HomeMy WebLinkAboutDel's Lemonade Xfinity - 12/31/2021FOR BOARD OF HEALTH USE
Date Received Permit Fee
Approved
## issued 111
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: Del',5 U i`!1vriade _ D6.4 Q H 5, L)K SAcThe
Establishment Address: i) n ; -r r r& v, d (l' e nc 6 Z61 !) ('j
Establishment Mailing Address (if different):
Establishment Telephone No: t A i -,Z 3 3
2) ApplicantlOwner Name & Title: ay Sv `' s/(q,, _ bW)rYe-/K"
A licant/Owner Address: # r
Applicant/Owner Telephone No:
Applicant/Owner Email address: e i f'V 41 e f S 0 911v i% , (L O'l
& Title: A d � CX 1,,),-)` r 1 C4 kCx"
3) Person In Charge of Onsitepp��
tOperatiions
PIC Address: qqf ,5dA-1 014) 5f bux0 S(1�61 1Ci2'My—
PIC Telephone No: - G/i y`y f Emergency/onsite Telephone No:
PIC Email Address: G- ek brc „i, t) q 6 (074
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4) Event Attending:
Date(s): � t� I Z t� J I{' 7 i O A�&4
Event Name:�d� r�
Event Location:'Tnkaid
Event time: �� w 5
5) Check one
O Food Truck
o Caterer
LAP" Other: C zf'-Rr
6) Solid waste disposal plan:
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7) Water Source: h
, i t'I
8) Sewagedisposal plan:
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9) Please give a briefdescription oftghe� food to be served:
��ryp (( Pppy6ap}i yy $✓i..'1P+��d✓('i?' 9$(j/ �ryp,{
"��(}°C/tp}h..,% pof f Ly��. oPtC%( -+ f ie(rl
10 ) Food will be prepared:
o Onsite for immediate consumption
o Onsite and held at proper hot/ cold holding temperatures
W" 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: 't� i4
Food Safety Manager: f
Allergen Awareness:
12) Please describe on site hand washing facilities that will be utilized:
(j1'i)d e er i needed
tvojt ' S. awl 0t9md
13) Please list all sanitizing solutions that will be on site:
J,VsoI � 'Pure,(
14) If applicable, please describe your FOG management plan or attach the written plan:
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15) For caterers: Cityrrown 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 Commissary permit:
C. adi Z<jQL,4d M EL
1, 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 obtain copip5'of Y0RMR 590.000 and the federal Food Code.
19) Signature of
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.
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20) Social Security Number or Federal ID: !
y v
21) Signature of Individual or Corporate Name:
Food Protection Questionnaire for Catered Events
Date of Event: Udy i N � Event Time:
Location of Event: )( I i it) ij ( 0 m ka,,r M tl h 1� -field
muil}f;ekq ` A 0&t'E-IF
List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location:
On ice/Refrigerated
Cooking Reheating
M j A NJ �4
Food Manager Certification Person Trained On Site? ft4es o No
Allergen Awareness Menu Label Present? M Yes o 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:
2 `P
How will the PHF be kept at or below 4l°F9 tll ff Pf t .0 ec4tit"
How will the PHF be kept at or above 140°F? d J /,f
Time of PHF? Setup Li; 6 u Served 7;p,�, //,-zx;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.
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.
Si re of Individual or Corporate Name
"*Social Security No. (Voluntary) or Federal
Identification Number
pd
By: rporate Officer (Mandatory, if Applicable)
*This license wilt 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.
the Commonweatrn ojmassaenuserts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: aR h m (ilia C{ J i 1 W rid S' 11
Address: 2ff ,WL'Od.i AJDj� l>`id) L'Lk)a,L T- be-4
City/State/zip: N QY A' S`(j ' k, Z1- Phone #: ti b f - Lf p � - 13-0
Are youan employer? Check the appropriate box:
Business Type (required):
1. I am a employer with employees (full and/
5. Retail
or part-time).*
6. estaurant/Bar/Eafing Establishment
2. ❑ I am a sole proprietor or partnership and have no
7.0 Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
[No workers' comp. insurance required]
3.M We are a corporation and its officers have exercised
9. Entertainment
their right of exemption per c, 152, § 1(4), and we have
10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
11.0 Health Care
4.n We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12.n Other
my 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
ganization should check box #1.
