HomeMy WebLinkAboutSmithfield Deli Sampling Tour - 7/31/2019�0
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: TEMPORARY RETAIL SNACK
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:.
SIGNATURE MARKETING GROUP
Whose place of business is:
SIGNATURE MARKETING GROUP - SMITHFIELD DELI SAMPLING TOUR
390 WEST STREET
PERSON(S) IN CHARGE:
RANDAL COLLIGNON (ONSITE ONLY)
Permit Expires: July 31, 2019
Food Fee: $50.00
License Number: TRS -1
BOARD OF HEALTH
MichaeCHeaCey, Chairman
Date Received
FOR BOARD OF
Permit Fee
Approved By
Permit # Issued. ._
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: S't fq� t-� KUVV_Ay
2) Establishment Address: S� tl�l � "v6� 0 "CSV— S - �A�
3) Establishment Mailing Address (if different): t (�� S . (.A- S\O5 � -
4) Establishment Telephone No: "�(�y_ 3�_C�o�y
5) ApplicanttOwner Name & Title: �1 _ i C Uu
6) ApplicantlOwnerAddress: BOG S,i { '�S :t� LAOS
7) Applicant/Owner Telephone No: --I � 3 1_ tJ I. z� , ""•! ��-(
8) Applicant/Owner Email address: �U v- Si ar-<- S-.. 6vk-3
9) Person Directly Responsible For Onsite Operations:
Name &Title:
Address:
,� 05 C
Telephone No:
--d _ -� Fax: —I VA - 3 L _ -LL.
Emergency Telephone No:
LA " t 0
10) Event Attending
Date(s):
Event Name:
Event Location:
'S�d� S,d- Ste,--{
Event lime:3
> " I
11) Check one
-1 Food Truck
D Caterer
Other:
12) Solid waste disposal plan:
�}
13) Water Source:
0t,kVc
14) Sewage disposal plan:
rPlease give a brief descrl nofhefood to be served:
. SVU Saw -'Qs aF > �i
16 ) Food will be prepared:
Onsite for Immediate consumption
Onsite and held at proper hot/ cold holding temperatures
n Offsite and held at proper hot/ cold holding temperatures
Ll Offsite, cooled and reheated on site
n Other:
17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
kTr Food Safely Manager:
Allergen Awareness: 4_q�.21"
18) For caterers: City/Town where food establishment permit Is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the permits:
I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been Instructed
by the board of health on how to obta0 copes of 105 CMR 590�00�0 and the federal Food Code.
19) 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 filed all state tax returns and paid state taxes required under law.
20) Social Security Number or Federal ID: 1 `AS ` i 33 u`( 9
21) Signature of Individual or Corporate Name4_ i l"T-
Food Protection Questionnaire for Catered Events
Date of Event:
Location of Event:
Event Time:
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
Food Manager Certification Person Trained On Site? ❑ Yes ❑ No
Allergen Awareness Menu Label Present? ❑ Yes ❑ No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41'F?
How will the PHF be kept at or above 140°F?
Time of PHF? Setup Served
Removed
List all equipment that will be supplied for an event, including but not limited to food
thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc.
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name B :Corporate Officer (Mandatory, if Applicable)
LAS- 13 � Li L_\ L_t CA
"*Social Security No. (Voluntary) or Federal
identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV rvww.tttass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:_dSbO S SA-- Stti6k{- L -i 9S
City/State/Zip; C�&v Lo" -c_ LIC- ILLL! Phone#: _� 4'-4-
Are you an employer? Check the appropriate box: Business Type (required):
I. F1 I am a employer with (0 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. g. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their tight of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp, insurance required]* I l.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.[�Other fir -
*Any applicant that checks box #1 must also lint 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 #I.
I am an employer tliat is providing workers' compensation intstn•ance for my employees. Below is the policy information.
Insurance Company Name: t-� o \o\C- \IiS VA—Com-- AA t `S o c
Insurer's Address: F^ 305 li
City/State/Zip: py 1. o A 4-e (y
'-923_
Policy # or Self -ins. Lie. # In I'
D�
Expiration Date: g� 1
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 Ger eGy cerhfy, ander the pains and penatties of perjury that the information provided above is trite and correct.
