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Home My WebLink AboutNE Sportservice, Inc.(FOG) Xfinity - 12/31/2021.,. -1 aR 173Moill Business/ Food Establishment Name: New England Sportservlce, Inc. Address:885 South Main Street, Mansfield, MA 02048 Mailing Address:250 Delaware Ave., Attn: Licensing, 12th FI., Buffalo, NY 14202 Phone/Fax Number: (508) 261-2900 Licensing: (716) 858-5162 Email: bsalansk@delawarenorth.com or GM - aferadelawarenorth.com Contact Person/Title for Grease Traps: Albert Fera, GM (401) 644-2553 cell Name of Company scheduled to pump internal grease trap(s) monthly: _ Name of Company scheduled to pump external grease trap quarterly: 3 1 Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and ackn led es that the information submitted in these documents is true, accurate n12Z omplete. Sign Date Print Na A rt Fera, General Manager 1 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): 17,500 Seating Capacity (Actual Count): 17,500 Normal Hours of Food Preparation/Service: Monday n/a Tuesday n/a Thursday n/a Sunday n/a Friday n/a Wednesday n/a Saturday n/a5 Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 5 2 3 compartment sink 6 2 Handwashing sink 1 1 Commercial Dishwasher 1 Bar sink 0 Mop Sink 0 Garbage Disposal 6 Ice Making Machines 12 Fryolators 8 Grills or Ovens 5 Exhaust Hoods 6 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Yes; On Site; Third Party Is dinnerware pre -rinsed before being washed? Yes No No If yes, at what station/sink? Single Use Items 2 Grease Trans and Grease Removal_ Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 5 Please list fixtures attached to each grease trap Grease Trap 1 3 Bay Sink; Dishwasher Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? x Yes No Size gallons Where is the existing outdoor GRU located? Courtyard If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: Property Owner's Address: Property Owners Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Yes Where is the grease storage unit located? Storage Bins next to recycle How often is this grease storage unit emptied? as needed (bl weekly) Please list the vendor who removes the waste: Newport Biodiesel 2 z 3 \ ) j \ z / 5 &| m! WE IM t §\ (+M O N M 7.. r0 N M E_ m it Y Z y' 0 D Z E N w 00 O LL N LL 0z S r N w ¢$ x w .E C ) 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. New England Sportservice, Inc. Signature of Individual or Corporate Name 04-3466949 "Social Security No. (Voluntary) or Federal Identification Number &" _ 8,, xy y: Corporate Officer (Mandatory, if Applicable) *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. CAUsers\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: New England Sportservice, Inc. @ Vinity Center Address: 885 South Main Street City/State/Zip: Mansfield, MA 02048 Phone #: (508) 261-2900 Are you an employer? Check the appropriate box: Business Type (required): 1.21 I am a employer with 280 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 10. ❑ Manufacturing no employees. [No workers' comp. insurance required] 4. ❑ We are a non-profit organization, staffed by volunteers, I i.❑Health Care with no employees. [No workers' comp. insurance req.] 12.® Other food & beverage at amphitheater *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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: New Hampshire Insurance Company Insurer's Address: 175 Water Street, 18th Floor City/State/Zip: New York, NY 10038 Policy # or Self -ins. Lic. # WC 017-51-5891 Expiration Date: 10/01/2021 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 the pains and penalties of perjury that tit information provident 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 Person: Phone #: 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 contract 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 a joint 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 permit/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 1-977-MASSAFE Fax # 617-727-7749 www.mass.aov/dia MS ED BY i)IL STOER :NFAg11NCf COLIPANY IIL+iL1N t; 2L LTO TIIF Cii' TANYNEW ; HAMPSHIRE INSURANCECOMPANY Est PFNNSYLVANIA 0076789-00 WC 017-51-5891 055-04-1020-10 D5Er, pp�►EE CO PANIES, INCORPORATED LLG NNp�jO�RTH WOE142® BUFF�AIEO E000 An AID company EXECUTIVE OFFICES: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street Now York, NY 10030 LDO 910526731 INSURANCE, LLC STEPHENS WORKERS COMPENSATION AND PLO 111 CENTER ST IJApB1ILLITY LICY INFORMATION PAGE STE 1410Lg ROCK. AR 72201-4431 �W CORP®RATION po RRENEWAL t ICY NUMBER OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990510 ITEM 2 POLICY PERIOD t2.0 AM. M.ndard time at the Inared's mailing address FROM 10/01120 To 10/01/21 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA WI B. Employers Uebllity Insurance: Part Two of the policy applies to the work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1 .000.000 each accident Bodily Injury by Disease S 1 .000.000 policy limit Bodily Injury by Disease S 1 .000.000 each employee C. Other Slates Insurance: Part Three of the policy applies to the states, If any, listed here: NONE D. This policy Includes these endorsements and schedules:. SEE EXTENSION OF ITEM 3.13. OF THE INFORMATION PACE - WC990512 ITEM4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below Is subject to verification and change by audit. Rectum End Total fibtaa Iun Role Per Fsumated Reolum OasdRoalimn Oxfe Nwho. stow OF as. Annual D 3 Year Munarstlan Annual Q3. SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7764 TAXES/ASSESSMENTS/SURCHARGES $8,943 EXPENSE CONSTANT (EXCEPT MWM APPLICABLE BY STATE) $ MA MINIMUM PREMIUM SgOQ W1 TOTAL ESTIMATED ANNUAL PREMIUM $445,477 N Indlcalad below. Intedm adjualriants of gatdum "I be mere: ❑ Semi -Amorally ❑ alaledy ❑ Monthly DEPOSITPREMIUM $445,477 10/22/20 BOSTON 04 Issue Date Issuing Office 39957 JRWd 04108) • Via Aulhadad Rsireaantatlw WC 00 OD OIA Bank H: Packet M Town of Mansfield SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: Public Health Department De t # 512P _ Schedule #: !Permits - Date: 07/08121 Source Account Number CODE Amount Xfmity Food Permits 1051200-445010 BOHPER 5 concession stands $ 875.00 1 kitchen / commissary $ 175.00 1 Courtyard kitchen �_ $ 175.00 1 FOG permit (3 Traps throughout establishment) $ 50.00 i I I — i TOTAL: $ 1,275.00 ! Mansfield, MA 07/08/21 To The Officer Making the Payments: The above is a detailed list of moneys collected by me, amounting in the aggregate to: for the period ending ;07/08121 which I have paid to the Town Treasurer whose recei t hold therefor. I i Em to De t Head rod 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 stomers. 1 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 Te ing 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 rozen, 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 �ylaw is adhered to at the permitted food establishment. I understand violations of this bylaw 411 result n fines. Applicant Signature Applicant Name (please print clearly)