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities IB Retail Sale of Salvage, Out -Of -Date or Reconditioned Food --- To be completed by the Board of Health Total Permit Fee: Payment is due with application (R waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 cosies of 105 CMR 590,000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, see, 49A,Tcertify under the penalties of perjury that Uo my best knowledge and belief, have filed all stale tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England$portservlce, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R.Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose piece of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - UPPER LOTSIDE FOOD PERSON(S) IN CHARGE.: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-12 BOARD OF HEALTH Michae[Heafey, Chairman J X- rs -- 12 - FOR BOARD OF HEALTH USE ONLY Permit t/js'suod ' -'- FOOD ESTABLISHMENT PERMIT APPLICA (Application must be submitted at least 30 days before the planned'ppehing date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Upper Lotside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: . Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IN An Association partner. IN A Corporation Name Title Address O An Individual Please see the attachment. _ 0 A Partnership IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): (John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: Caterer $35.00 IN Mobile Mobile Start Dale: M Retail -NO FOOD PREP ( Sq. Ft) $125 IH Milk & Cream $10.00 Mobile End Date: Food Service up to seats ® Mobile Food Consession Mobile Comments: TR INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream Length of Permit: Food Service for 101 -200 seals $250.00 $25.00/freezer Q Annual Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: f3 Residential Kitchen $100.00 ---- IIN Seasonal Seasonal Dates Supermarkets $400 Tobacco Products $150.00 Temporary Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions: PHF- Potentially hazardous food (fime/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Q Sale of Commercially Pre -Packaged Non-PHPs is PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ry 9 Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer C❑7 Reheating of Commercially I] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand IH Customer Self -Service of Non PHF and Non- '❑LJ'- Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for "1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Full Menu ® Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service _ ® Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ,;;1 waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 cafes of 105 CMR 59Q.000 and the federal Food Code. Signature of Applicant: ' J `I* t :6u "" ' Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury and paid stale taxes required under law. to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - GRAB & GO PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-13 BOARD OF HEALTH MichaeCHeaCey, Chairman r r f FOR BOARD OF HEALTH USE ONLY Permit FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned opening date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Grab & Go Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. A Corporation Name Title Address An Individual Please see the attachment. O A Partnership (A Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): rD (John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: Caterer $35.00 Mobile Mobile Start Date: e Retail -NO FOOD PREP ( Sq. Ft) $125 0 Milk & Cream $10.00 Mobile End Date: Food Service to 100 Mobile Food Consession Mobile Comments: up seats INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 F -=i Manufacture Frozen Desserts/Ice Cream Length of Permit: ® Food Service for 101 -200 seats $250.00 $25.00/freezer Annual (�-Food Service for 201+ seats $300.00 0 Pushcart $50.00 # of Pushcarts: f0 Residential Kitchen $100.00 aH Seasonal Seasonal Dates: ' Supermarkets $400 if Tobacco Products $150.00 3 Retail Snack Food $50.00 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) 0 Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And 0 PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service EJ Delivery of Packaged PHFs Susceptible Population Facility ❑`-1 Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- i� Customer Self -Service Perishable Foods Only I.� Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) 0 Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for IR Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepared Salads, Sandwiches, 0 prepares Food/Single Meals for Fe Offers RTE PHF in Bulk Quantities Bottled Beverages g Catered Events or Institutional Food Service 0 Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Tobe completed by the Board of Health Total Permit Fee: Payment is due with application [j] waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply ,,�'th 105 CMR 590 0 and all of at applicable law. I have been instructed by the board of health on how to obtain copi$s of 105. CIyjR 90.000 and the ederal Food Code. Signature of Applicant: -_ duer- pPursuant to MGL Ch.62C, sec. 49A, ify under utes oerju hat I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal to: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER LOTSIDE FOOD PERSON(S) IN CHARGE. JOHN VELEZ, INTERMIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-14 BOARD OF HEALTH MichaeCHeaCey, Chairman y Li FOR BOARD OF HEALTH USE ONLY Permit�Issa?e%"'W" y 9 k FOOD ESTABLISHMENT PERMIT APPLICATION 'd _. (Application must be submitted at least 30 days before the planned opening date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Lower Lotside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FI., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. A Corporation Name Title Address 0 An Individual Please see the attachment. Id A Partnership E Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): I] (John Velez is working on obtaining this.) Location: N Permanent Location Establishment Type: Caterer $35.00 Mobile Mobile Stan Date: ® Retail -NO FOOD PREP ( Sq. Ft) $125 ] Milk & Cream $10.00 Mobile End Date: ` Food Service up to 100 seats Mobile Food Consession Mobile Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Frozen Desserts/Ice Cream Length of Permit:Manufacture Food Service for 101 -200 seats $250.00 $25.00/freezer ®' Annual Qq Food Service for 201+ seals $300.00 ]Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 ---- i] Seasonal Seasonal Dates: Q Supermarkets $400 Tobacco Products $150.00 Temporary Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potenfially hazardous food (Iimeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs w7 PHFCooked To Order ] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I] Sale of Commercially Pm -Packaged PHFs a Preparation of PHFs For Hot And (] PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery of Packaged PHFs rY -- Susceptible Population Facility - ] Sale of Raw Animal Foods Intended to be Prepared by Consumer`❑'1 ❑ Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours IH Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- I] Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) - I] Ice Manufactured and Packaged for Retail Sale Preparation of Nan-PHFs Other Food Operations [] Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Full Menu ] Prepares Food/Single Meals for --Offers RTE PHF in Bulk Quantitie H s Catered Events or Institutional Food Service ® Retail Sale of Salvage, Out -Of -Date — or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application I] waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comp)g( wit.ty1'��105 CMR 590.0¢¢QQ and all other applicable law. I have been instructed by the board of health on how io obtain cobiesldf 105 CMR$9Vol( 0 and the feperal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all stale tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of individual or corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOWER LOTSIDE PORTABLE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December31,2019 Food Fee: $300.00 License Number: XFS-15 BOARD OF HEALTH Michae(HeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name: New England Sportservice, Inc. @ Xfinity Center Lower Lotside Portable Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FL, Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or R An Association partner. R A Corporation Name Title Address R An Individual Please see the attachment. O A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508) 261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): (] (John Velez is working on obtaining this.) Location: Permanent Location Establishment Type: kJ Caterer $35.00 ® Mobile Mobile Start Date: Fy Retail -NO FOOD PREP ( Sq. Ft) $125 9 Milk & Cream $10.00 Moblie End Dale: 7 Food Service up to 100 seals fJt Mobile Food Consession Mobile Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Frozen Dessertslice Cream Length of Permit:Manufacture Food Service for 101 -200 seats $250.00 $25.00/freezer Nil Annual [ Food Service for 201+ seats $300.00 Pushcart $50.00 # of Pushcarts: ® Residential Kitchen $100.00 - - r Seasonal Seasonal Dates: Supermarkets $400 Tobacco Products $150.00 r.J