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HomeMy WebLinkAboutMinuteman Kettle Corn - 12/31/2021< % y U 6 J ° JUL '� 5 Zo2r FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit !�f Mobile Food Establishment (MFE) Permit Application (Application must be submitted at least 14 business days before the planned opening date) 1) MFEName: Mlnb Pallan Oki, earn 2) Applicant/Owner Name B Title: 7 AA. Ettivin" - Applicant(OwnerAddress: 74 W , ' Applicant/Owner Telephone No: s � 05 ApplicantJOwner Email address: I tl 3) Person In Charge of Onsite Operations & Title: S PIC Address: 5 -b / PIC Telephone No: Emergencylonsite Telephone No: S ,r PIC Email Address: 4) Location of Service: d � , � s, �• n/1 J� al, t • l f' t Ut n R!1 Dates) if applicable: O Z Ois i�l S t ( i Event Name if applicable: Oh � W / "tl) t ltjf lG Event/ Service Location: S S , B Event/ Service time: All EvaNi,-a s (Slul�i-ri+t� V'unlz�� " rri 3.3d -5.3a 6) Length of Permit 6) Solid waste disposal plan: p , /ar16'C G 1�11� Annual vyiwcesm 0 Temporary �CdJ,nfllS50ry (t/µ FYN 20 ff,,00 $ �� • �(/UYU'S'ia� !��' i���° fj Dates: ( 7) Water Source: ALL pL+}&W—Wwab—lf— 8) Sewage disposal plan: `()vNrttKsr<rxl C W RP 14-- 0rc+,-Cfs si-•I I. 0yosbR- At4-016Lj� 9) Food will be prepared: Onsite for immediate consumption = 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 % �4�BrriE6" / •t'b%�%�J [0 Other.. e t>✓l O�'•r VV UV 10) Please attach a menu or a website link to the menu or give a brief description of the food to be served: hertz- Litz t'o ect c�eiil -L'rm ) S+pc� 4,1 10'peorn ) Liw-EzLeke-j Ulztr�CcuA MuGf2= �-v�C�rG�eA-frz�lt CN�•�rvrt-czt�Jr1,9�S/ �t;firAcQ ktG�Yz. H/HL6 {tom r ^" 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager. �tSCxr+s, Allergen Awareness. n jam(i u bf 12) Please describe on site hand washing facilities that will be utilized: Wt byq A <i h(nitd N "k tV6,4 ('ousts/- oWISIVi/4j fil&61411A C&I kakAvlo&> 10def G//J/1� ,Halyd 'oaf) 31 � re : p to pj- tiuPJ w(AA = zp�& Cud jxcslu l5 t�ee<Q �pr icQ I✓{1 1 �GtO(��is c%s�oszdl d(� (!N/tsH�sst�y 25 Fra�nsSf. k/ev�sE ai6P6 13) Please list all sanitizing solutions that will be on site: ChlorlKe-/i at?,r Sc4f76, 96-0pml GIL edtSUiz lad/> w/SGiil�i?e-Y i5 14) Do you have propane, fryolators and/or hoods on your truck? AM If yes, you must first be inspected and approved by the Mansfield 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: ,n,/t ('�vy,�15sGw�� ouM u� 4�Oe^C�sf�)z ions f;vd Hob 25 Tr6oasSf./ Wdvies� Mn wid eomZ Fo - (Fals t d l s 16r-&,& ) M(4ftP er pl'1)(eC 4WS ed-Akl'- and prael-tad le 7awl . 16) Location of Base of Operations or Commissary: tNrnYtZtc itC� a,JEnd 6f 26hw or }inl[WDa RAC/A Please attach copies of Base of Operations or Commissary Permit V) Please list additional communities where a food permit is held: �"a/ya !t jZ A i A- .AiurCx�Fot� ►A� 1, the undersigned, attest to the establishment operation will co'. the board of health on how to 0 18)Signature racy of the information provided In this application and I affirm that the food with 105 CMR590.000 and all other applicable law.1 have been Instructed by copies of 105 CMR 690.000 and the federal Food Code. Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. •' 19) Social Security Number or Federal ID* t�%—L i�7Er�U 20) Signature of Individual or Corporate Name: AAmA.0mah 1.6,flP ct7ryl 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. A IVj(J him V/11& 6*1 1--P 4AA) Signature of Individual or Corporate Name By. &4orate Officer (Mart story, if Applicable) -SV SA4,. M , -F [I Vol H7- gobO�,,)y **Social Security No. (Volrintary) 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:\Us \s1eiteWes1"p\8cotrs Do ents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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 statementsthat 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 checkout bags to customers. V 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. --- Z-1 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. /f 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 _ I Lt A cu, D 7l� -- n Date: OL Applicant Name (please print clearly) 81 S(A la yJ� The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UIV ttnvtt:massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: IvtIA MIaM VPAftQ tr 6r" City/State/Zip:, Are you an employer? Check the appropriate box: Ln I am a employerwith employees (full and/ _nor parttune) * 2. % I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp, insurance required]' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #: 50k- Business Type (required): 5. ❑ Retail 6_ ❑Restaurant(Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment lo.❑Manufacturing I Ln Health Care p 12. ]❑&er Me �rI r-oLi *Any applicant that checks box #1 must also fill out the section below shoving their workers' compensation policy information. **Ifthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box#1. - I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Insurees Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 andpenalties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or tows oguzol 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 Phone www.mass.gov/dia GREASE TRAP CLEANING GUIDE (UNDER 50 GALLONS) 2,5 fr6Lanccs 5 — /wUrfe56-t t+w 61bo. Why Should Your Grease Trap Be Cleaned Frequently? Reduced odors:The longer waste stays in a grease trap, the stronger the odors become. Longer Trap Life: Rotting foods create acids that can deteriorate the internal components of the tank. This reduces the lifespan of the trap, leading to higher maintenance and/or replacement costs. Easier Cleaning: Frequently cleaned and maintained traps are easier to clean. No Clogs or Backups: Regular cleanings help reduce blockages in sewer pipes and backups due to clogged lines. Tools/Materials Needed: Hex Head Wrench • Flathead Screw Driver or Pry Bar • Scraper or Putty Knife • Paper Towels • Trash Can with Heavy Duty Trash Bags or Container with a Lid • Absorbent Material (kitty litter or another type of granular absorbent) • Wet/Dry Vac or Scoop for Removing Contents of Grease Trap Preparation: 1. Develop a maintenance schedule and adhere to it. Typically, inspect the grease trap once a week and clean no less than every month. 2. Clear area around grease trap of debris, bottles, cleaners, etc. 3. Line a trash can with a heavy duty trash bag and add the absorbent material to the bag. The absorbent material will soak up some of the liquid and make the transport to the dumpster cleaner and safer. Make sure to check with the waste hauler before disposing of the removed grease trap contents. CONTINUED ON OTHER SIDE Cleaning the Grease Trap: 1. Shut off the flow valve if available. 2. Remove the cover of the grease trap. Observe how the internal parts are installed because they will need to be reinstalled after the cleaning. 3. Remove all of the solids and liquids from the grease trap by scooping by hand or vacuuming them out, and place them in the trash bags or container. 4. DO NOT use hot water, degreasers, detergents, or soaps to clean the trap. 5. Scrape the interior walls, baffles, and screens to ensure easy flow of water through the grease trap. 6. Inspect the condition of all internal and removable parts. Schedule repairs and replacements if needed. 7. Reassemble the internal components of the grease trap. 8. Clean and inspect the gasket and replace if necessary. NEVER use tube silicone as a gasket. 