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HomeMy WebLinkAboutEpicurean Feast @ Tyco Kendall 12/31/2016 (2)Commonwealth 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 HOLDINGS CO., INC. Whose place of business is: EPICUREAN FEAST @ TYCOXENDALL 777 WEST STREET PERSON(S) IN CHARGE: GERALD PACE Permit Expires: December 31, 2016 License Number: FS -87 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH NichaeCNcCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: LPM HOLDINGS CO., INC. having a place of business at.- EPICUREAN t: EPICUREAN FEAST @ TYCO/KENDALL 777 WEST STREET 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 -87 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 Date received: Date Inspected: Approved By: Permit # Issued j FS -87 FOOD ESTABLISHMENT PERMIT APPLICATION - (4pp�n mine-su-bmitted-aVleasf-W-d-a-y-s ire the p>annecTo_pening date) 1) Establishment Name EPICUREAN FEAST @ TYCO/KENDALL 2) Establishment Address 5 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 24 MAIN STREET MAYNARD, MA 01754 i 4) Establishment Telephone No (508) 261-8000 -- - - - 5) Applicant Name & Title: RUSSELL QUEENAN, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 375-4899 24 Hour Emergency No.: (774) 284-3071 8) Owners Name & Title LPM HOLDINGS CO., INC. 9) Owner Address (If different from applicant) 24 MAIN STREET, MAYNARD, MA 01754 Owner's telephone number (978) 375-4899 10) Establishment Owned By: F1 1) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. i W A Corporation Name � Title Address es IJ An Individual i fS-��t_.— �� t ❑ A Partnership t( ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: GERALD PACE Address: 113 JACKSON DRIVE NORTH PROVIDENCE, RI 02911 Telephone No: (4q+yM--@9M F., a _2A Hour Emergency No: (774) 284-3071 FAX: (978) 897-3719 E-mail: GERALD.PACE@_COVIDIEN.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: (RUSSELL QUEENAN Address: 2 LIBERTY STREET, CLINTON, MA 01510 Telephone No: (978) 375-4899 24 Hour Emergency No: (978) 375-4899 FAX: (978) 897-3719 E-mail: RQUEENAN@COVIDIEN.COM Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-FRI 7:00 AM -1:30 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 1 18) Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. 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: 91 Permanent Location ❑ Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: 0 Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): 22) Establishment Type ❑ Retail ( Sq. Ft) ❑d Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) GERALD PACE ❑ Caterer $12.50 i 0 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 ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order D Hot PHF Cooked and Cooled or Hot Held - -- -- - - { for More Than a Single Meal Service ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service _ _ _ ---- ------ L] PHF and RTE Foods Prepared For Highly _— _ __ - _ -.- - Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended -E] to be Prepared by Consumer I Vacuum Packaging !Cook Chill _ --__ —_ - -- ❑ Use of Process Requiring A Variance ❑ Customer Self -Service and/or HACCP Plan (including bare hand - _ ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) - ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin — -- — ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service -- ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date-- - or Reconditioned Food To be completed by the Board of Health - - J Total Permit Fee: $62.50 d �-Payment is due with applicabon D—' aived 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 590.00 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify nder 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: EPICUREAN FEAST @ TYCO/KENDALL ADDRESS: 5 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: (978) 897-3719 OWNER OF BUSINESS: LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 375-4899 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $5.00 PERMIT NUMBER: FS -87 SIGNATURE: DATE: f 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 or` Corporate Name (Mandatory) By: Cc rporate Officer (Marndafory, if pplicable) ** Social Security Number (Voluntary) or Federaf 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 021.11 u,p www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant information p Please Business/Organization Name: �1 i C i tib co, Pf- I)E F ►Cts C + 4k_> f -e 4 S -t- Address: j YAA c' &) &4' + City/State/Zip: � - q _ fU a • C11q b4 Phone #: Are yo an employer? Check the appropriate box: Business Type (required): 1. Lam` I am a employer with. L) & employees (full and/ 5. F1 Retail or part-time).