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HomeMy WebLinkAboutNE Sportservice, Inc. Xfinity - 12/31/2021 (2)--------- FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) j 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 FI., Buffalo, NY 14202 i 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 GM cell: (401) 644-2553 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 Q An Association partner. IN A Corporation Name Title Address O An Individual Please see the attached officer & direct list. d A Partnership OO Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:.General Manager Albert Fera i Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 644-2553 FAX: (508) 261-7799 E-mail: afera@delawarenorth.com Alt E-mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: i 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: GM Albert Fera If more than 3 Individuals are certified, complete list is on file. Also, Jaime Rivera and Jonathan Imes --- -._.-..---- _ �— ---- Person Trained In Anti -Choking Procedures (if 25 Seats or more): I?� Location: N Permanent Location 13 Mobile Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: ® Annual l.. Seasonal Seasonal Dales; Temporary Stan Date: Temporary End Date: TemporaryTime;. Rain Dater Establishment Type: Retail -NO FOOD PREP ( Sq. Ft) $1 Q Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Q Food Service for 101 -200 seats $26( N Food Service for 201+ seats $300,00 Q Supermarkets $400 FMI Caterer$35.00 ® Milk & Cream $10.00 ® Mobile Food Consession NO PHF PREPARED ON SITE $100.00 0 Manufacture Frozen Dessertstice Cream $25.00/freezer t"A Pushcart $50.00 # of Pushcarts: to Residential Kitchen $100.00 [FA1 Tobacco Products $150.00 0 Retail Snack Food $50.00 Food Operations: Definition:PHF - Potentially hazardous food(tlme4emperature contaxrequired) Non-PHF's - non -potentially hazardous food(no dmartempemfure controls required) Check all that apply): RTE - reedy-lo-eal foods (Ex. sandwiches, salads, muffins which need no lunher processing) f,0] Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order to Hot PHF Cooked and Cooled or Hot Held — ---- _-�-- for More Than a Single Meat Service Sale of Commercially Pre -Packaged PHFs le Preparetion of PHFs Far Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared Far Highly ® Delivery of Packaged PHFs Susceptible Population Facility -_ •-• -- Q Sale of Raw Animal Foods Consumer Mended _ Reheating of Commemially - _ "`" " Processed Foods for Service Within 4 Hours to be Prepared by Consumer Q Vacuum Packaging !Cook Chill Perishable Foods Only Other Food Operations Main Kitchen & Commissary ----i N Use of Process Requiring A Variance Self -Service and/or HACCP Plan (including bare hand sctured and Packaged for contact alternative, time as a public health Retail Sale ( Juice Manufactured and Packaged fort Q Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Retail Sale of Salvage, t or Reconditioned Food I, the undersigned, aitesl to the accuracy of the information provided in this establishment operation will comply with 105 CMR 590.000 and all othej ar board of health on how to obtain copies 9110*VMR 5j)0.000 anytthe der Q Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: Payment is due with application n waived Ion and affirm that the food law.. I hape been instructed by the Signature of Applicant:.. . 1 Pursuant to MGL Ch.62C, sec. 49N I certify un. r the penalties of perjury that I, to my best knowk4e 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. C FOR BOARD OF HEALTH USE ONLY permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening 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 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, NY14202 Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: Applicant Email: Beth Salansky GM cell: (401) 644-2553 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 0 An Association partner. M A Corporation Name Tide Address ED An Individual Please see the attached officer St director list. ED A Partnership EI Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: General Manager Albert Fera Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 644-2553 FAX: (508) 261-7799 E-mail: afera@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: WATER SOURCE: Town DEP Public Water Supply No: (If applicable): Food Establishment Information SEWAGE DISPOSAL. No, of Food Town wil DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: GM Albert Fera