HomeMy WebLinkAboutRob Peters Entertainment, INC. - 12/31/2021I io ®S - Ago,
FOR BOARD OF HEALTH USE ONLY
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Date Received Permit Fee Approved By flu m/4Y 2 T
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name Q
1A".
Establishment Address:d-
r'
Establishment Mailing Address (if different):
Establishment Telephone No:18 1 . PM
qL.2� 7
2) Applicant/Owner Name & Titled
G
Applicant/Owner Address,
Applicant/Owner Telephone No:
Applicant/Owner Email address: 1 Lr
3) Person In Charge of Onsite Operations & Tit :
PICAddress: C 't
PIC Telephone No: r-�' _„(.
Emergency/onsite Telephone No:
PIC Email Address r ' tf-� t J l'7i
4) Event Attending:
Date(s):
Event Name:
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Event Location:
llL„AAA"'fff��/ UY"
Event time:
5) Check onee
L-r Food Truck
o Caterer
o Other:
6) Solid waste disposal plan:
7) Water Source: c
8) Sewage isposal plan: Lei
9 ) Please give a (b�r`ief description of the food to be served:
`i'�..�/ �t'�i�/`.11--.i^?.�3`Y` �1Yf'" i.`A UL} /k...�
10 ) Food will be prepared:
nsite for immediate consumption
o Onsite and held at proper hot/ cold holding temperatures
o Offsite and held at proper hot/ cold holding temperatures
O Offsite, cooled and reheated on site
o Other:
11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety ManaJ 1
Allergen Awarenes �-`
12) Please describe on site hand washing facilities that will)be utilized:
13) Please list all sanitizing solutions that will b% on siytee-
14) If applicable, please describe your FOG management plan or attach the written plan:
IS) 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 Base of Operations
or mm/i sary perim '.
.��,4'CiC�� i
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 a all other applicable law. I have been instructed
by 19) the
Signature of Appl'csant o dies of C 590. and tlfederal Food Code.
/�j
Pursuant to MGL Ch. 62C, sec. 49A, 1 certify under the pefialties gf perjury that 1, to my best
knowledge and belief, have filed all state tax returns a`}nd id statetaxesrequired under law.
20) Social Security Number or Federal ID: / V
21) Signature of Individual or Corporate NaffibQ � S Q i /�7i KWI_,
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name By: Corporate Officer
"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.
Food Protection Questionnaire for Catered Events
Date of Event: 6 i3 � 12 CO t Event Time: I IA _3 0
Location of Event:
List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location:
On ice/Refrigerated
c�
Cooking Reheating
Food Manager Certification Person Trained On Site? E_' Y es o No
Allergen Awareness Menu Label Present? �_'Yes o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
ist the required temperature for eac food as it leaves your preparation site:
tLL`
How will the PHF be kept at or below 41 °F? �(/ /, y-' ee_
How will the PHF be kept at or above 140°F? c A 1 1(
Time of PHF? Setup Served
Removed
Please describe hand washing and sanitizing supplies that will be provided on site:
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.
r
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
to Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
City/State/Zip: 1���_fi� Phone #: t 1C�� "y`i 7Zry�
Are you an employer? Check the appropriate box: Business Type (required):
1. [�I am a employer with cg 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 (met. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non- rofit
3.❑ We are a corporation and its officers have exercised 9. ntertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** I I.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #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 91.
I am an employer that is providing workers' compensation insurance for my emWloyees. Below is the policy information.
Insurance Company Nan
Insurer's
City/State/Zip: I 1 ! 1JU ,._)_J 7 _ L
Policy # or Self -ins. Lic. #1 1 o Expiration Date:
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
Investieations of the DIA for insurance coverage verification.