Temporary 41 Retail Snack Food $50.00 Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food (Nme4emperature controls required) Non-PHFs - non -potentially hazardous /ood(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PH FCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service rl Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hol And [N PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service l Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods -Intended to be Prepared by Consumer Reheating of Commercially _ ❑a' Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- a Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) _ Ice Mann - ufactured and Packaged for Retail Sale �1 Preparation of Non-PHFs Other Food Operations F3 Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Burgers, Dogs, Sausage, Bottled Water Prepares Food/Single Meals for Mo Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Q Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application H waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 of 10� CNN 590.000 and the feral Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury`that I, to my bes kno ledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal to: 04-3466949 Signature of Individual or corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J• Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOTSIDE FRIED DOUGH PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-16 BOARD OF HEALTH MichaeCHeaCey, Chairman y F_s- I(, FOR BOARD OF HEALTH USE ONLY Permi lsStaed ` t'_ FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned dogrI hg date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center Lotside Fried Dough Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. FL, Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansl<@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ❑O An Association partner. A Corporation Name Title Address O An Individual Please see the attachment. O A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansl(@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): (John Velez Is working on obtaining this.) Location: N Permanent Location Establishment Type: cc1 Caterer $35.00 Mobile Mobile Start Date: 0 Retail -No FOOD PREP ( Sq. Ft) $125 F3 Milk & Cream $10.00 Mobile End Date: Food Service up to seals 0Mobile Food Consession Mobile Comments: TR INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Dessertslice Cream Length of Permit: Food Service for 101 -200 seals $250.00 $25.00/freezer X, Annual [ Food Service for 201+ seats $300.00 Supermarkets $400 Pushcart $50.00 # of Pushcarts: ® Residential Kitchen $100.00 ------ Seasonal Seasonal Dates: P3 Tobacco Products $150.00 a Temporary Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions. PHF Potentially hazardous food (fimeltemperature controls required) Non-PHFs - non -potentially hazardous lood(no tima/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno turtherprocessing) Q Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order er Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ,`❑ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service t❑,1 PHF and RTE Foods Prepared For Highly F Delivery of Packaged PHFs ry g Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑." Reheating of Commercially 0 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance and/or HACCP Plan (including bare hand A Customer Self -Service of Non PHF and Non- M Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale ❑'1` Preparation of Non-PHFs Other Food Operations ❑G Juice Manufactured and Packaged for F7 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Fried Dough, Bottled Water Q Prepares Food/Single Meals for ❑t-- Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date ---_--_ ----- To be completed by the Board of Health or Reconditioned Food Total Permit Fee: Payment is due with application ca waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 1Qq5 CMR 590.000 all other applicable law. I have been instructed by the board of health on how to obtain copies ofd 05 QMR 590,,J00 and the federal FAd Code. Signature of Applicant: I a — 113 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, lorry best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England 5portservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - BOSE PERSON(S) IN CHARGE: JOHN VELEZ, INTERIM GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: XFS-17 BOARD OF HEALTH MichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the x SpA, 'ng date) Establishment Name: New England Sportservice, Inc. @ Xfinity Center BOSE Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Establishment