If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera and Jonathan Imes -- Y -- - Person Trained in Anti -Choking Procedures (If 25 Seats or more): t I Location; 0 Permanent Location Establishment Type: 4x Mobile Mobile Start Date;- Retail -NO FOOD PREP ( Sq. Ft). $1 Mobile End Date: Q Food Service up l0 100 seats Mobile Comments: INCLUDING FOOD TRUCKS $175A0 ( Length of Permit: to Food Service for 101 -200 seats $250, i ® Annual j---------------- - [M Food Service for 201+ seats $300.00 01 Seasonal Seasonal Dates, Temporary Start Date: Temporary End Dale; Temporary'nmei. Rain Date: Supermarkets $400 Q Caterer $35.00 xt Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/ice Cream $25.001freezer Pushcart $50.00 tk of Pushcarts: Residential Kitchen $100.00 Tobacco Products $150.00 Retail Snack Food $50.00 Food Operations: Definitions: PHF - Potendakyhezardousfood (Inerlemperalure controls required) NomPHF's - non-poteal/airy hazardous tood(no dmerlemperature controls required) Check all that apply): FITE- ready -:seat foodsfEx. sandwldhes, salads, muMds which need no furtherprocessinq) Sale of Commercially Pre -Packaged Non-PHFs ❑D PHFCooked To Order QQ Hot PHF Cooked and Cooled or Hot Held ---=--m--=-- - -- for More Then a Single Meal Service 1 Sale of Commercially Pre -Packaged PHFs i+ Preparation of PHFs For Hot And Delve of Packaged PHFs Cold Holding For Single Meal Service f1 PHF and RTE Foods Prepared For Highil ❑ Delivery 9 Susceptible Population Facility ------------------------ ft Sale of Raw Animal Foods Intended ______ Reheating of Commercially to be Prepared by Consumer ]Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours —.--.-_.- Customer Seff-Service of Non PHF and Non- 101 Car Perishable Foods Only G:il Ice and/or HACCP Plan (including bare hand contact alternative, time as a public health ] Preparation of Non-PHFs Retail Sale V VY V e Other Food Operations r Juice Manufactured and Packaged for ® Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Full Menu - —'- ] Prepares FoodlSingle Meals for Q Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service 0 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 ] 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 9L105 CMR 590.000 antttrle federahFood Coda. Signature of Applicant. `'�T Pursuant to MGL Ch,62C,.sec. 49A, I under the penalties of perjury that 1„ to my bes nowledge and belief, have Hied all state tax returns and paid state taxes required under law. Social Security Number or Federal lot 04-3466949 Signature of Individual or Corporate Namw New England Sportservlce,Inc. FOR BOARD OF HEALTH USE ONLY Permit # Issued Ito FOOD ESTABLISHMENT PERMIT APPLICATION (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 GM cell: (401) 644-2553 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 0 An Individual Please see the attached officer & director list. O A Partnership OO Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: General Manager Albert Fera Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 644-2553 FAX: (508) 261-7799 E-mail: afera@delawarenorth.com Alt E-mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: Town DEP Public Water Supply No:, (If applicable) DAYS/HOURS: Varies by event being held SEWAGE DISPOSAL: Town No. of Food Employees: 280 Name of Person In Charge Certified in Food Protection Management: GM Albert Fera If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera and Jonathan Imes Person Trained in Anti -Choking Procedures (if 25 Seals or more): no Locatfon; ® Permanent Location Establishment Type: Mobile Mobile Start Date: r.'s Retail -NO FOOD PREP ( Sq. Ft) $1 Mobile End Dale: FUl Food Service up to 100 seats Mobile Comments: INCLUDING FOOD TRUCKS $175,00 Length of Permit. M Annual Q Seasonal Seasonal Dates; Lj� Temporary Temporary Start Date: Temporary End Date:. Temporary7fine: Rain Date: rn Food Service for 101 -200 seals $25C IN Food Service for 201+ seats $300,00 Q Supermarkets $400 E Caterer$35.00 tit Milk & Cream $10.00 di Mobile Food Consession NO PHF PREPARED ON SITE $100.00 El Manufaclure Frozen DessertsiIce Cream $25.00/freezer B Pushcart $60.00 # of Pushcarts: E Residential Kitchen $100.00 lu Tobacco Products $150.00 n Retail Snack Food $50.00 Food Operations; Oenndlons:PHF- Potendeffy hazardous trod fdme4emperature controls required) Non-PHF's -non-potenlfeiy hazardous roodfno #mMemperatum controls required) Check all that apply); RYE- ready-to-eal foods (Ex. sandwiches, seleda muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFa vl PHFCooked To Order Ea Hot PHF Cooked and Cooled or Hot Held ---��---s�— - for More Than a Single Meat Service Q Sale of Commercially Pre -Packaged PHF: U+ Preparation of PHFs For Hot And DeliveryEg of Packaged PHFs i Cold Holding For Single Meal Service ;•= PHF and RTE Foods Prepared For Highly g r,..