9. Make sure gasket is positioned correctly and put the cover back on the grease trap. Make sure all the screws are properly tightened. 10. Add additional absorbent material to the heavy duty trash bag or container if needed. Securely tie the bag so the contents won't spill or leak. 11. Gently place the bag or container in the dumpster or designated disposal area. DO NOT dump grease into floor drains, toilets, storm drains, ponds, outdoor areas, or sinks not connected to grease traps. 12. For larger grease traps or grease interceptors, contact an approved grease rendering company to remove and properly dispose of the grease. IReporting and Documentation: I • Grease cleaning maintenance logs and a list of approved grease rendering companies can be downloaded at http://www.worcesterma. gov/e-services/document-center/housing-health • Maintain and keep the cleaning documentation at trap location and provide with future food permit application renewals. L] City of Worcester, Massachusetts Grease Trap / Interceptor Maintenance Log *Exterior Grease Interceptor Must Be Inspected Monthly and Cleaned Every Three Months (Min.) or When 25% Full *Interior Grease Trap Must Be Inspected W eekly and Cleaned Monthly (Min.) or When 25% Full FACILITY NAME: ADDRESS: PHONE: LOCATION OF INTERCEPTOR: DEPTH OF WATER IN UNIT (INCHES): Date Performed Description of Work Depth Of Grease (Inches) Depth Of Solids (Inches) Manager's Initials * Copies of this maintenance log and an approved grease rendering company list can be found at: htin`l/wwwv�arcest rrna.�ovle-servic s/document-center/housing-health !' i § »! � \ f {a� a EES- an *&!:\ >.! \ 5`0 \ woo - @<Oc { \w\/ \ 2 ® & ©e o C) }� 0 M gp� I I � � I 0 l< O a n --i o CL 4D (D CD n a$ 0) c (D < (D 0 C) 0 3 (D r1t, o- (D rl- QL 0 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE PO BOX 7010 BOSTON, MA 02204 o� MINUTEMAN KETTLE CORN a 5 DALY ST �® WORCESTER MA 01605-3203 Dear Taxpayer, 4030 Notice Dale: 05/23116 Taxpayer ID Number: 474 060 664 Below please find your Sales Tax on Meals and All Beverages Registration Certificate (Form MT-1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of Revenue Massachusetts Department of Revenue MT-1 Customer Service Bureau. PO Box 7010 Boston, MA 02204 c �gvogma ya Y�<CRx{ k-yr� Yce"' ��yR {,.,(7 c � ♦ �iT^i+k-^i� �iiw`a3�nCi'`cu91a '"s e' .iye ,y Y�g� �kTaFt k... )%.��� ". IW�� _ _. .�:: �4-➢..».+t.%k£: _ _ �'i:...,. .�. - tVt c'A� . kg_ The vendor herein named is registered to sell meals and beverages pursuant to the General Laws, Chapters 62C and 64H. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct MT-1 can be issued. IDIINT➢IC TION MINUTEMAN KET T1,E CORN NUHaaa 5 DALY STREET 474-06D-654 WORCESTER MA 01605 ISSnR DATE 04/15/16 This registration must be displayed for customers to sco and is not assignable or transferable. COMMISSIONER OF REVENUE 3/30/2021 CITY OF ® �° MA r d 4 • Deparhnent of Inspectional Services 25 Meade Sheet, Worcester, MA 01610 �*r Phone: (508) 799-1198 - k .� FOOD ESTABLISHMENT PERMIT PIN: 280134 PERMIT EXPIRES. December 31, 2021 EFFECTIVE DATE: January 1, 2021 PERMIT FEE: $V_6 2021 In accordance with Regulations promulgated under authority of M.G.L- c. 94, ss 305A; c.111, ss. 5123A,105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder MINUTEMAN KETTLE CORN Name of Food Establishment MINUTEMAN KETTLE CORN Address of Food Establishment 25 FRANCIS SY OPERATIONS PERMITTED Comments: ATTN: LOCAL PERMITTING AUTHORITIES, THIS PERMIT IS FOR A COMMERCIAL KITCHEN LESSEE AND IS VAUD ONLY Restrictions: UPON THE VERIFICATION OF FOOD HUB MANAGER SHON RAINFORD 508.667-5792 OR BY EMAIL info@worcestedoodhub.org Common Notes: Nottlication of Changes: This permit Is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this business is to dose or there