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Home My WebLink AboutThe Ultimate Grille Food Trailer/Mike's Vending - 12/31/202144)-13 - 175, ) FOR BOARD OF HEALTH USE OP Date Received Permit Fee Approved By NAY 10 ZO r, Mobile Food Establishment (MFE) Permit Application (Application must be submitted at least 14 business days before the planned opening date) 1) MFE Name: ( r � ( A I j-e °C 2) Applicant/Owner Name & Title:' e,,' rl {-�( r") Applicant/Owner Address: L� (� �r :�1�(J� F Applicant/Owner Telephone No: ' Applicant/Owner Email address: I e r riffci i qc" cA oa C,0" 3) Person In Charge of Onsite Operations & Title: PIC Address: Al 9C1< SCaV,V1-eI( PIC Telephone No: '� U, _ 3,5 c' Emergency/onsite Telephone No:Wagc1 a q% q� PIC Email Address: if'17C6 IvA1 Sfyl0G3✓"6LI 4�`trry, C IS.-C ,. 4) Location of Service: C e - f ' Aq Date(s) if applicable:V d.,, / i - I Event Name if applicable: Event/ Service Location: Event/ Service time: m i 5) Length of Permit: ka Annual I--] Temporary Dates: 6) Solid waste disposal Ian: 90 � 2 1 7) Water Source: PC L . 8) Sewage disposal Ian: e G ed icr 9) Food will be prepared: l Onsite for immediate consumption O Onsite and held at proper hot/ cold holding temperatures O Offsite and held at proper hot/ cold holding temperatures I--] Offsite, cooled and reheated on site o Other: 10) Please attach a menu or a website link to the menu or give a brief description of the food to be served: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: / Food Safety Manager: Allergen Awareness: 12) Please describe on site hand washing facilities that will be utilized: c r"� W h S 90 a� E b .1c ,J - c cnkll d,rty i.J< —er 13) Please list all sanitizing solutions that will be on site: j 14) Do you have propane, fryolators and/or hoods on your truck? S If yes, you must first be inspected and approved by the Mansfielb Fire Department. Phone number: 508-261-7321 Fire Department Signature of Approval: 15) If applicable, please describe your ^FOG management plan or attach the written plan: 16) Location of Base of Operatio s or Commissary: :I(-) Tiienr1 f Please attach copies of Base of Operations or Commissary Permit. 17) Please list additional c mmunities wh re a foo p. t is held:- 1V1A 1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 10 CMR 5 0.000 and all other applicable law. I have been instructed by the board of health on how to ot/tain copies, of 100 gIVIR 590.000 and the federal Food Code. 18)Signature of Pursuant to MGL Ch. 62C, set. 149A, I certify have filed all state tax returns and paid slate 19) Social Security Number or Federal ID:_ 20) Signature of Individual or Corporate the penalties of perjury that 1, to my best knowledge and belief, required under law. , TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. - 1941z JJ '4� Z411 Sig4re of lndivid al or Corporate Name By: Co rate Officer ( ltdatory, if Applicable) 16 c `7S r1 **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 Establisluneals- Temp\TAX CERTIFICATION FORM.doc � R®® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDMYY) 03/22/2021 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 po icy(ies) must have ADDITIONAL INSURED provisions or be en . orse f 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 endorsements . PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 AICNr o Est: 1-800-328-2317 AIC. No: 1-260A59-5502 E-MAIL ADDRESS: into@eventinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC9 INSURED INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: Michael Griffin DBA: Mikes Moonwalk Rentals & Backyard BBQ 144 Shrewsbury St. Boylston, MA 01505 INSURER C: INSURER D: INSURER E: A Member of the Sports, Leisure & Entertainment RPG NSURER F: rnllGaer=g CERTIFICATE NUMBER: W01918982 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD R WVD IMBER POLICY NU POLICYPOLICY MMfDDM' MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS- OCCUR MADEFx1 6BRPG0000007459900 03/23/2021 12:01 AM EDT 06123/2021 12:01 AM EACH OCCURRENCE $1,000,000 D G O RENTED PREMISES Ea Occunence $300 DDD MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 DENT AGGREGATE LIMB APPLIES PER: POLICY ❑ PET ❑ LOC OTHER: PRODUCTS-COMP/OP AGO $1.000,000 PROFESSIONAL LIABILITY LEGAL LIM TO PARTICIPANTS AUTOMOBILE UABILRY ANY AUTO OWNED AUTOS SCHEDULED ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY NOT PROVIDED WHILE IN HAWAII COMBINED Ea accidentihnn NG DMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Peraccident UMBRELLA LWB OCCUR EXCESS UAS CLAIMS -MADE DED n RETENTION EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERI YIN EXECUTIVE OFFICERIMEMBER ❑ EXCLUDED? (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS bslox