I do heryAy-FeRW,under theRai� pen tiespfperjury 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. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact
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April 29, 2021
Location:Fairfield by Marriott
License Plate: 26J 614
Town of Walpole
Health Department
1 bile Food `stablishmenl eund
MC-21-5
Rob Peters Entertainment
Type of Mobile Unit:Non-complex food preparation
Type of Food Served:Hot dogs, Chili & Condiments
279 E Central St
Franklin, MA 02038
F OD MCH,
19
n1buc Health
Explres:December 31, 2021
Health Director;�ad�,/�,
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19
n1buc Health
Explres:December 31, 2021
Health Director;�ad�,/�,
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Food Establishment Inspection Report —Town of Norwood, Health Qepartment — 781-762-1240
Establishment:
G
Seating Y N
Date: U 111 Page 1 of 13
Address: 27q
- — � Ve
?F^aW11V4--
Time in: Time out:
Telephone:
/
Permit No.: [
U
Number of Violated Provisions Related
to Foodborne Illness Risk Factors
and Interventions (Items 1 through 29):
1
l
Owner: <
Email:
Person -in -charge:
/I
I A-7L 10
Number of Repeat Violations Related
to Foodborne Illness Risk Factors
and Interventions (Items 1 through 29):
Inspector: Me (
FOODBORN LNESS RISK FACTORS AND PUBLIC;HEALTH INTERVENTIONS
IN = in compliance OUT= out of compliance N/A = not applicable
N/O = not observed COS = corrected on -site during inspection R = repeat violation
Compliance Status
I IN
JOUTINIAINMIC04R
Supervision
1
Person -in -charge present, demonstrates
knowledge, and performs duties (PO
2
Certified Food Protection Manager (c)
;Employee Health
3
Management, food employee and
conditional employee; knowledge,
responsibilities and reporting (PO
4
Proper use of restriction and exclusion(P)
6
Procedures for responding to vomiting
and diarrheal events (PO
Good Hygienic Practices
6
Proper eating, tasting (P) , drinking, or
tobacco use (c)
7
No discharge from eyes, nose, and
mouth (c)
Preventing Contamination by Hands'
8
Hands clean & properly washed (P) (PO
9
No bare hand contact with ready -to -eat
food (P)
10
Adequate handwashing sinks properly
supplied and accessible (PO (c)
;,Approved Source
11
Food obtained from approved source(P) (PO
mist
12
Food received at proper temperature(P) (PO
13
Food received in good condition, safe, &
unadulterated (P)(PO
14
Required records available (PO:
shellstock tags, parasite destruction (P)
Compliance Status
IN
OUT
NIA
NIO
COS
R
Protection from Contamination
15
Food separated and protected (P) P
16
Food-corANt surfaces; cleaned &
sanitize '(P) PO(c)
17
Proper disposition of returned,
previously served, reconditioned &
unsafe food (P)
Time/Temperature Control for Safety
18
Proper cooking time & temperatures (P) (PO (c)
19
Proper reheating procedures for hot
holding (P)
20
Proper cooling time and temperature (P)
21
Proper hot holding temperature (P)
22
Proper cold holding temperature (P)
23
Proper date marking(PO and disposition(P)
2
Time as a Public Health Control(P) TO (c)
Consumer Advisory
25
Consumer advisory provided for raw /
undercooked food(PO
Highly Susceptible'Populations'
26
Pasteurized foods used; prohibited foods
not offered (P) (o>
Fo6dlC61or A lditives ind Tdxic,Substances
-
27
Food additives: approved & properly
used (P)
28
Toxic substances properly identified (PO,
stored(P) & used (PO
Conformance with Approved Procedures
29
Compliance with variance(P)/ specialized
process(PO / HACCP Plan (PO(c)
Official Order for Correction: Based on an inspection today, the items marked "OUT" indicated violations of 105 CMR 590.000 and
applicable sections of the 2013 FDA Food Code. This report, when signed below by a Board of Health member or its agent constitutes
an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food
establishment permit and cessation of food establishment operations. If you are subject to a notice of suspension, revocation, or non -
renewal pursuant to 105 CMR 590,000 you may request a hearing before the board of health in accordance with 105 CMR 590.015(B).