-.-_,.,_.__._,___,.-__._,_.__._., Susceptible Population Facility of Commercially Foods for Service Within 4 Hours Customer Self -Service of Non PHF Perishable Foods Only Other Food Operations Full Menu to be Prepared by Consumer L; Vacuum Packaging I Cook Chill -- ----- Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (Including bare hand Ice Manufactured and Packaged for I contact alternative, time as a public health - Retail Sale g] Juice Manufactured and Packaged Retail Sale I Pill Offers RTE PHF In Bulk Quantities I Retail Sale of Selvage, or Reconditioned Food Offers Raw Or Undercooked Food Of Animal Origin _. Prepares FoodtSingle Meals for Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: Payment Is due with appliwtlon n waived 1, the undersigned, attest to the accuracy of the Information provided In this application and affirm that the food establishment operation w4i 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 VO CMR 590.000 V 3the federal FoACode, Signature of Applicant —r Vv tr - Pursuant to MGL Ch,62C, sec, 49A; 1 certify under the penalties of penury that 1 tom t 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 $portseryice, Inc. FOR BOARD OF HEALTH USE ONLY permit # Issued l FOOD ESTABLISHMENT PERMIT -APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: New England Sportservice, Inc. @ Xfinitx,Center Upper Woodside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., ,;Atn: 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 GM cell! (401) 644-2553 Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: O An Association 0 A Corporation 111 An Individual O A Partnership G Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Please see the attached officer and director list. Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: General Manager Albert Fera Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: cell: (401) 644-2553 FAX: (508) 261-7799 E-mail: afera@delawarenorth.com Alt E-Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town I DEP Public Water Supply No, (if applicable) L No. of Food Employees: 280 DAYS/110URS: Varies by event being held - ----- _._...-.---_-___—___ j Name of Person In Charge Certified in Food Protection Management: interim GM John Velez complete list is on file- Also, Jaime Rivera 17=_ --------- --- — and Jonathan Imes --- -.._ - - Person Trained in Anti -Choking Procedures (If 25 Seats or more): -- — ....................-- — — Establishment Type: ® Caterer $35.00 Location: Z] Permanent Location sa Mobile Mobile Start Date: F1 Retail -NO FOOD PREP ( Sq, Ft) $12 [] Milk & Cream $10.00 j Mobtle End Date: Food Service up to 100 seats ® Mobile Food Mobile Comments: INCLUDING FOOD TRUCKS $175,00 NO PHF PREPARED OON N SITE $100.00 Length Permit: r, Food Service for 101 -200 seats $250.00 i Manufacture Frozen Desserts/ice Cream ❑ $25,00/freezer Annuall -. Food Service for 201+ seats $300.00 H Pushcart $60.00 # of Pushcarts: 8 Residential Kitchen $100.00 -- r Seasonal Seasonal Dates: _ , ® Supermarkets $400 Q Tobacco Products $150:00 Retail Snack Food $50,00 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Oepn/tlonsr PHF-Pgtentiallyhazardous food(tlmaRempera(ureeontrots required) NOrr+PHF's - non-potentislty hazardous load(no dri eRemperatare cnnlmis required) (Check all that apply): RTE, reedy-lo-eat roods (Ex sandwiches, salads muMns which need no ludherpmceasing) [51 Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order &I Hot PHF Cooked and Cooled or Hot Held for More Then a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs - r<r Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ❑ n' • �-------- Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer ® Reheating of Commercially "-- � -'"�"' —'—'-- ®Vacuum Packaging I Cock Chill Processed Foods for Service Within 4 Hours - :i Customer Self-service of Non PHF and Non- — .—.._..— ❑Q Customer Self -Service Use of Process Requiring A Variance- and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health -- ---— -- I] Ice Manufactured and kag Paced far Preparation of Non-PHFs Retail Sale control) Juice Manufactured and Packaged for Q Offers Raw Or Undercooked Food Of Other Food Operations 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 6 - - or Reconditioned Food Board of al e completed bThe Health Y rTpoa't�'l Permit Fee: p 3 ment Is due with a licationwaived—._-,--..