HomeMy WebLinkAboutCourtside Pub 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: FOOD ESTABLISHMENT
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
STEPHEN PULIAFICO, PARTNER
Whose place of business is:
COURTSIDE PUB
31 OXFORD ROAD
PERSON(S) IN CHARGE:
GARY BEATTY
Permit Expires: December 31, 2016
License Number: FS -133
Food Fee: $62.50
Milk & Cream V
BOARD OF HEALTH
NichaeCMcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that.
STEPHEN PULIAFICO, PARTNER
having a place of business at.
COURTSIDE PUB
31 OXFORD ROAD
Town of Mansfield
6 Park Row
Mansfield, MA 02048
in the Town of Mansfield has been granted a license to sell MILK and CREAM and
is subject to the Provisions of the Laws of the Commonwealth of Massachusetts,
relating to the terms and conditions, and to the rules and regulations established by
the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream
and shall remain in force until 1213112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -133
Scott Leite, Heaah Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
- - - - - - FOR BOARD OF HEALTH USE ONLY -- --
i I Date received: Date Inspected: Approved By: Permit # Issued
i
FS -133
I
FOOD ESTABLISHMENT PERMIT APPLICATION
-- -- -
Wpiication mustesubnmffe� at7eas� 30 days b ire the-pT nned opening date)
1) Establishment Name COURTSIDE PUB
r - -
2) Establishment Address 31 OXFORD ROAD
3) Establishment Mailing Address (if different) 31 OXFORD ROAD
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 337-3100
5) Applicant Name & Title: BCL PREMIER SPORTS - MANSFIELD, LLC
6) Applicant Address 31 OXFORD ROAD, MANSFIELD, MA 02048
�7) Applicant Telephone No.: (508) 337-310024 Hour Emergency No.: (5oal szz-s�sz
8) Owners Name & Title STEPHEN PULIAFICO, PARTNER
15 WADSWORTH WAY
9) Owner Address (If different from applicant)
SHARON MA 020
Owner's telephone number
10 Establishment Owned By: % 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association I or partner.
❑ A Corporation Name Title Address
❑ An Individual - - --- -- -
❑ A Partnership - - -
0 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title i-- Qn --- - AK -1 aFATTY - - - - -
Address: r3l OXFORD ROAD MANSFIELD MA 02048
Telephone No: (508) 337-3100 >C 2l ® 24 Hour Emergency No: (508) 922-3182
FAX: (508) 406-2245
-------
E-mail: _ C �YLi�'rt� EM P t- ESC Cvrv►
Alt E -Mail: �-
13) District Or Regional Supervisor (if applicable)
Name & Title: N/A
Address:
Telephone No
FAX: j E-mail:
14) WATER SOURCE: TOWN
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 4
17) DAYS/HOURS: 7 DAYS PER WEEK 9 AM - 9 PM
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file. FRAt406 1900T)4E_
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): W
20) Location: 0 Permanent Location
22) Establishment Type
❑ Moblie Moblie Start Date:
❑ Retail ( Sq. Ft)
Moblie End Date:
Food Service up to 100 or
Moblie Comments:
up to 10' PHF display $62.50
21) Length of Permit:
❑ Food Service up to 101 -200
Annual
or up to 25' PHF display $75.00
El Seasonal
1 ❑ Food Service up to 201 +
j or 25'+ PHF display $137.50
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
i(Check all that apply):
❑ Food Service - Institution
( Meals/Day)
❑ Caterer $12.50
Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts:
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non -PRFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre Packaged PRFs
❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
;-_ ____ - -
-- - - -- ---
Cold Holding For Single Meal Service
F-1PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs
-_---- - __ ___.__ _
Susceptible Population Facility
-- ---------- - --
❑ Sale of Raw Animal Foods Intended
0 Reheating of Commercially
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
_ __ —_ __- __-__
____ - -- -
-- --- - 1
❑ Use of Process Requiring A Variance
0 Customer Self -Service of Non PHF and Non-
Customer Self -Service
and/or HACCP Plan (including bare hand
Perishable Foods Only
on -
❑ Ice Manufactured and Packaged for
contact alternative, time as a public health
Preparation of Non PHFs
Retail Sale
) i
-- - - - - -
Other Food Operations
El Juice Manufactured and Packaged for
E]Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Prepares Food/Sin le Meals or
�❑ Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
-
Lor Reconditioned Food
1 To be completed by the Board of Health
-- -_-- -
Total Permit Fee: $62.50
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 of 1 Ve)?MR 59,400 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify
and paid state taxes required under law.
e penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
25) Social Security Number or Federal ID: 46-1415572
26) Signature of Individual or Corporate Name: Bo, eatm X12 SP02TS MANSF%Ul. Lu(-
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Milk and Cream Permit
I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year.