Date of Reinspection: Discussion with Person -in -Charge:
Date:
Food Establishment Inspection Report —Town of Norwood, Health Department — 781-762-1240
Establishment: (� Date: � j a) Page 2 of
GOOD RETAIL PRACTICES AND MASSACHUSETTS-ONLY'SECTIONS
IN = in compliance OUT= out of compliance NIA = not applicable NIO = not observed COS = corrected on -site during inspection R = repeat violation
Compliance Status IN OUT
NIA
Nro I cos R
'Safe Food and Water
30
Pasteurized eggs used where
required (P)
31
Water & ice from approved source(P)
32
Variance obtained for specialized
processing methods (Pt)
Food Temperature(Control
33
Proper cooling methods used(Pp(c);
adequate equipment for
temperature control (PO
34
Plant food properly cooked for hot
holding (Pr)
35
Approved thawing methods used(c)
36
Thermometers provided & accurate (Pg (o)
Food Identification
37
Food properly labeled(P9; original
container (c)
Prevention of Food Contamination
38
Insects, rodents, & animals not
present (Pa (c)
39
Contamination prevented during
food preparation, storage and
display (c) customer self-service("), ice(")
40
Personal cleaniiness(PO(c)
41
Wiping cloths: properly used &
stored (c)
42
Washing fruits & vegetables (P)(PElm
Proper Use.of Utensils
43
In -use utensils properly stored(c)
44
Utensils, equipment & linens:
properly stored, dried, & handied(c)
45
Single -use / single -service articles:
properly stored & used(P) (c)
46
Gloves used properly(c)
Utensils, Equipment and Vending
47
Food & non-food contact surfaces
cleanable, properly designed,
constructed & used (P) (PO (c)
Compliance Status
IN
00T
NIA
N/O cos
R
48
Warewashing facilities: installed,
maintained, & used test strips(Pr) (c)
49
Non-food contact surfaces clean(°)mini
Physical Facilities
50
Hot & cold water available;
adequate pressure (Pt)
51
Plumbing installed; proper backflow
devices (P) (PQ (c)
52
Sewage & waste water properly
disposed (P)(P6(c)
53
Toilet features: properly constructed,
supplied, & cleaned(Pg (c)
54
Garbage & refuse properly
disposed; facilities maintained(c)
55
Physical facilities installed,
maintained, & clean(P) (P9 (c)
56
Adequate ventilation & fighting;
designated areas used(c)
Additional Requirements listed in 105:CMR 590.011 ;
M1
Anti -choking procedures in food
service establishment(c)
M2
IFood allergy awareness(c)
Review of Retail Operations, listed in 105 CMR 590.010
M3
Caterer
M4
Mobile Food Operation
M5
Temporary Food Establishment
M6
Public Market; Farmers Market
M7
Residential Kitchen; Bed-and-
Breakfast Operation
M8
Residential Kitchen: Cottage Food
Operation
M9
School Kitchen; USDA Nutrition
Program
M10
Leased Commercial Kitchen
MI I
linnovative Operation
Local Requirements
L1
Garbage Grinder
L2
Other
Type of Operation(s):
Type of Inspection:
Other Information:
❑ Food Service Establishment
❑ Routine
❑ Retail Food Store
❑ Re -inspection
❑ Residential: Cottage Foods
Pre -operational
❑ Residential; Bed &
Illness investigation
Br akfast
❑ General complaint
Mobile/Pushcart
❑ HACCP
❑ emporary Food Estab.
❑ Other
❑ Other
Signature of Person-in-Charg Date:
Signature of Inspector:
n
Date:
MOPH report form- Norwood 0312019 versions v I r tL
Food Establishment Inspection Report —Town of Norwood, Health Department — 781-762-1240
lEstablishment: O`er jDate: YQO/d/ PageT�Lof\:'I_
Temperature Observations
Item I Location
Temp °F
Item I Location
Temp °F
Item l Location
Tem °F
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Signature of
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Food Establishment Inspection, Report - City/Town of /L "
]Establishment: T 11-- __ 41 _" (Date:. - /' (. - .1 i Page _ of _1 I
`Tem eratureObservations 'r
Item I Location
Temp °F
Item 1 Location ,
Temp °F
Item 1 Location
Tom°F
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Observations and/or Corrective Actions
Violations cited in this report must be corrected within the time frames stated below or in Section B-405.11 of the Food Code
Item
Number
Section of Code
Description of Violation
Date to Correct By
j_.