Phone #:
')nLA - 3-,? l-OO'�F
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
wvm.mass.gov/dia
Phone
0
A�r1 ® CERTIFICATE OF LIABILITY INSURANCE
DAT7/1712 D19
7/17/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Noble Insurance Advisors, LLCme
2101 Rexford Rd Ste 131 E
Charlotte NC 28211
CONTACT
NAME: StaCle Bmwn
NE Ea : 704-550-4964 A/c N.: 704-817-4772
E-MAIL
ADDRESS: brown@nobleia.com
INSURERS AFFORDING COVERAGE
NAIC N
V
INSURER A: Allmerican Financial Benefit
_
8113/2020
INSURED SIGSP-1
Signature Marketing Group LLC
1300 S Mint St Ste 405
Charlotte NC 28203
INSURER e: Hanover Insurance Company
22292
INSURED C: Hanover American Ins. Co.
36064
INSURER D: Alimerica Financial Alliance Insurance
INSURER E:
PERSONAL &ADV INJURY $1,000,000
INSURER F:
CERTIFICATE NUMBER' 1913547002 KEViSiGN rvUNlocR:
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
/LTR
TYPE OF INSURANCE
ADDL
SUM
POLICY NUMBER
POLICY EFF
MM/OD/YYYY
POLICY EXP
MM/DDNYYY
LIMITS
C
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE EXI OCCUR
Y
V
ZMA39592205
8113/2019
8113/2020
EACH OCCURRENCE $1,000,000
DAMA E TO RENTED
PREMISES His occu ence $100,000
MED EXP (Any one person) $10,000
PERSONAL &ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERALAGGREGATE $2,00Q000
PRODUCTS - COMP/OPAGG $2,000,000
POLICY ❑ PRO- � LOC
JECT$
A
OTHER:
AUTOMOBILE LIABILITY
Y
Y
AVM -A372391-06
8/1312019
8/1312020
COMBINED SINGLE LIMIT $
Ea accident 100 _W0__
BODILY INJURY (Per person) $
X ANY AUTO
BODILY INJURY (Per accident) $
ALLOWNED SCHEDULED
AUTOS NON_OWNED
X OS X AUTOS
PROPERT —DAMAGE $
Pereccidenl
5
B
X
LIAR
tDED
X
OCCUR
Y
Y
UH6A40013205
811312019
811312020
EACH OCCURRENCE $5,000,000
AGGREGATE $5,000,000
AB
CLAIMS -MAGE
RETENTIONS
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE
H _ $
X STATUTE ER
D
Y
WDSA38930303-05
0/13/2019
9/13/2020,; p`
E. L. EACH ACCIDENT $1,000,000
E.L. DISEASE- EA EMPLOYEJ $1,000,000
OFFICER/MEMBER EXCLUDED4 ❑
(Mandatory in NH)
NIA
E.L. DISEASE - POLICY LIMIT $1,000,000
I(gs, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/ LOCATIONS [VEHICLES (ACORD 101, Atltlitional flemarka Schetlule, may be attached II more space is required)
Those Usual to the Inured's Operations: Re: 2019 Smithfield Packaged Meats Mobile Sampling Tour; July 31, 2019 event. Smithfield Packaged Meats Sales
Corp. (and its participating brands), Signature Sports Group, Inc. and Creative Management Group, 1142 Pelican Bay Drive, Daytona Beach, FL are Additional
Insured per the GL Broadening Endorsement 4212915 attached to this policy.
CANCELLATION
GER iFiCAIc HO=H
.-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Shaw's
AUTHORIZED REPRES NTE ATIVE
390 West SL
MA 02048
Mansfield
%% r, FJ/J/�/',rN`4�r —'_
V ivuu-2004 ACORD CORPORATION. ION. NII rights reserve..
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
2019 Smithfield Deli Sampling Tour Standard Operating Procedure
1. The mobile tour manager assigned to each particular retail store location will arrive approximately 90 minutes
prior to the scheduled start time of the event.
2. Tour Manager checks in with on-site Store Manager on where to set up.
3. Tour Manager checks in with Store Manager and Deli Manager to confirm product shipment arrived and
everything is ready for the event.
4. Product is purchased
a. Product to be sampled is purchased daily from each store location and immediately placed on ice in
coolers. Note that product will not be placed on top of ice, but submerged (only when fully sealed) in
the ice to cover on all sides. As a reminder, mechanical refrigeration is not used to store the product due
to the fact that this is only a temporary (4 hour) event. Cooler will have a thermometer to show
temperature.
5. Set Up
a. Outside Assets include:
L (1) 5 x 5 EZ -UP branded tent
ii. (1)2x4'table
iii. Branded table covers and tent back wall
iv. (2) Branded sail sign
v. (2) GWP A -Frame signs placed at the entrance of the store.
b. Inside Assets include:
i. (1) Branded Deli Kiosk
ii. (1) Branded Grab & Go Cooler
iii. (1) 2x4' Branded table for product prep
6. Food Preparation/Sampling
a. Deli Meat and Cheese Preparation and Sampling
i. Deli meat and cheese is sliced by the deli department and each slice is rolled up and cut into 5-6
bite -sized pieces. They will then toothpick each one and place in the covered deli dome with an
ice -packed tray on the bottom.
ii. A deli dome with an ice tray is used for sampling. Ice is replenished as needed, and a dome
covers the sampling tray at all times (except when a sample is being retrieved).
iii. Samples are disposed of every 15-20 minutes and replaced with fresh ones as needed.
b. Pinwheel Recipe Preparation and Sampling
L Deli meat, cheese, mustard, and tortillas are purchased upon arrival to the store and
immediately placed in an ice -packed cooler.
ii. Deli meat and cheese is sliced by the deli department.
iii. Using gloves, the tour managers will spread a quarter -sized dollop of mustard on a 6" tortilla.
They will then place the meat and cheese on top of the tortilla and roll everything together.
They will then cut the roll into 5-6 bite -sized pieces and stick each with a toothpick and place in
the covered deli dome with an ice -packed tray on the bottom.
iv. A deli dome with an ice tray is used for sampling. Ice is replenished as needed, and a dome
covers the sampling tray at all times (except when a sample is being retrieved).
v. Samples are disposed of every 15-20 minutes and replaced with fresh ones as needed.
Cleanup
a. All leftover samples and product will be discarded appropriately at the conclusion of the event.
b. All utensils and cooking supplies are washed, rinsed, and sanitized appropriately, and are cleaned after
every use.
c. Wastewater and trash will be disposed of appropriately.
The following items are part of the event setup:
0 Test Strips
• Metal Stem Thermometer
• Hats/Hair restraints will be worn by all staff
• No eating will take place by staff near the preparation of samples/sampling
• All food and supplies are stored at least 6 inches off the ground
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This ceilificale is awarded to
BEN SCHMITT
Cosgrdulalloasl You haus completed
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3/29/2022
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Allergen Awareness Approval N: 163594
Employee Food Safety Online Course & Exam
Date: 7/12/2019 (valid+ until 7/12/2022)
Course reference: AA
Learner reference: 131431
This training is approved for 1 continuing education hour toward the initial or
recertification application for ACF certification
Nick Eastwood The Always Food Safe Company #1203
President 899 Montreal Circle, St. Paul, MN 55102.
The Always Food Safe Company www.alwaysfoodsafe.com
Congratulations! Go ahead and frame the big copy-- you've earned it!
Keep in your wallet for anytime, anywhere proof you passed!
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Students: Did you buy this course yourself?
Give this code to your manager! if they use it, we'll
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For your manager to keep and admire
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Jane Doucette
From: Kristine Tucker <KTucker@signaturesportsgroup.com>
Sent: Tuesday, July 30, 2019 9:32 AM
To: Jane Doucette
Subject: Re: SIGNATURE MARKETING GROUP.pdf
Attachments: Randal Collignon Mass. Allergen Certificate.pdf; Randal-Collignon ServSafe Manager
Certificate.pdf
Jane - I apologize, I just realized, we had a team switch events and there will be a different onsite contact for this event,
Randal Collignon. I have attached his MA Certificate of Allergen Awareness and his ServSafe Food Manager certification.
Do you think this will be an issue? Let me know if you need anything else in order to make this change.
Thankyoul
Kristine
From: Jane Doucette <Joucette@mansfieldma.com>
Date: Tuesday, July 30, 2019 at 9:27 AM
To: Kristine Tucker <KTucker@signaturesportsgroup.com>
Subject: SIGNATURE MARKETING GROUP.pdf
Hi Kristine, here is the permit for the July 3151 event at Shaw's.
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
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Course reference: AA
Learner reference: 131320
The mways Food safe Company
This training is approved for 1 continuing education hour toward the initial or
recertification application for ACF certification
Employee Food Safety Online Course & Exam
Nick Eastwood The Always Food Safe Company
#1203
President 899 Montreal Circle , St. Paul, MN 55702,
The Always Food Safe Company www.alwaysfoodsafe.com
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