HomeMy WebLinkAboutLPM @ Covidien 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:.
LPM HOLDING CO., INC.
Whose place of business is:
COVIDIEN
15 HAMPSHIRE STREET
PERSON(S) IN CHARGE:
GERALD PACE
Permit Expires: December 31, 2016
License Number: FS -80
Food Fee: $62.50
Milk & Cream V
BOARD OF HEALTH
MichaeCMcClean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that.
LPM HOLDING CO., INC.
having a place of business at.
COVIDIEN
15 HAMPSHIRE STREET
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 12131/2016
License No.: FS -80
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 Permit# Issued
Date received: Date Inspected: Approved By:
FS -80
FOOD ESTABLISHMENT PERMIT APPLICATION
the ova–nh--ed-dp—e�i-�in—g-d-ate�
1) Establishment Name COVIDIEN
2) Establishment Address 15 HAMPSHIRE STREET
15 HAMPSHIRE STREET
MANSFIELD, MA 02048
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
(508) 452-4114
5) Applicant Name & Title: RUSSELL QUEENAN, GENERAL MANAGER
6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754
7) Applicant Telephone No.: (508) 261-8215 24 Hour Emergency No.: (978) 375-4899 (774) 284-3071
8) Owners Name & Title
9) Owner Address (if different from applicant)
Owner's telephone number
LPM HOLDING CO., INC.
24 MAIN STREET, MAYNARD, MA 01754
(978) 897-0660
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
El An Association or partner.
W A Corporation Name Title Address
D An Individual
_6a<_k1 L__ C e U,
El A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)___
Name & Title: JS
tic
Address:
Telephone No:
FAX:(774) 218-1613
C
E-mail: ARQUEENAN(cD-LPMHCI.COM
Alt E -Mail: ECAFE861(cD-EPICUREANFEAST.COM
13) District Or Regional Supervisor (if applicable)
Name & Title: RUSSELL QUEENAN
24 Hour Emergency No:
Address: �2 LIBERTY STREET, CLINTON, MA 01510
Telephone No: (978) 375-4899 24 Hour Emergency No: (978) 375-4899__
4A
CU
FAX: (978) 897-3719 -mail: gt
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: M -F 6 AM - 5 PM
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 4
18) Name of Person In Charge Certified in Food Protection Management: ,L
If more than 3 individuals are certified, complete list is on file. t C ` A C
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): 0
20) Location: Permanent Location 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: 0 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
W Annual or up to 25' PHF display $75.00
❑ Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
❑ Caterer $12.50
n 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
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) - -
-
L]I
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
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And -_ -- _—_ _ -__-- — - - -I
-- - - Cold Holding For Single Meal Service r❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs _—__— _--.---_ _-_— _ Susceptible Population Facility
—_—_ -- -- ❑ 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 - -
_ ❑ Use of Process Requiring A Variance
❑ Customer Self -Service of Non PHF and Non- Customer Customer Self -Service— and/or HACCP Plan (including bare hand
Perishable Foods Only ❑ d fcontact alternative, time as a public health
Ice Manufactured and Packaged
-- -- control)
❑ Preparation of Non-PHFs Retail Sale ------ -- -- -- - - -�,
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Ongin
--j -
-- p 9
❑ Offers RTE PHF in Bulk Quantities
Prepares Food/Sin le Meas or
Catered Events or Institutional Food Service
❑Retail Sale of Salvage, Out -Of -Date --- or Reconditioned Food To be completed by the Board of Health
Payment is due with application
62.50
Pa
---- - - L Total Permit
r _ ❑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 105 CMR 59p 000 and theederal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I cer 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.
25) Social Security Number or Federal ID: 04-2273500
26) Signature of Individual or Corporate Name:
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: COVIDIEN
ADDRESS: 15 HAMPSHIRE STREET
TELEPHONE AT LOCATION: (508) 452-4114
FAX NUMBER:
OWNER OF BUSINESS:
(978)897-3719
LPM HOLDING CO., INC.
TELEPHONE OF OWNER: (978) 897-0660
FEDERAL ID/SS NUMBER: 04-2273500
FEE: $10.00
PERMIT NUMBER: FS -80
SIGNATURE:
DATE:
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.
