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Home My WebLink AboutKrave Pure Foods 09/24/2016Commonwealth 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: TEMPORARY 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:. JAKE LASTRINA Whose place of business is: KRAVE PURE FOODS - THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: BRYNN MEENAN Permit Expires: September 24, 2016 License Number: T-149 Food Fee: $100.00 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date inspected Approved By Permit # Issued Date Received p _ , -0 Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: KRAVE Pure Foods 2) Establishment Address: 117 W Napa St Suite C 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 603-315-8050 5) Applicant Name & Title: Jake Lastrina/ Marketing Manager 6) Applicant Address: 1 Fairlee St #2 Somerville MA 02144 7) Applicant Telephone No: 6033158050 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 24 Hour Emergency No: 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. Home Address m An association Name Title __---- m A corporation m An individual m A partnership m Other legal entity C Corporation Ll B 'C 0rYA VOY erson in Charge, Supervisor, Manager etc Fax: Fax 12) Person Directly Responsible For Daily Operations (Owner, F Name & Title: Brynn Meenan Address: 8 Laban Pratt Rd Dorchester MA Tele hone No: 7816260149 Emer enc Tele hone No: 13) District Or Re ional Su ervisor if a licable Name & Title: Address: Telephone No: Ll B 'C 0rYA VOY erson in Charge, Supervisor, Manager etc Fax: Fax Food Establishment Information ❑ 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. ❑ Sale Of Raw Animal Foods Intended to be Prepared by Consumer. ❑ Customer Self -Service ❑ Ice Manufactured and Packaged Retail Sale ❑ Preparation Of Non-PHFs ❑ Juice Manufactured a for Retail Sale ❑ Vacuum Packaging/Cook ❑ Use Of Process Requiring A Variance And/Or HACCP Plan (including bare hand contact _ alternative time as a public health control) ❑ Offers Raw Or Undercooked Food Of Animal Origin. ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service LiOffers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health Total Permit Fee: ❑ Retail Sale of Salvage, Out -of Date or Payment is due with application Reconditioned Food I, the undersigned, attest to the accuracy of the inf mation provided in this application and I affirm that the food establishment operation will comply with 105 CM 5 0.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 690-OOP 90.0 4n�dederal Food Code. 24) Signature of Applicant: L Pursuant to MGL Ch. 62C, sec. 49A, I certify 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: 27-5381507 26) Signature of Individual or Corporate Name: Krave Pure Foods 15) Sewage disposal: NA 14) Water Source: NA DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 2 18) Name of Person In Charge Certified in Food Protection Management: please attach of rtlficate ance with 105 CMR 590.003(A co ce Re uired as of 10/1/2001in accord . 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes GK No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer ❑ Food Delivery (check one) ❑ Retail ( Sq. Ft) Food Service - ( Seats) Ll Food Residential Kitchen for Retail Sale LlPermanent Structure Ll Food Service -Takeout ❑ Residential Kitchen for Bed and Breakfast Ll Mobile LiFood Service - Institution Home ❑ Residential Kitchen for Bed and Breakfast ( Meals/Day) Establishments ❑ Frozen Dessert Manufacturer 21) Length Of Permit: Other (Describe) (check one) Event based only ❑ Annual ❑ Seasonal/Dates: 7/22,8/5,8/12, 9/24 ❑ Temporary/Dates/Time: Definitions: PHF- potentially hazardous food(time/temperature controls required) 23) Food Operations: Non-PHFs- non- potentially hazardous food (no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) check all that apply): Ll PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for ® Sale of Commercially Pre- More Than a Single Meal Service. X Packaged Non-PHFs Sale Commercially Pre- ❑ Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly ❑ of Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility — ❑ 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. ❑ Sale Of Raw Animal Foods Intended to be Prepared by Consumer. ❑ Customer Self -Service ❑ Ice Manufactured and Packaged Retail Sale ❑ Preparation Of Non-PHFs ❑ Juice Manufactured a for Retail Sale ❑ Vacuum Packaging/Cook ❑ Use Of Process Requiring A Variance And/Or HACCP Plan (including bare hand contact _ alternative time as a public health control) ❑ Offers Raw Or Undercooked Food Of Animal Origin. ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service LiOffers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health Total Permit Fee: ❑ Retail Sale of Salvage, Out -of Date or Payment is due with application Reconditioned Food I, the undersigned, attest to the accuracy of the inf mation provided in this application and I affirm that the food establishment operation will comply with 105 CM 5 0.