�-.�..-.�,.. I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 106 CMR 590.000 and all other applicable law, I have been Instructed by the board of health on how to obtain copies of 590.000 and t federal Food C Signature of Appllcant,105 MR b, , kj_ Pursuant to MGL Ch,,62C, sec. 49A, I certify unVW1he penalties of per ury that I to my best Wkowledge 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 5portservice, Inc. FOR BOARD OF HEALTH USE ONLY Permit # Issued (mil FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days be ore the planned opening date) Establishment Name: New England Sportservice, Inc. @ Xftnity Center Courtyard Establishment Address: 885 South Main Street, Mansfield, MA�02048 Establishment Mailing Address (if different): 250 Delaware Ave., .ttn: 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 GM cell: (401) 644-2553 bsalansk@delawarenorth.com Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: O An Association (N A Corporation O An Individual 0 A Partnership E) Other legal Entity — - ----- ------ If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Please see the attached officer & director list. Person Directly Responsible For Daily Operations (owner, person in'charge, supervisor, manager etc.) Name & Title: General Manager Albert Fera Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 HourFmergency No: cell: (401) 644-2553 FAX-: (508) 261-7799 E-mail: afera@delawarenorth.com Alt E-Mail: bsalansk@delawarenorth.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL, Town DEP Public Water Supply No: (if applicable) _.._..__.�_.__..._.... No. Of FOOd Employees: 280 I DAYS/HOURS: Varies by event being held Name of Person In Charge Certified in Food Protection Management: GM Albert Fera If more than 3 individuals are certified, complete list is on file. Also, Jaime Rivera and Jonathan Imes ( Person Trained in Anti-ChoRing Procedures (If 25 Seats or more): (John Velez is working on obtaining this.) Location: Q Permanent Location Establishment Type: B Caterer$36.00 j{@Mobile Mobile Start Date: Q Retail -NO FOOD PREP( Sq. Ft) $125 ® Milk & Cream $10.00 Mobile End Dated G Mobile Comments: Q Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 ' " ' "' '•— "' `"' 1 Length of Permit: Q Food Service for 101 -200 seats $250.00 �,, Manufacture Frozen DessertsiIce Cream $25.00/freezer Da Annual -------- IN Food Service for 201+ seats $300.00 Q Pushcart $50.00 # of Pushcarts: , [] Residential Kitchen $100.00 --------- ------ `!. Q Seasonal i Seasonal Dates; M Supermarkets $400 [D Tobacco Products $150.00 Temporary E] Retail Snack Food $50.00 I Temporary Start Date: Temporary End Date: Temporary Time; Ram Date Food Operations: a Defailuc PHF- Potenflaly hazardous food(t/martemperature controls required) Non-PHF's - non-potanRa/y hazardous fxtatno ffmaRempereture controls inquired) ;Check all that apply): RTE-ready-l"atloods (Ex. sandwiches, salads, muffins which neadno farther processing) Sale of Commercially Pre -Packaged Nan PHFs as PHF Cooketl To Order .® Hot PHF Cooked and Cooled or Hot Held -- -- �— - - --�—-a•�-- for More Than a Single Meal Service Delivery of Packaged PHFs of Commercially Foods for Service Within 4 Hours Customer Self -Service of Not Perishable Foods Only Other Food Operations Full Menu I, the undersigned, attest to the establishment operation will com board of health on how to obtain Cold Holding For Single Meal Service I U PHF and RTE Foods Pr Sale of Raw Animal Foods Intended Susceptible Population ..-._-...----a---�---- to be Prepared by Consumer � Vacuum Packaging f Cc and/or HACCP Plan (including bare hand contact alternative, time as a public health - Retail Sala I conrro0 ❑C Juice Manufactured and Packaged for ® Offers Raw Or Undercooked Food Of Retail Sale I Animal Oriain PHF in or Reconditioned Food f of the Information provided In this 105 CMR 590.000 and all other op of 1p5 CMR 590.000`W the feden ® Prepares Food/Single Meals for Catered Events or Institutional Food Service Total Permit Fee: Payment is due with application n waived on and affirm that the food law. I have been Instructed by the Signature of Applicant. t'V- Pursuant to MGL Ch.62C, sea 49A,1 certify der the penalties of perjury that I, to my est 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. FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days