* Signature of Individual dr
Corporate Name (Mandatory)
By: C orate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 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.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please
Business/Organization Name: am lhi,61roqe ITPCIAL, &U
Address:
i`' t4k) 4
City/State/Zip:
C E Phone #
Are yob an employer? Check the appropriate box: Business Type (required):
1. I am a employer with & 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, E] Office and/or Sales (incl, real estate, auto, etc,)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• E] 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
1 l ,❑ Health Care _
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers', comp. insurance req.] 12.C'tl Other C f ` L
*Any applicant that checks box #I 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' compcnsation 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: L t I fA - A I i � & Q—Ab ii C-' =1 L= t-- '
Insurer's Address: _ [ -
City/State/Zip: t Yc i
Policy # or Self -ins. Lie, #, cit LL boon Cad a Expiration Date: tilti.
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, pnder the pains and pnalties of perjury that the information provided above is true and correct
c;.,r,an,rP• ' � ._.Data'
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:
www,mass,gowaia
Phone
,eco® DATE (MM/DD/YY) CERTIFICATE FLIABILITY INSURANCE
4/14/2016
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, EXTEND 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(les) 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 NAME: CT Janelle Litto
Roger Keith & Sons PnHic°NIJo Ext: (508) 583-1106 FAIic No: (508)583-8478
1575 Main Street ADDRESS:Jlitto@rogerkeith.coln
P.O. BOX 3067 INSURERS) AFFORDING COVERAGE NAIC #
Brockton MA 02304 INSURER A ;Travelers Pro ert & Casua, Ins . TPCO01
INSURED INSURER B :Charter Oak Fire Ins Co 25615
LPM Holding Co. Inc. INSURER C :FEDERAL INSURANCE
DBA EPICUREAN FEAST INSURER D -MA RETAIL MERCHANTS WC GROUP
24 Main Street INSURERE:NH ASSOCIATION MEMBERS WCT
Maynard MA 01754 1 INSURER F: I I
r�wwre r. he EvnriPAT'C tuttaaoco.gn7 r� RATRTTRRAN MASTER RFVI-RION NUMBER:
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 BY THE 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
"DL
5 BR
POLICY NUMBER
—POLICY
M DDNEY
MWDD VYY
LIMITS
X COMMERCIAL GENERAL LIABILITY
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
A
CLAIMS -MADE a OCCUR
MED EXP (Any one person) $ 10,000
63060830447
1/1/2016
1/1/2017
INCLUDES LIQUOR LIABILITY
PERSONAL & ADV INJURY $ 1,000,000
$1,000,000 LIMIT
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 3,000,000
PRODUCTS - COMP/OP AGG $ 2,000,000
X PRO � LOC
POLICY ❑
Liability $ 1,000,000
OTHER:Liquor
AUTOMOBILE LIABILITY
Eaa accidenlSINGLE LIMIT $ 1,000,000
BODILY INJURY (Per person) $
BANY
AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
X HIRED AUTOS X NON -OWNED
AUTOS$
8107C399675
$1,000 DEDUCTIBLES
1/1/2016
1/1/2017
BODILY INJURY(Per accident) $
PROPERTY DAMAGE $
Per accident
A
X
UMBRELLA LIAR
X
OCCUR
ZUP91M4890816
1/1/2016
1/1/2017
EACH OCCURRENCE $____25_,000, 000
AGGREGATE $ 25 000, 000
C
X
EXCESS LIAR
CLAIMS -MADE
79882528
1/1/2016
1/1/2017
DED X RETENTION $ 10,000
35,000,000 $ 35, 000, 000
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEM13ER EXCLUDED?
(Mandatory In NH)
NIT] / A
pJUB6C87139-8-16
1/1/2016
/1/2017
X STATUTE OERH
E.L.EACH ACCIDENT $ 1,000,000
E.L DISEASE- EA EMPLOYE $ 1 000,000
E.L. DISEASE - POLICY LIMIT 1 $ 1,0001000
II yes, Rdescrib
DESCeIPTION underOFOPERATIONS below
AZ, CT, NE, NJ, NY, PA, RI
D
WORKERS COMP. MA ONLY
014000502016116
1/1/2016
1/1/2017
1,000,000/1,000,000/1,000,000
E
WORKERS COMP. NH ONLY
030009100240116
1/1/2016
1/1/2017
1,000,000/1,000,000/1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
POLICY LIMITS IN EFFECT AT POLICY INCEPTION
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ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF MANSFIELD
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
6 PARK ROW
MANSFIELD, MA 02048
AUTHORIZED REPRESENTATIVE
DONOVAN DUNN/KEIJJI
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ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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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 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. to 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 bum 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
Form Reviscd 5-26.05