is a change in ownership, The DIS must be notified at least two weeks prior to dosing and this permit must be returned to the DIS. Director of Housing and Health Inspections 1/1 May 5, 2021 Minuteman Kettle Corn is a member in good standing of the Worcester Regional Food Hub. Minuteman Kettle Corn uses the Food Hub's commercial kitchen as its base of operations and commissary kitchen. Please contact me if you have any questions. Sincerely, Shon Bamford Director WORCESTER REGIONAL FOOD HUB, 25 FRANCIS STREET, WORCESTER, MA 01606 (508) 667-5792 INFO@WORCESTERFOODHUB.ORG 5/15/2021 CITY OF WORCESTER, MA m Department of Inspectional Services r , k S� 25 Meade Stree4 Worcester, MA 01610 tines , cfi Phone: (508) 79&8539 k�,:vi FOOD ESTABLISHMENT PERMIT PIN: FM-134 PERMIT EXPIRES: Apri130 2022 EFFECTIVE DATE: Mav 94 2021 PERMIT FEE: 250 2021 In accordance with Regulations promulgated under authority of M.G.I. c. 94, as 305A; c. 111, ss. 5 123A, 105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder Susan Flym Name of Food Establishment MINUTEMAN KETTLE CORN Address of Food Establishment _ I OPERATIONS PERMITTED DURATION OF PERMI Comments: Restrictions: Common Notes: Renewal of Permit: An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the expiration of the permit Notification of Changes: This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior to closing and this permit must be returned to the DIS. Director of Housing and Health Inspections 1/1 Food 11ShMent InSpecdon Reporl - Ofty of Worcester k : l Establishment Date: Page l of Address: a,7-- Time in: Time out Telephone: _ :, Number ofMolated Provisions Related to to Foodborne Illness Risk Factors Owner: - s' - t t and Items I through 29 : Person -in -charge: Number of Repeat Provisions Related to Foodborne Illness Risk Factors Inspector: ,.` i . , ,� �,,� yr: .;:- ,� ? and Interventions (Items I through 29)- Typetf 00eration(s): ❑ Food Service Establishment ❑ Retail Food Store ❑kii68e/Pusbcart ❑ Temporary Food Fstablis6ment ❑Other Type of Inspection: 0,110 -rne ❑ Re -inspection ❑ PmOpemtional ❑ Illness Investigation - ❑ General Complaint ❑ HACCP ❑ Other FOOD$OI IE ! -, 88 RISK PASTORS -ND PUBLIC HEATH INTisRVI?AtTI®�T$ '" , IN = in compliance OUT= out of compliance NIO = not observed NIA = not applicable COS = corrected on -site during inspection R= repeatviolation Compliance Status I IN'OUT N/A / CO R Supervision's. 1 __ Person-in-chargepresent, demonstrates Knowledge, and performs duties 1 - 2 Certified Food Protection Manager .',; EmployeeHeaJt6 . 3 Management, Food employee and conditional employee, knowledge, Responsibilities and reporting _ s J,,] 1 roper use of restriction and exclusionrocedures 1di for responding to vomiting and arrheal events Good HygienicPiadims 6 Proper eating, tasting, drinking, or tobacco use 7 No discharge from eyes, nose,. and mouth ' "Pieventing Cuntaminarronbyllands 8 Hands clean & properlynashed 9 No bare hand contact with ready -to -eat food 10 Adequate hand -washing sinks properly supplied and accessible TPPtnredsaurce -, �,.: _ 11 Wood obtained from approved source 12 Food received at proper temperature 13 Food received in good condition, safe, & unadulterated 14 Required records available: shellstock tags, parasite destruction Compliance Status IN OUTN/A !i, 10 O 11 Psutecuonhvm Cunt@ntinatian - _ 15 Food separated and protected 16 Food -contact surfaces: cleaned & sanitized _ Proper disposition ofreturned, ,r-'•''` 17 previously served, reconditioned & - unsafe food TunvR'egrpztaln;g Control or 6at41F',.. I8 Proper cooking time & temperatures: - Proper reheating procedures for hot 19 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 �` Cootiumer 4dsiwry - Consumer advisory providedfor raw ( 25 undercooked food ;I;fg6l➢Snscepti6lePnpalations -. 