N/A PER OTHER STATUTE El EACH ACCIDENT EL. DISEASE -CA EMPLOYEE E1. DISEASE -POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Booth Operations of the Named Insured; # of Trailers: 1 eFRTIPICATP Rien ncu CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S. events and activities. "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas 1 '+ CERTIFICATE OF LIABILITY INSURANCE GATE (MM/DOA'YYY) 01/26/21 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(fes) most have ADDITIONAL INSURED provisions or 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 NAME: Stratford Insurance Financial ac°NN ExI : 617�394.9300 Afc, No : 617-394-9301 info@Stratfordlns.com lESF--Iinfo@Stratfordlns.com 181A South Main Street Middleton, MA 01949 INSURER(S)AFFOROING COVERAGE NAIGN INSURERA: Travelers INSURED INSURER B : INSURER C : Mike's Vending, LLC INSURER D : 144 Shrewsbury Street Boylston, MA 01605 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE NSD D POLICY NUMBER MMIDOYEFF POLICY EXP LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE RENTED PREMISES Ea occurrence $ MED EXP An one person)S PERSONAL BAUV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY❑j O- 0LOC S OTHER: AUTOMOBILE LIABILITY EaeBINMEantSINGLE LIMIT $ BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per accident) S OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ $ UMBRELLA LWB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS DNB CLAIMS -MADE DED I I RETENTION$ WORKERS COMPENSATION _ STATUTE EERR $ A AND EMPLOYERS'LIABIUTY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEWMEMBER EXCLUDED? (Mandatory in NH) N f A UB6J692799 11110I20 19110121 E.L. EACH ACCIDENT $ 1,000,000 EL DISEASE -EA EMPLOYE $ 1, 000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 IF yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mare space is required) Operations: Sale of Fast Food —Pushcart Vendor INSURED COPY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Michael T Supino n 1RRR-2015 ACORD CORPORATION. All rights reserved. TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. , Applicant Signature Applicant Name (pleasg(orint clearly) Ine uommonweattn ofmassacnusetrs Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses nnTicant Information Please Business/Organization Naine: (l i e y- VQAL( , G-• City/State/Zip: Roybl+�` _ Phone #: ��, C11 c7C Are you an employer? Check the appropriate box: Business Type (required): La I am a employer with I_�_ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, A ��) with no employees. [No workers' comp. insurance req.] 12. Other p t( 6.� *Airy applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. I ant ati employer ihat is providing lvorker ' coppensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: 9 _'i C , City/State/Zip: Policy # or Self -ins. Lic. # <✓ Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy numbe 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 insurameg coverage verification. I do hereby certif , under the ain rd penalties ofperjury that the information provide ab ove is true and correct Signature: Date:/ Phone #: Oljtcial 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 www.mass.g0wdia Phone 0 v O m z [ wa y (\E! !mAt % ® 2\2{ \7}( \ ( ]ate / }\n \ E)o // 4 /w` � \ R & § \ ) § / ; ( / / 7 I allp ► I I " �+ 'M I I Italian Sausage.................................................$9.00 HotDogs..........................................................$3.00 8 oz Angus Burger..........................................$9.00 Fried Chicken Sandwich................................$8.00 Steak & Cheese...........................................$10.00 BLT Sub .............................. ......................$7.00 Chicken Fingers & French Fries .......................$11.00 Lg French Fries..................................................$7.00 Sm French Fries.............................................$4.00 Fried Dough ..................................... ...........$6.00 Fried Oreos...................................................$6.00 Fried Brownie Bites .................. . ......................$7.00 Fried Pickle Chips..............................................$7.00 Fried Mac & Cheese Bites................................$7.00 Pulled Pork Sandwich......................................$9.00 Grilled Chicken Kabob Sub .... . ..........................$8.00 Grilled Teriyaki Chicken Sub.............................$8.00 Soda& Water.................................................$2.00 Gatorade.............. ......................................... $3.00 N � � n � w fC'71M fR m 0 W fin m capa n � Q W t�fr "{7 Q W f�D CL 7 L1. 4 Q n N N ul Iq owl 0 N N No O ig ^+� X OD co Cl) co . ) 0 � M