Telephone No: (508) 261-2900 Applicant Name & Title: New England Sportservice, Inc. Applicant Address: 250 Delaware Ave., Attn: Licensing, 12th. Fl., Buffalo, NY 14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky interim GM cell: (401) 301-9610 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 9 An Association partner. IN A Corporation Name Title Address O An Individual Please see the attachment. O A Partnership IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: interim General Manager John Velez Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 301-9610 FAX: (508)261-7799 E-mail: jvelez@delawarenorth.com Alt E -Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 280 DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: interim GM John Velez If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera, Jonathan Imes, Kullen Pacheco and David Seprinski (copies of certificates attached) A copy of David Seprinski's Allergen Awareness Training Cert. is also attached. Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0 (John Velez is working on obtaining this.) 1 1 _ Location: X, Permanent Location Establishment Type: <1 Caterer $35.00 Mobile Mobile Start Date: "❑� Retail -NO FOOD PREP ( Sq. Ft) $125 Milk & Cream $10.00 Mobile End Date: Mobile Comments: ~= Food Service l0 seats INCLUDING FOO TROD TRUCKS $175.00 ❑' Food Service for 101 -200 seats $250.00 r Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length Of Permit: ® Annual Food Service for 201+ seats $300.00 ® Supermarkets $400 rA Pushcart $50.00 # of Pushcarts: xtJ Residential Kitchen $100.00 M Tobacco Products $150.00 Seasonal Seasonal Dates: I'd Temporary Temporary Start Dale: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non-potentrally hazardous lood(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) 0 Sale of Commercially Pre -Packaged Nan-PHFs PHFCooked To Order -._. Q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 'J Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours Vacuum Packaging / Cook Chill I Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) `.❑J Customer Self -Service of Non PHF and Non- Perishable Foods Only [9 Customer Self -Service IH Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations 2 Juice Manufactured and Packaged for Retail Sale tj Offers Raw Or Undercooked Food Of Animal Origin Full Menu 0 Prepares Food/Single Meals for Catered Events or Institutional Food Service I� Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application r0 waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 copie�lyof 105 CMR 590.(!(00 and the federat,, Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec, 49A, I celylfy under the penalties of perjury that (Jo my best knowledge and belief, have filed all state lax returns and paid state taxes required under law. Social Security Number or Federal ID: 04-3466949 Signature of Individual or corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Nicholas D. Liberto Janice R. Trybus Title Director Title President Vice President -Finance Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 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. New England Sportservice, Inc. Signature of Individual or Corporate Name 04-3466949 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Man story, 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:\Users\sleite\Desktop\Scott's Documeots\Food Estnblislnnents- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts UfDepartment 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: New England Sportservice, Inc. @ Xfinity Center 885 South Main Street City/State/Zip: Mansfield, MA 02048 Phone #: (505) 261-2900 Are you an employer? Check the appropriate box: Business Type (required): 1. X❑ I am a employer with 280 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, I l.❑ Health Care with no employees. [No workers' camp. insurance req.] 12191 Other food & beverage at amphitheater *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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: New Hampshire Insurance Company . Insurer's Address: 175 Water Street, 18th Floor City/State/Zip: New York, NY 10038 Policy # or Self -ins. Lic. # WC 013-77-8773 Expiration Date: 10/01/2019 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 certi y,under fbe pnhns andpenalties ofperjury that the information provided aboveistrue and correct. Signature: Date: \,_. I � �t7Z Z Phone #: 716-858-5000, x5162 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 #: anvwanass.gov/dia ISSUED BY THE STOCK INSUBANCE COMPANY HEREIN CALLED THE COMPANY NEW HAMPSHIRE INSURANCE COMPANY I:I INCORPORATED UNDESHE. LAWS AGENT NUMBER POLICY NUMUEB 111. 