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 690-OOP 90.0 4n�dederal Food Code. 24) Signature of Applicant: L Pursuant to MGL Ch. 62C, sec. 49A, I certify 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: 27-5381507 26) Signature of Individual or Corporate Name: Krave Pure Foods 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. crL`j 61�fi -� /KRAVE Jerky Signature of Individual or Corporate Name 27-5381507 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandator,/, 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe 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: Kra eco The Hershey Cornl2any Address: 100 Crystal A Drive City/State/Zip: Hershey, PA 17033 Phone #: Are you an employer? Check the appropriate box: 1. ® 1 am a employer with 41 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,] 71.7-534-4200 Business Type (required): 5. ❑ Retail 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,❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy infunriation. **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 fl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy Information. Insurance Company Name: RI.. Insurance of America Insurer's Address: 70 Seaview Avenue City/State/Zip: Stamford, CT 06902 Policy # or Self -ins, Lic. # RWD300064001 Expiration Date; 01/01/2017 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 tine 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 paint and penalties of perjury that the information provided above is true and correct. 717-534-8310 Official use only. Do not write in this area, to be completed by city or town of 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.gov/dia Phone #: A CERTIFICATE OF LIABILITY INSURANCE DATE(MM1)DNYYY) I 042016 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 have ADDITIONAL 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 lieu of such endorsement(s). PRODUCER Aon Risk services central, Inc. PA office One Liberty Place 1650 Market street Suite 1000 Philadelphia PA 19103 USA CONTACT NAME; PHO, NE No. (866) 263-7122 aC.Nodc (600) 363-0105 (AICPhiladelphia A1311PESS: INSURER(S) AFFORDING COVERAGE NAIL # INSURED The Hershey Comoanv Attn Risk Management Department 100 crystal A Drive Hershey PA 17033 USA INSURER A: XL Insurance America Inc 24554 INSURER B: XL Specialty insurance co 37885 INSURER a Greenwich insurance Company 22322 INSURER D: INSURER E: INSURER F: oCv191ntU UI IfI1RFR� _ _--- -- -•..----- ....................., G(UVEKAki" t,zm r irturn i c t1unnu— — — ,— � — — 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. Limits shown are as requested L C TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY cIAIYPEO I XU occuR INgp yf/ POLICY NUMBER RGU 1 SIR applies per policy ter MMID condi M DD :ions LIMITS EACH OCCURRENCE $1,900,000 $1,900,000 PREMISES Ea occurrence MED EXP (Any one person) PERSONAL &ADV INJURY $1,900,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY❑ JECT PRO- n LOC GENERAL AGGREGATE - $4,000,000 AGGREGATE PRODUCTS -COMPIOPAGG $4,000,000 OTHER: C AUTOMOBILE LIABILITY RAD943773301 01/01/2016 01101/2017 COMBINEOSINGLELIMIT $2,000,000 Ea accident BODILY INJURY (Pet person) X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOG NON -OWNED ONLY AUTOS ONLY BODILY INJURY (Per accidenl) PROPERTY DAMAGE eraccidenl B X UMBRELLAUtAB EXCESS LIAR X OCCUR CLAIMS -MADE US0006641OL116A 01/01'2016 01/01/2017 EACH OCCURRENCE S,000,D00 AGGREGATE $5,000,000 DED X RETENTION 514,060 A A a WORKERS COMPENSATIONAND EMPLOYERS'LIABILIY YIN ANY PROPRIETOR/ PARTNER/ EXECUTNEE.L, OFFICERIMEMBER EXCLUDED? N (Mandatory in NH) ILyes,descrIbeunder DESCRIPTION OF OPERATIONS below 1 Excess WC NIA RW030006 001 RWR300064101 RWE943547301 CA, PA, VA & IL Only SIR applies per policy terns 01/017101701/07101-7 01/01/2016 01/01/2016 & condi 01/01/2017 O1 0112017 ions '0x PER U7 IOT H- EACH ACCIDENT S1,000,000 E,L, DISEASE -EA EMPLOYEE $1,000,000 E,L. DISEASE -POLICY LIIAT $1,000,000 EL Each Accident $1,000,000, EL Disease - Policy $1,000,000' EL Disease - Ea Emp $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Addl4oreal Remarks Schedule, maybe attached If more space is required) The Named Insured includes The Hershey company and its subsidiaries and affiliates including, but is not limited to the following: Artisan confections Company Krave Pure Foods, Inc. Hershey chocolate of Virginia, Inc. Hershey chocolate & confectionery corp. Hershey International Ltd. CERTIFICATE HOLDER CANCELLATION 011888-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICEWILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Hershey Customer Or Business Partner c/o The Hershey Company 100 Crystal A Drive• Hershey PA 17033 USA AUTHORIZED REPRESENTATIVE - p (% is?TAS c /et�i p Q s3�d�a�i e /eL 011888-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000048802 qC ��®® LOC #: �----� ADDITIONAL REMARKS SCHFDI)1 F _ AGENCY NAMEDINSURED Ann Risk services Central, Inc. The Hershey Company POLICY NUMBER see certificate Number: 570061937918 CARRIER MAIC CODE See Certificate Number: 570061937918 AMM. - RAI EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Add lional Deacdptbn of operation 1 Looatlona I Vehicles; Hershey Canada Inc. CSH Foods, Inc. Ripple Brand -Collective LLC DBA barkTHSN5- Coverage is effective 4/25/2016 to 1/1/2017, Additional insured, waiver of subrogation, notice of cancellation, and primary and non-contributory status apply as per terms of executed agreement. Please note that because the Umbrella/Excess policy terms follow the underlying policies, there are no separate additional insured, waiver of subrogation, and primary and non-contributory endorsements applicable to this policy. Workers compensation Policy includes Employer's Liability for monopolistic states of North Dakota, Ohio and Washington. Insurance coverage is subject to actual policy terms. This certificate does not amend, extend or alter the insurance coverage, _ ACORD 101 (2008t01) X72008 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD