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Home My WebLink AboutCousin's Maine Lobster - 12/31/2020B Q° Date Received FOR BOARD OF HEALTH USE ONLY Permit Fee Approved By Mobile Food Establishment (MFE) Permit Appli6at'on (Application must be submitted at least 14 business days before the plannning date) 1) MFE Name: 2) Applicant/Owner Name & Title: CA a e n Applicant/OwnerAddress: Applicant/Owner Telephone No: ` - �`- Applicant/Owner Email address: W Q 4n � (IM ob J del, Mon 3) Person In Charge of Onsite Operations & Title: fv L PIC Address: 'Name, \V� \� )n i I��ri � i � �(� , ® vJ PIC Telephone No: Emergency/onsite Telephone No: PIC Email Address:�}�,� �h�,'�` e� • (�� _ 4) Location of Service: Z' V) 1A CA\w 015 C S`ana anvp Date(s) if applicable:ai�N(Aae0n( errmV rmwed Event Name if applicable: Event/ Service Location: Event/ Service time: h 5) Length ofPermit: JAnnual Dates:orary U 6) `Solid waste disposal plan: 7) Water Source: Q�mmil s ,low 8) Sewage disposal plan: nla 9) Food will be prepared: 9 I 9 [4 Onsite for immediate consumption Ql��d a� � e a��1 ��(� rj\j \ ))Ct o Onsite and held at proper hot(cold holding temperatures o Offsite and held at proper hot/ cold holding temperatures o Offsite, cooled and rehgated on sho- o Other: �^(� 1M\ b V l (�6'CRir1 �I !i , 10) Please attach a menu or a website link to the menu or give a brief description of the food to be served: �u�w. Co�Jin�ma�ne %Vty. cam lmct J a"iMr) -mat 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: for a oet 5 �jn Allergen Awareness: Taira Wlpp'. `1W 12) Please describe on site hand washing facilities that will be utilized: 3bay ��nr� 00q,ct N Y)(An0w0Y)lv1q SM ( w) SC)Ctp �Gper f- U)e� J 4per JicthGq� 13) Please list all sanitizing solutions that will be on site: MMW ahWV S\ernrn'Me 14) Do you hav ro , fryolators andlo ood n your truck?.. 2—cAW 1On \D� po n ep f on rJ If yes, you must first be Inspected and approved by the Mansfield Fire Department. Phone number: 508-261-7321 Fire Department Signature of Approval: 16) If applicable, please describe your FOG management plan or attach the written plan: ()or Comm W&14 Mni Q)n 1 a gfeaJ( \Yo\o�hl,b ti U1eO1 (\ Very ANM . e �5� �3zvgoAy)�o Viet nor tNer all QtCt-q, 16) Location of Base of Operations or Commissary: 12',hulWon S) heclWM rA 0,70.53 Please attach copies of Base of Operations or Commissary Permit. 17) Please list additional communiti s where a food permit is held: ftwCi �1 fd Mr hGi'1��0�11)n c,0 ICt Yvl'1, ( rttn Iron, 1, the undersigned, attest to the u,e mva,v vi inaiiif tiff hoW t0 ,el 18)Signature of >f the Inform p"njirovided in this application and I affirm that the food all other applicable law. I have been instructed by fs of 10 CMW690MO and the federal Food Code. Pursuant to MGL Ch. 62C, sec. 49A,1 certify have filed all state tax returns and paid 19) Social Security Number or Federal 20) Signature of Individual or Corporat underhe penalties of perjury that I, to my best knowledge and belief, 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. LobYle(1/Aub LU — -- 4 � zz'', �— Signature of Individual or Corporate Name 10. Corporate Officer (Mandatory, if Applicable) **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. CAUsem\sleite\Desktop\Scotts Docoments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc �, o N o e� Pay c � °`� Ctj ® E"' � Ca �;w � � 41 Ci ] � � G N u ,1, L =. C � � <C � � r eC c, � � x F, [� ® °"" � 4 � Q � ® � � � �, ^., � � � � 5_ � r O � v � � � "� �_ � e� JSE}SS•Et�s2 ^�• 1 o � W s ¢ u, C f� p� � � �p I y`r J 'dv �M�13H1•IN��Pv 0 �' c v u M 0 n The Conlnlornvealth ofMassachtisetts Department ofladtrstrial Accidents I Congress Street, Suite 100 Boston, MA 02I14-2017 wrutv.mass gov/dla Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDlicant Information Please Print Legibly Business/Organization Name: L o bf iP r Mob L L C Address: 6birm t3Lir1[ re/ City/State/zip: 11 rG1 WQq Y)A 07053 Phone #: 617 - 9B 1- _7832 Aree u an employer? Check the appropriate Business Type (required): 1.[� I am a employer _ 15 employees (full 5. ❑ Retail with orpart-time).` hirir79[n)7r06rXr 6. ❑Restaurant/Bar/Eating Establishment 2.0 lam a sole proprietor or partnership and 7. ❑ Office and/or Sales (incl. real estate, auto,]etc.) have no employees working for me In any hag ❑Non-profit capacity. Y ❑ [No workers' comp. insurance required] 9. ❑ Entertainment 3. We are a corporation and its officers have to.❑ Manufacturing exercised their right of exemption per c. 152, El§1(4), and we have 11.[] Health Care no employees. [No workers' comp. insurance 12.[✓rOlher L L C **If the corporate ofacen have exempted themselves, but corporation has other employees, a workers' compensation policy is required and such an organisation should check box ql. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Harrel jjj I U r 0 h C nm P-0 h q Insurer's Address: 1Q PnrrlA)Qt,r NQrfh City/State/Zip: nt erf`l-eeld" �i- ) L W' o 15 l- Policy # or Self -ins. Lic. # t ty V 01 G.38-79 "01 Expiration Date: 2 2 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 hereby certify, under thepains and penalties ofperjuty that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Scanned with CamScanner WORKERS COMPENSATION INFORMATION AND EMPLOYERS ORMA ONRS LIABILITY INSURANCE POLICY III MARKET Original Printing issued February 7, 2020 Standard NCCI Cellar Code:22616 Type : Stock Policy Number: Markel Insurance Company MWC0163879-01 Ten Parkway North Renewal of Policy: Deerfield, IL 60015 E— Rewrite of Policy: --� Feln s J Rlsk ID N: 42469167/ 1. The broured's Name and Mailing address: Lobster Hub LLC 6 Birch Bark Rd Medway, MA 02053-2401 6173207923 DBA Name Cousins Maine Lobster SIC CODE: 5812 Other work place not shown above:See Attached Location Schedule Type of Limited Liability Company entity: 2• The policy period Is from 02105QO20 to 02M5)2021 [12.01 AM Standard Time] at the Insured's mailing address. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: MASSACHUSEITS B. Employers liability Insurance: Part TWO of this policy applies to work in each state listed In Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident: $100,000 each accident Bodily Injury by Disease: $500,000 policy limit Bodily Injury by Disease: $100,000 each employee C. Other States Insurance: Part Three of this policy applies to the states, 0 any, listed here All states except those listed In Item 3A of the Information Page and the following states or territories: District of Columbia, ID, MT, NY, NO, OH, OR, WA, WY, Puerto Rico and US Virgin Islands. D. California Endorsements and Schedules Other State Endorsements and Schedules: MDWCIOOI, MWC 1201, WCOOOOOOC, WC000I 15, WC000308, WC000406A, WC000414, WC000414A, WC000422B, WC000425, WC 2003 01, WC 20 03 02 A, WC 20 03 03 D, WC 2004Ol, WC 20 04 05,WC 20 06 01 A, WC 20 06 04, MJWCI000, M6. 1214,MPIL 1083, MP1L 1007 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. Ail Information required Is subject to verification and change by autlf. Minimum Premium: 195.00 Deposit Premium: Total Estimated Annual Premium:$1,764.00 Pay plan: Payroll Reporting- 0% Producar.Allentown-Automatic Date Processing Ins Agency Inc Countersigned By: 740 Hamilton S) 484-201-2950 Date: Allentown PA 18102 02t( 7/2020 Servicing office: Markel Service, Inc., (888) 500-3344 Central Park Plaza, 222 South 15th Sheet, Suite I SOON Omaha, NE 68102-1680 THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY MDWC 100105 10 Scanned with CamScanner EXTENSION OF INFORMATION PAGE Worker's Compensation and Employer's Liability Policy Schedule Of Premium Information Policy Number: MWC0163879-01 Issued to : Lobster Hub LLC Effective Date; 02/05/2020 - 02/05/2021 Coverage Provided By: Markel Insurance Company Carrier Code : 22616 Period of Operation: 02/05/2020 - 02/05/2021 State of Operation: MA Code Classification 9079 Restaurant Noc Manual Premium 9037 Rate Deviation Total Manual Premium Subject Premium Total Subject Premium Modified Premium Standard Premium 0900 Expense Constant 9740 Terrorism Charge Estimated Annual Premium DIA Assessment Total Amount Due Premium Basis Rate Per Estimated Total $100 of Annual Estimated Annual Remuneration Premium Remuneration $140,000.00 1.030 $1,442.00 $1,442,00 -0,040 ($58.00) $1,384.00 $084.00 $ 094.00 $1,384.00 $1,394.00 $338.00 0.030 $42.00 $1,764.00 3.510 $51.00 $1,815.00 Scanned with CarnScanner EXTENSION OF INFORMATION PAGE Worker's Compensation and Employers Liability Polley LOCATION SCHEDULE Policy Number: MWC0163979.01 Issued to: Lobster Hub LLC Effective Date: o2/0wall to 02/05/2021 Coverage Provided By: Markel Insurance Company Carrier Code 22616 Other workplaces not shown above: Location FEIN PHONE SIC CODE ENTITY TYPE 1 123 Holliston St Limited Medway, MA 02053-1954 842469167 6173207923 5812 Liability Company Scanned with CamScanner MWC 120105 10 Worker's Compensation and Employer's Liability Policy Payment Schedule Policy Number: MWC0163879-01 Issued to: Lobster Hub LLC Effective Date: 02/05/2020 Coverage Provided By: Markel Insurance Company Cartier Code: 22616 Month Payment If you elect a payment plan, then you will be subject to installment fees for each payment ranging from $3-$10 depending on the state, If you elect electronic funds transfer, these fees will not apply. Ed. 05 10 Scanned with CamScanner PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Partners Officers Others Todd Nelson This endorsement changes the policy to which it Is attached and Is effective on the date issued unless otherwise stated. (rho Inforsnadon balm Is required only when this endorsement Is Issued subsequent to preparation of the policy.) Endorsement Effective 0VOW2020 Policy No. M=0793979.01 Endorsement No. Insured: LobSW Hub LLC PremWm(See Attached) Scanned with CamScanner E3 § 3 f � \ _ �§r t & } i� (-W� z � z � � I � � W z W 94 � � � Is \, ) / ƒ § l ® \ % ( i / k \ % z / m \ ...I.: , IN]j%§] &Kƒ \ { \ \ z Zi \ �\\\ � /