NAME OF BUSINESS: COURTSIDE PUB
ADDRESS: 31 OXFORD ROAD
TELEPHONE AT LOCATION: (508) 337-3100
FAX NUMBER:
OWNER OF BUSINESS: STEPHEN PULIAFICO, PARTNER
TELEPHONE OF OWNER:
FEDERAL ID/SS NUMBER: 46-1415572
FEE: $5.00
PERMIT NUMBER: FS -133
SIGNATURE:
DATE: �/Z(� zo `�
I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
`L.JCIL ?261 IetZ, 8F69 iS rnANffICLD LL C
* Signature of Individual or
Corporate Name (Mandatory)
Cia2Y 6EArrY
By: Corporate Officer
(Mandatory, if applicable)
46- �LHSSW-
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the certification clause is signed by
the applicant.
i
** Your Social Security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or tax
payment obligations. Licensees who fail to correct their non -filing or delinquency
will be subject to license suspension or revocation. This request is made under
the authority of Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
3Ct- SP02TS n'IANSFlF_LrJ LLC
Address: 3 t OXF02p (ZOA(J
City/State/Zip: M- ANS -FIC L b , 0A 620
Are ou an employer? Check the appropriate box:
1. I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c, 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4, ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers'.comp, insurance req.]
Phone #: S0$-_ 92o:�--3 16 0
Business Type (required):
5, ❑ tail
6. Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc,)
8. ❑ Non-profit
9, ❑ Entertainment
10, ❑ Manufacturing
11, ❑ Health Care
12.90ther SPORTS fACW7)
*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: AT-(, A NT ll C C 14 A 2I&(L I N S V ri LA A CO--
Insurer's Address: CIO S)ALNV&L tASI /AAeAlCi, 10To R.NPIKFST•_-tf12g t Z
City/State/Zip: C4 AJ 7 G N, MA 0 20 Z t
Policy # or Self -ins, Lie, # W C V 0 10 6 4- i 0 o Expiration Date:, 3 1 g 1 Lo I"+
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 DTA for insurance coverage verification,
I do hereby certify, u�ehe painsAnd penalties of perjury that the information provided above is true and correct
Phone#: res Z)o
Official use only. Do not write ir: this area, to be completed by city or town official
City or Town;
Permit/License #
s /26120 l b
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:
www,mass,gov/dia
Phone
RLf CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
INSR
LTR
TYPE OF INSURANCE
5/26/16
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, EMEND 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(ies) must 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
CONTACT
Shenkel Insurance Agency, Inc.
1/8/16
PHONE
1017 Turnpike Street #12B
781 575-9111 A!X No: (781) 401-9995
E-MAIL
Canton, MA 02021
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC#
INSURERA:Greenwich Insurance Company
DAMAGE TO
SES occurrence) $ 300,000
INSURED
INSURER B: Atlantic Charter Insurance
BCL Premier Sports -Mansfield
c/o LCB Senior Living LLC
INSURER C :
3 Edgewater Dr., Suite 101
INSURER D:
Norwood, MA 02062
INSURER E:
INSURERF:
f+A\/CDA I'+G G. �.�e�r.e.�• �� ... ...w....
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 BYTHE 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
ISR
SUBR
WVD
POLICY NUMBER
POLICY EFF
M/DD/Y
POUCY EXP
M 1DD/YYYY
LIMITS
A
GENERAL LIABILITY
ASG089000101
1/8/16
1/8/17
EACH OCCURRENCE $ 1,000,000
-RENTED
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO
SES occurrence) $ 300,000
MED EXP (Arty one person) $
CLAIMS -MADE 1XI OCCUR
PERSONAL& ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 51000,000
GEN'L AGGREGATE LIMIT APPLIES PER
X POLICY PRO LOC
PRODUGTS-COMP/OPAGG $ 5,000,000
LIQUOR LIAB$ 1,000,000
A
AUTOMOBILE LIABILITY
ASA0898546
1/8/16
1/8/17
GL�ELBIMH
aaccidert $ 1,000,000
ANYAUTO
ALLOWNIED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
X HIREDAUTOS X AUUTNOSWNED
PROPERTY DAMAGE $
eraccdent
$
AUMBRELLA
X
LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
ASU089000601
1/8/16
1/8/17
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
OFFICERMEM ANY PROPRIETOR/PARTNER/EXECUTIVE
7
$
1 WC STATU- OTH-
I.
B
NIA
WCV01064100
3/7/16
3/7/17
E.L. EACH ACO DENT $ 500,000
E.L. DISEASE -EA EMPLOYEE $ 500,000
(ManIfKes story in ander
DRR PTIONOF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $ 500,000
DESCRIPTION OFOPERATIONS/LOCATIONS /VEHICLES (Attach ACORD 101,Additional Remarks Schedule, if more space isrequired)
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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
Steven M.
v ivoo-Au-w AL'UMU GUKVUKA I [UN. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
Phone: (781) 575-9111 Fax: (781) 401-9995 E -Mail: steven@shenkel.com
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: FRANCIE BOOTHE
Certificate Number: 2356246
Date of Completion: 61112016
Date of Expiration 6/1/2021
The above-named person is hereby issued this certificate
for completing an allergen awareness training program;
recognized by the Massachusetts Department of Public Health
in accordance with 10.5 CMR 590.009(G)(3)(a).
This certificate will be valid for five (5) years frons date ofcompletion.
Issued By:
R
NATIONAL
RESTAURANT
-.n-
ASSOCIATION,
Massachusetts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
wwsv.restaurant.org
Southborough, MA 01772
508-303-9905
www, marestauran tnssoc.org
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 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 Iocal 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 not 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov(dia
Farm Revised 5-2"5