* 6. EJRestaurantBar/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] S. F-1 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]**l l .❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] _� � � { 12.[x,] Other 6- C *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' 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, Blow is the policy information. Insurance Company Insurer's Address: (� ` (1b 0 3� �%2 City/State/Zip: ' Policy # or Self -ins. Lic. # i" ©� C)f ca ` U S �0 Expiration Date: 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 thepayi)ns and p nalties ofperjury that the information provided above is true and correct AAI B dxk) a �� 1�atP 4't lIJ 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 11 Contact Person: Phone #: 1 www.mass.gowa+a ® CERTIFICATE LIABILITY INSURANCE DATE (MWDDNYYY) 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(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). PRODUCERCO Roger Keith & Sons 1575 Main Street A T Janelle Litto NAME: A/CNNo Ext: (508) 583-1106 FAX No: (508)583-8478 E-MAILs:7litto@rogerkeith.com ADDRE INSURERS) AFFORDING COVERAGE NAIC # P.O. BOX 3067 INSURER A :Travelers Pro ertV & Castlalt Ina . TPCO01 _ Brockton MA 02304 INSURED INSURERB:Charter Oak Fire Ins Co 25615 INSURER C :FEDERAL INSURANCE LPM Holding Co. Inc. - INSURER D :MA RETAIL MERCHANTS WC GROUP DBA EPICUREAN FEAST iNSURERE:NH ASSOCIATION MEMBERS WCT 24 Main Street INSURER F: Maynard MA 01754 rnvGonr_t=c C_ERTIFIC`ATF NIIMRFR-2U16 EPICUREAN MASTER KtVI5WIV NUMt3tli: 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. ILTR TYPE OF INSURANCE iNgn wvn SUER POLICY NUMBER MM DDY YY FF MM/DDY YYYP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 --UA-M—AGETO RENTED 1,000,000 PREMISES a occur ence $ A CLAIMS -MADE ❑X OCCUR _ MED EXP (Any one person) $ 10,000 63060830447 1/1/2016 1/1/2017 PERSONAL & ADV INJURY $ 1,000,000 INCLUDES LIQUOR LIABILITY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 $1,000,000 LIMIT PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO [_]LOC JECT Liquor Liability $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1, 000, 000 Ea accident _ BODILY INJURY (Per person) $ B ANY AUTO ALL OWNEDSCHEDULED AUTOS X AUTOS NON -OWNED X HIRED AUTOS X AUTOS 81070399675 $1, 000 DEDUCTIBLES 1/1/2016 1/1/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accidentL_— A X UMBRELLA LIAB X OCCUR ZUP91M4890816 1/1/2016 1/1/2017 EACH OCCURRENCE $____25 000 000 AGGREGATE $ 25, 000, 000 C X EXCESS LIAB CLAIMS -MADE 79882528 1/1/2016 1/1/2017 DED I X I RETENTION $ 10,000 35,000,000 $ 35, 000, 000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE �Y / N OFFICER/MEMBER EXCLUDED? L-1 (Mandatory In NH) N / A PJUB6C87139-8-16 1/1/2016 1/1/2017 X STATUTE _LER_O E.L EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEd $ 1,000,000 I E.L. DISEASE - POLICY LIMIT 1,000,000 ItDESCyes, Rdescrib IPTIONe under OF OPERATIONS below A2, CT, ME, NJ, NY, PA, RI I 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 ncnTi CIn ATC Uf%I r%co rANr2Fl 1 ATION V lUtltf-LU14 Al;UMU L,U"rUMAIIVIY. All n911lt5 re5ervcu. ACORD 25 (2014101) 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 6 PARK ROW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE DONOVAN DUNN/KEIJJ1 - umwl V lUtltf-LU14 Al;UMU L,U"rUMAIIVIY. All n911lt5 re5ervcu. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) C Q o ria co CL x LL o: C G y @ U� N � O a� o 0) o m U- r - co o co o� U UJ O O C 0. U O - LLL c N Q N %to N N o O G o N O c th 0 0 -` m70 g z z m Y E w m o 0 C ® a acc Q. -0 ._ �_ 5 E z ¢ 3 0 4a a N U W U . O O w U N U � U � w w m c> G •� m x 2 3E c= •� N o C to E > e o Q r_ g m � � o zo a� _ scm �_ 62vt I Ill c 0 Ln < O� aim IA (13 0 o2 X a (.0 LO < C LO T- 2 4D V) 00 Q) Z (U Sao E 0 0 LL- _0 w —0 > E :3 LO LO 0 CL u CY)