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,'
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NOTICE OF ASSIGNMENT
EMPLOYER:
ROB PETERS ENTERTAINMENT INC
279 EAST CENTRAL ST
FRANKLIN, MA 02038
The Waiver of Our Right to
Recover from Others Endorsement
is available on Pool policies.
Contact your agent for details.
AGENT ALEXIA INSURANCE INC DBA BERRY INSURANCE
OR STACY HEARN
PRODUCER: 31 HAYWARD ST SUITE J
FRANKLIN, MA 02038
AGENCY FEIN: 814538162
CLASSIFICATION OF OPERATION
THEATER NOC: PLAYERS, ENTERTAINERS OR
MUSICIANS
THEATER NOC: ALL OTHER EMPLOYEES
EMPLOYERS LIABILITY 1000/1000/1000
STANDARD PREMIUM
EXPENSE CONSTANT
TERRORISM CHARGE
TOTAL POLICY MINIMUM PREMIUM
TOTAL ESTIMATED PREMIUM
DIA ASSESS. 3.51%
COMBO I.D.
001183271
COVERAGE GROUP
1267343
STATUS OF EMPLOYER
Corporation
Coverage under this assignment
applies to Massachusetts
operations only. For coverage
outside of Massachusetts, contact
the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
PENNSYLVANIA MANUFACTURERS ASSOC INS
CO
PMA INSURANCE CO / ORMARKS
P 0 BOX 9325
MINNEAPOLIS, MN 55440-9235
(877) 347-3596
CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
9156
$71,240 1.55 $1,104
9154
$0 1.29 $0
9812
$75
$1,179
0900
$338
9740
$21
$308
$1,538
$39
TOTAL EST. PREMIUM PLUS ASSESSMENT $1,577
INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $1,577
THIS IS NOT A BILL
COMMENTS
Coverage effective 12:01 AM on 08/26/20.
CARRIER NOTE: The WCRIBMA reviewed the classifications and description provided with the
application and determined that a change to the classes provided on the application was
warranted. The classes listed on the Notice of Assignment are correct based on the
information submitted.
DATE OF NOTICE: 0 8/ 2 6/ 2 0 PREPARED BY:
* * SERVICING CARRIER ASSIGNMENT * *
Joanne Shea
EXT 530
\/kjN
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 • FAX (617)439-6055 • www.weribma.org
Food Establishment Inspection Report — Town of Mansfield
Establishment: Zis-
Date: Page 1 of _
Address:
Time in: Time out:
Telephone:
Permit No.:
Number of Violated Provisions Related
to Foodborne Illness Risk Factors
and Interventions (Items 1 through 29):
Owner:
Person-in-ch rge:
Number of Repeat Violations Related
to Foodborne Illness Risk Factors
and Interventions (Items 1 through 29):
Inspector:
,� - - c- c..._w�.a.,�(
F DBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS
IN = in compliance
OUT= out of compliance NIO = not observed NIA = not applicable COS = corrected on -site during inspection R = repeat violation
Compliance Status
I IN
OUT
NIA
I NIO
I cos
I R
Supervision
1
Person -in -charge present, demonstrates
knowledge, and performs duties
2
ICertified Food Protection Manager
Employee Health
3
Management, food employee and
conditional employee; knowledge,
responsibilities and reporting
4
Proper use of restriction and exclusion
✓
5
Procedures for responding to vomiting
and diarrheal events
Good Hygienic Practices
6
Proper eating, tasting, drinking, or
tobacco use
7
No discharge from eyes, nose, and
mouth
Preventing Contamination by Hands
8
Hands clean & properly washed
9
No bare hand contact with ready -to -eat
food
10
Adequate handwashing sinks properly
supplied and accessible
Approved Source
11
Food obtained from approved sIsafe,
12
Food received at proper temper
13
Food received in good conditionunadulterated14
Required records available: she
tags, parasite destruction
Compliance Status
IN
OUT
NIA
WO
cos
I R
Protection from Contamination
15
Food separated and protected
16
Food -contact surfaces; cleaned &
sanitized
17
Proper disposition of returned,
previously served, reconditioned &
unsafe food
Time/Temperature Control for Safety
18
Proper cooking time & temperatures
19
Proper reheating procedures for hot
holding
20
Proper cooling time and temperature
21
Proper hot holding temperature
22
Proper cold holding temperature
23
Proper date marking and disposition
24
Time as a Public Health Control
Consumer Advisory,
25
Consumer advisory provided for raw /
undercooked food
Highly Susceptible Populations
i
26
Pasteurized foods used; prohibited foods
not of
Food/Color Additives and Toxic Substances
27
Food additives: approved & properly
used
28
Toxic substances properly identified,
stored & used
Conformance with Approved Procedures
29
Compliance with variance / specialized
process / HACCP Plan
Official Order for Correction: Based on an inspection today, the items marked "OUT' indicated violations of 105 CMR 590.000 and
applicable sections of the 2013 FDA Food Code. This report, when signed below by a Board of Health member or its agent constitutes
an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food
establishment permit and cessation of food establishment operations. If you are subject to a notice of suspension, revocation, or non -
renewal pursuant to 105 CMR 590.000 you may request a hearing before the board of health in accordance with 105 CMR 590.015(B).