26 of arered ze too s used, prohibited oo not TT FoodJCplorAdditiees aid%rlrSubstan«s ,..^' r Food additives: approved & properly used Toxic substances properly identified, stored - & used 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 Food Protection Inspector constitutes an order of the Department of Inspectional Services. 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(11). Date of Reinspection Discussion with Person -in -Charge: Signature of Person-inrCharge • ; 'rp 21 j Date: bPt =1 Signature pfinspectar _ -- Date: Ned EStablishment Inspecdai Establishment: IN = in compliance OUT= out Other Information: mod - ON d Worcester Date: Page 2 of not observed N/A = not applicable COS = corrected on -site during inspection R = mpeat violation 3ignatore of Person -in -Charge: Date. signature of Inspectoe Date• item Location Temp (OF) Item Location Temp (OF) item Temp (OF) Violations cited in this report most be co=ted urithin the time frames stated belour or in Section 8-405.11 of the Food Code Item Nmber Section of Code Description of Violation Date to Correct By Signature of Inspectorr' Date. Ac�R� CERTIFICATE OF LIABILITY INSURANCE tta�4rtw" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEA CONTRACTBEIWEEK THE ISSUING ONSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: lithe certificate holder ism ADDITIONAL INSURED, the poricy(ies) must haVeADDTTRONAL 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 Neu of such endorsemerd(5), PRODUCER NABS Commercial Lines Prascottand Son lneimareAgemy.1m 883 Eastern Avenue PHONN E:1 (781)3222350 (FAz-�- FAX At) E - Malden MA 02148 _ INSURERIS)AFFOItgN6COYf=eK •—_— NAIC# INSURERA- Mourd Vernon Fre Ins CD INSURED INSURERS: Susan Flynn, DBIL Minuteman Kettle Com INSURER e- 5DalySL mSURERD: INSURERE- Vlbmester MA 01605 MUFF- _ COVERAGES CERTIFlCATFNI1MQIPR• CL2152130759 .. _._._._ .........— THIS IS TO CERTIFY THAT THE POLICIESOF INSURANCELISTEJ BELOW HAVE BEEN ISSUEDTOTHEINSURED NAMEOABOVE FOR THE POUCYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OFANYCON RACTOR OTHER DOCUMENT WITH RESPECT70WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCEAFFORDED BY THE POLICIES DESCR93ED HEREIN ISSU6AECT TOALLT14E TERMS, ECCLUSIONSAND CONDITIONSOFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIM TYPEOFRSURANCE INSD IWD POUCYRUMBER PoUcY ITF Olt EXP Usms A WMM9iCNLGE1f3RA1.UA&LIIY CINMSAI/AE ® OCCUR CL 267BUSF DWIW021 EACH OCCIIRiENCE�- S 2,000,000 ThTB PREWSES "arooumnoa S 100,000 MEDEXP(Aff. u) S 5,000 06/19/2022 PESONALaADVINAINY s 2,000.0DO GENLAGGREGATEUMITAPPLIESPM POLICY ❑ � ❑ LOC OTHER - GENERALAGGREGATE S 2,000,000 PRODUCTS-COMPIOPAGG S Included AUTOMOBILE uABN.LTY ANYAUTO DINNED S(XIM "I AUTOSONLY Autos HIRfD NO COM O AUTOS ONLY AUTOS ONLY COP.nIMEUSi UMR f jemded S GODLY INAIRY(Perpnsm) S BOOLYPLURY(Perarddml) S PROPERLY DA6N(i ecdde"d S S U111 UAB EXCESSIIAB OCCUR GNMSMADE EACHOCCURRENCE S AGGRCGATE S DIED RETENTION S S WORREts COMPENSA11pN ANDEMPLOYERSUABLnY YIN ANY PROPRETOLUPARTNEREXECULME OFPICEROAENBEREX.CLUD®Y ❑ 9AaMatary iotLll) Nyes, desaipeunder DESCRIPTIONOFOPERATJ N beJ" NIA PFR OTH- STATUtE ER EL FACHACCIDENT. 5 EL DIBEABE-FA EMPLOYEE S E.L. DISEASE -POLICY LIMIT 5 DESCfdFilON OFOPERAiWNS/LOCATIONSIVinICLS (ACORD 10f,Addnional Rammksedceduigmey ire alWCM1ad IImore epnceiseaquued) SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEPDRE THE EXPIRATION DATE THEREOF NOTICE WELL BE DELIVERED IN Minuteman Kettle Cam ACCORDANCE WITH THE POLICY PROVISIONS. 5 Daly Street AUTHORLMD REPRESEITATNE Wanxstm MA 0160 1 ty/oAaYN-ac./.J+�.+�d-fo-2.r<i.14� 09988+2015 ACORO CORPORATION 011 .:,.Me.n�e...ed ACORD 25 (2016103) - The ACORD name and logo are registered marks ofACORD