11 WC 013-77-8773 055-oA-1o18-to MINIMUM PREMIUM $900 W1 TOTAL ESnMATED ANNUAL PREMIUM $911,366 If Indlceted belgvk Interim adjustments or premium shall be made: ❑ Semi -Annually ❑ Cuartedy ❑ Monthly CEPOSITPREMIUM $911,36B 10/09/18 BOSTON 04 Issue Dale Issuing OUR.. 39W (Wd 01106) eepresanuuva WCDOODO1A DELAWARE NORTH COMPANIES INCORPORATED A l G 250 DELAWARE AVENUE B FFALO, NY 14202-0000 An AIG company - EXECUTIVE OFFICES: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE- WCGOO610 175 Water Street ' New York, NY 10036 LDA 910526731 MARSH USA INC, WORKERS COMPENSATION AND EMPLOYERS 6500 SHERIDAN DRIVE LIABILITY POLICY INFORMATION PAGE SUITE 114 WILLIAIMSV LL �N �t CORPORATION �s RENEWAL ucYN UlER23278773 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC900610 ITEM 2 POLICY PERIOD 1241 A•M. rtandard time at the Insured's mallag oddre s FROM 10101/18 TO -101011.19:3. ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed hero: MA WI B. Employers IJability Insurance: Part Two of the policy applies to the work In each state listed In Item 3,A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 .000, 000 each accident Bodily Injury by Disease $ 1,000,000 policy Ilmit Bodily Injury by Disease $ .1 ,000,000 each employee C. Other States Insurance: Part Throo of the policy applies to the states, If any, listed here: AK AL CT DC DE HI IN KY ME NE MM OR SD UT VT 0, This policy Includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.0, OF THE INFORMATION PAGE - WC990612 ITEM4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below Is subject to verification and change by audit, awsiticetions Cada Number RannumnBasis To Rete Por $too eF Ra. Esated tim P.1ure Annual ❑ 3 Year munaration p Annual ❑ 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $19,133 EXPENSE CONSTANT(EXCEPTWHERE APPLICABLE BY STATE) $ 38 MA MINIMUM PREMIUM $900 W1 TOTAL ESnMATED ANNUAL PREMIUM $911,366 If Indlceted belgvk Interim adjustments or premium shall be made: ❑ Semi -Annually ❑ Cuartedy ❑ Monthly CEPOSITPREMIUM $911,36B 10/09/18 BOSTON 04 Issue Dale Issuing OUR.. 39W (Wd 01106) eepresanuuva WCDOODO1A NQ L.1_ CK /N_ ^Q Rnb+mnl lu tl.Iun] oid P ., dI , Conlal m witlr W+olnmul 233S Woo Rive WIe]6W, r]iirnoo, I M,M 6363,,,Y.Mobflnkuro¢ N M N 00 N N N O Z W H a U LL F z W U n U) 5W IFE r U 00 N co M oa�:tio CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Date of Completion: David P. Seprinsld 3/12/2019 Date of Expiration: 3/12/2024 The nhove-mooned permn i.r hereby irmed this m-lii i'rwe Jar romf�kting mr ellerger: n2ummmtt tminiugprayrnro recognized by the Mmmebtuals Depm'th..eut of Public Phxdth in neconlance with 105 C111IR 590.009(C)(.7)(n). 77iit certPrate wit/ he valid jar five (5) yenrrJi-ora Ante ofronrrletiwr. lesned By: Ucr¢shlre AHEC Tran Flealth ¢dueminn C.A. 1'ills¢cld• Bla'snc4uvclLv ............ nllergyvaining.nrg Delaware NJ North... April 26, 2019 Via FedEx Town of Mansfield Attn: Amy Donovan -Palmer Health Department Six Park Row Mansfield, MA 02048-2433 Re: Xfinity Center Concessions Renewal of Health Permits Dear Ms. Donovan -Palmer: 250 Delaware Avenue Buffalo, New York 14202 T 716-858-5000 F 716-858-5056 www.delawarenorth.com t: APR 2 `9 2019 Enclosed please find our renewal applications for the health permits covering our food & beverages operations at Xfinity Center. Also enclosed are two checks totaling $4,820.00 to cover the fees, If you have any questions, please contact me at (716) 858-5162 or email at BSalansk@delawarenorth.com. Very truly yours, New England Sportservice, Inc. Be h A. Salansky Lead Licensing Paralegal Enclosures i AV 2'9 2019 �. License No;_- License Details � i _ r ! Other Food Operations l.. XFS-1 Main Kitchen and Commissary- Main Kitchen &Commissary XFS-1 M&C :Main Kitchen and Commissary - M&C (milk & cream) XFS-10 XFS-12 Left Field Food Burgers, Dogs, Bottled Water Upper Lotside Food Full Menu XFS-14 Lower Lotside Food Full Menu XFS-15 XFS-16 Lower Lotside Portable Burgers, Dogs, Sausage, Bottled Water XFS-17, Lotside Fried Dough Fried Dough, Bottled Water BOSE Full Menu XFS-3 XFS-4 Right Field Food Burgers, Dogs, Bottled Beverages Upper Woodside Food Full Menu XFS.S Courtyard Full Menu & Milk & Cream XFS-S M&C Courtyard M&C (milk & cream) XFS-7 Woodside Fried Dough Fried Dough, Bottled Beverages XFS-.8 Lower Woodside Food Full Menu XFS-9 XFS-11 Lower Woodside Portable Burgers, Dogs, Sausage, Bottled Water XFS-13 Upper Lotside Portable Fries, Bottled Water, Fountain Soda XFS-6 Grab & Go Upper Woodside Portable Prepared Salads, Sandwiches, Bottled Beverages Fries, Bottled Water, Fountain Soda