Date of Reinspection:
Discussion with Person -in -Charge:
Food Establishment Inspection Report — Town of Mansfield
Establishment: Date: Page 2 of
GOOD RETAIL PRACTICES AND. MASSACHUSETTS-ONLYfSECTIONS
IN = in compliance OUT= out of compliance N/O = not observed NIA = not applicable COS = corrected on -site during inspection R = repeal violation
Compliance Status Iw OUT INIA �N1OICOS IR
Safe Food and Water
ed eggs used where
30 Pasteuriz
required
31 IWater & ice from aooroved source L`a
u r.w,ci„�ca�
32 processing methods
Food Temperature Control
Proper cooling methods used;
33 adequate equipment for
temperature control
34 Plant food properly cooked for hot
holding
35 Approved thawing methods used
36 Thermometers provided & accurate
Food Identification
37 Food properly labeled; original
container
Prevention of Food Contamination
38 Insects, rodents, & animals not
Food & non-food contact surfaces
47 cleanable, properly designed,
constructed & used
Compliance Status AINIC48Warewashing facilities: installedmaintained, & used; test strips
49 Non-food contact surfaces clea
"PhysicalFacilities
50 Hot & cold water available;
adequate pressure
51 Plumbing installed; proper backflow
devices
Sewage & waste water properly
52 disposed
53 Toilet features: properly
constructed, supplied, & cleaned
54 Garbage & refuse properly
disposed; facilities maintained
55 Physical facilities installed,
maintained, & clean
56 Adequate ventilation & lighting;
designated areas used
Additional Requirements listed in 105 CMF
M1 Anti -choking procedures In food
service establishment
M2 IFood allergy awareness
Review of Retail Operations listed in 105 CN
M5 (Temporary Food Establishment I
M6 Public Market: Farmers Market
M7IBreakfast Operation VG4 �11V
M8 Residential Kitchen: Cottage Food
Operation
M9 School Kitchen; USDA Nutrition
Program
M10 Leased Commercial Kitchen
M11 Innovative Operation
Local Requirements
L1 ILocal law or regulation
19 r)fhor
Type of Operation(s):
Type of Inspection:
Other Information:
❑ Food Service Establishment
❑ Routine
❑ Retail Food Store
❑ Re -inspection
❑ Residential: Cottage Foods
Pre -operational
Vie-operational
❑ Residential; Bed &
investigation
Breakfast
❑ General complaint
❑ Mobile/Pushcart
❑ HACCP
❑ Temporary Food Estab.
❑ Other
11 Other
Food Establishment Inspection Report — Town of Mansfield
Establishment: Date: Page _ of
Temperature Observations
Item I Location
Temp °F
Item / Location
I Temp (OF)
Item / Location
Temp °F
Observations and/or Corrective Actions
Violations cited in this report must be corrected within the time frames stated below or in Section 5-405.11 of the Food Code
Item Section of Code Description of Violation Date to Correct By
Number
Signature of Person -in -Charge:
Date: '..
Signature of Inspector:
Date:
MDPH rep.0 form-1015/18 version