ran an employer that is providing workers' compensation insurance for lily employees. Below is the polley information.
isurance Company
isurer's
ity/State/Zip: lt 1 0V f ? )
alicy # or Self -ins. Lic. # (0 � , 6 C-f 4 D L-i 6 C) P Expiration Date:
ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigations of the DIA for insurance coverage verification.
do hereby cert{ly, undee theppairo and penalties ofperfury that the information provided hboye is true and correct
hone #: �' L:-cS -5-06,5-- €
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 Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contact of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit,
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
m Revised 5-26-05
THE .4
HARTFORD
THE HARTFORD
BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
RM Sukaskas Inc DBA Deis Pawtucket
28 WOODSONG DR
NORTH SCITUATE RI 02857-1840
Account Information:
Policy Holder Details: RM Sukaskas Inc DBA Deis
Pawtucket
July 7, 2021
%Q Contact Us
Business Service Center
Business Hours; Monday - Friday
(7AM - 7PM Central Standard Time)
Phone: (877) 287-1316
Fax: (888) 443-6112
Email; agency.services0thehartford.com
Website; httos://business.thehartford.com
Enclosed please find a Summary Of Insurance for the above referenced Policyholder. Please contact us if you have any
questions or concerns.
Sincerely,
Your Hartford Service Team
WLTRO06
THE`
HARTFORD
Account Policy Information:
Agency Name
AUTOMATIC DATA PROCESSING INS
AGCY
Agency Code
176250874
Recipient Information
RM Sukaskas Inc DBA Deis Pawtucket
28 WOODSONG DR
NORTH SCITUATE RI 02857-1840
SUMMARY OF INSURANCE
Account
Policy Recap
Policy Number
Policy
Term
Premium
Worker's
Compensation
05/30/2021 to
Trumbull
76 WEG AD4EDP
05/30/2022
$579
Insurance
Company
July 7, 2021
Sum of Insurance
Summary of Insurance (Continued)
Workers' Compensation Summary of Insurance
with
Trumbull Insurance Company
A member company of The Hartford
05/30/2021 - 05/30/2022
Policy Detail: Worker's Compensation
Policy States: RI
Location 1 Premises Address:
1173 A Douglas Ave
Providence RI 02904
Location 2 Premises Address:
446 Central Ave
Pawtucket RI 02861
Location 3 Premises Address:
28 Woodsong Drive
North Scituate RI 02857
Worker's Compensation Coverages:
Employer's Liability Limits
Disease - Policy Limit
Bodily Injury — Accident
Disease - Each Employee
Limit
$500,000
$500,000
$500,000
Class/Payroll
Class Description
Class Code
Payroll
Detail
Location 1 - RI
STORE- DAIRY
8006
$5,000
PRODUCTS - RETAIL
Location 2 - RI
STORE- DAIRY
8006
$5,000
PRODUCTS - RETAIL
Location 3 - RI
STORE- DAIRY
8006
$0
PRODUCTS - RETAIL
This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions,
limitations or exclusions. Please refer to the actual policy forms for detailed coverages, limits and deductibles.
Sum of Insurance
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
/3355931
b0.5
a'gpops://ecode360.com
s to customers. The entire bylaw can be found online at h3.
l . 5 I have received a copy of the Plastic Waste Reduction bylaw or a link to it. 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, The entire bylaw can be found online at
https://ecode360. co m/36687921
C5. 1 have received a copy of the Polystyrene Container Reduction bylaw or a link to it. 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. The entire bylaw
can be found online at https://ecode360.com/36687903
• �- I have received a copy of the Plastic Straw/Stirrer Reduction bylaw or a link to it. 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.
hApplicant Signature 66 —" Date: 77
jj77
Applicant Name (please print clearly) co i `/ 1 �'< C" Y y