bLore the planned opening date) Establishment Name: New England Sportservice, Inc. @ Xfinft, Center Lower Woodside Food Establishment Address: 885 South Main Street, Mansfield, MA 02048 Establishment Mailing Address (if different): 250 Delaware Ave., m,ttn: 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 GM cell: (401) 644-2553 Owner Name & Title (If different from applicant): same Owner Address: Owner telephone number: Owner email: Establishment Owned By: O An Association IN A Corporation An Individual <] A Partnership Q Other legal Entity If a corporation or partnership, give name title, and home address of officers or partner. Name Title Address Please see the attached officer and director list. Person Directly Responsible For Daily Operations (owner, person f:: charge, supervisor, manager etc.) Name & Title: General Manager Albert Fera Address: 885 South Main Street, Mansfield, MA 02048 Telephone No: (508) 261-2900 24 Hoer c_-ergency No: cell: (401) 644-2553 FAX: (508)261-7799 E-mail: afera@delawarenorth.com Alt E-Mail: bsalansk@delawarenorth.com G*Wict Or Regional Supervisor (if applicable) Name & Tide: Address: Telephone No: FAX: E-mail: 24 Hour Emergeq�cy No: 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. GM Albert Feral If more than 3 individuals are certified, complete list Is on file. Also, Jaime Rivera and Jonathan Imes Person Trained in Anti -Choking Procedures (If 25 Seats or more); i Location: Q Permanent Location Establishment Type;. Q Caterer $35,00 Q Mobile Mobile Start Date; ® Retail -NO FOOD PREP ( Sq. Ft) $125 ® Milk & Cream $10.00 Mobile End Date:.. t: Food Service up to 100 seats E. Mobile Food Consesslon Mobile Comments; INCLUDING FOOD TRUCKS $175.00 © Food Service for 101 -200 seats $250.00 NO PHF PREPARED ON SITE $100,00 ® Manufacture Frozen DessertsiIce cream $25.00/freezer Length of Permit: DU Annual � Food Service for 201+seats $300.00 ®Pushcart $50.00 # of Pushcarts: MI! Residential Kitchen $100.00 ® Seasonal Seasonal Dates: Supermarkets $400 Tobacco Products $150,00 Temporary .� j Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations; Dadhillons: PHF- Potenffalty hazardous rood (GmeRemperature controls required) Non-PHFs - non-potentie(ty hazardous (nod(no llmaAempentore Controls required/ (Check all that apply): ATE - ready-fo-eef foods (Ex. sandwiches, salads, muffins which need no ru ther processing) 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 0 Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot Antl ®PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery of Packaged PHFs ry —"` Susceptible Population Facility O of Raw Animal Foods Intended too b be Prepared by Consumer of [] Reheating Commercially _. _-__.-.-_ ®Vacuum Packaging /Cook Chill . Processed Foods for Service Within 4 Hours 0 Use of Process Requiring di Variance and/or HACCP Plan (including belie hand ❑� Customer Self -Service of Non PHF and Non- p Customer Self -Service Perishable Foods Only contact alternative, time as a public health coma _ ®Ice Manufactured and Packaged for Retail Safe a Preparation of Non-PHFs Other Food Operations ® Juice Manufactured and Packaged for E3 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Full Menu Pre Food/Sin le Meals for Prepares P g I] Offers RTE PHFin Bulk Quantities Catered Events or Institutional Fond Service ❑® Retail Sale of Salvage. Out -Of -Data or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment Is due with application Ej 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 of at applicable law, I have been instructed by the board of health on how to obtain copies of 05 R 590.000 ahhnd thederal F od Code Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify un r the penalties of pedury that I, to my best k owledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal 10: 04-3466949 Signature of Individual or Corporate Name: New England Sportservice, Inc. Attachment to Town of Mansfield Food Establishment Permit Application New England Saortservice, Inc. it ct r Christopher J. Feeney Officer James C. Obletz Joseph M. Sims Nicholas D. Liberto Janice R. Trybus Title Director Title President Chief Operating Officer Vice President -Finance & Treasurer Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Obletz, James C. Residence: 925 Delaware Ave., #813, Buffalo, NY 14209 Sims, Joseph M. Residence: 6690 Cooper Road, Cincinnati, OH 45242 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127