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Home My WebLink AboutLL Bean 5K 10/22/2016N Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishmen Type: TEMPORARY FOOD PERMIT 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:. ERIK BOUCHER, RACE DIRECTOR & PRES. GIDDYUP PRODUCTIONS Whose place of business is: L.L. BEAN - L.L. BEAN BRIGHT NIGHT 5K 280 SCHOOL STREET PERSON(S) IN CHARGE ERIK BOUCHER, RACE DIRECTOR Permit Expires: October 22, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: $25.00 License Number: T-162 BOARD OF HEALTH MichaeCMcCCean, Chairman sm FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # FOOD ESTABLISHMENT PERMIT APPLICATION ----- (Application must be submitted at leastdays before the planned opening daiaj-- 1) Establishment Name L.L.Bean retail store at Mansfield Crossing. The event name is the L.L.Bean Bright Nig 2) Establishment Address 280 School Street, Mansfield, Massachusetts 02048 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 207-210-8655 5) Applicant Name & Title: Erik Boucher, Race Director and President of GiddyUp Productions 6) Applicant Address 141 School St, South Portland, ME 04106 7) Applicant Telephone No.: 207-210-8655 24 Hour Emergency No.: 8) Owners Name & Title Erik Boucher, Race Director and President of GiddyUp Productions 9) Owner Address (If different from applicant) Owner's telephone number 207-210-8655 10) Establishment Owned By: An Association A Corporation An Individual A Partnership x Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) it 5k Name & Title: Erik Boucher, Race Director and President of GiddyUp Productions Address: 141 School St, South Portland, ME 04106 ' Telephone No FAX: 207-210-8655 - '- — 24 Hour Emergency No: E-mail: erik@justgiddyup.com Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: NA Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: � Food Establishment Information 14) WATER SOURCE: bottles of Poland Spring water 15) SEWAGE DISPOSAL: NA DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: NA 17) DAYS/HOURS: this one time event will be held on 10/22/16 from 4:00 PM to 6:00 PM 18) Name of Person In Charge Certified in Food Protection Management: NA 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 i [19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): NA 20) Location: I Permanent Location 22) Establishment Type X Mobile Mobile Start Date: 10/22/16 ? Retail ( Sq. Ft) Moblie End Date: 10/22/16 ; =i Food Service up to 100 or Mobile Comments: this is a 5k road race up to 10' PHF display $125.00 21) Length of Permit: Annual Seasonal Seasonal Dates: 10/22/16 Temporary Temporary Start Date: 10/22/16 Temporary End Date: 10/22/16 Temporary Time: 4:00 to 6:00 PM Rain Date: NA Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275,00 >` Food Service - Institution ( Meals/Day) Caterer $25,00 Milk & Cream $10.00 Mobile Food & Consession $75.00 -, Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25 # of Pushcarts: Residential Kitchen $100,00 Retail Food $100.00 X Retail Snack Food $25,00 Tobacco Products $25.00 23) Food Operations I Definitions: PHF- Potentially hazardous food (timelemperature controls required) Non-PHFs - non -potentially hazardous food(no timellemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours X Customer Self -Service of Non PHF and Non Perishable Foods Only Preparation of Non-PHFs PHFCooked To Order = Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations Juice Manufactured and Packaged for ; ,j Offers Raw Or Undercooked Food Of Retail Sale Animal Origin We will be handing out cups of water I Prepares Food/Single Meals for __ Offers RTE PHF in Bulk Quantities and pre-packaged Clifbars to runners Catered Events or Institutional Food Service Ina 5k road race. Retail Sale of Salvage, out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: ---- 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 105 CMR 590.000 and the federal Fogd_Code. r — 24) Signature of Applicant: 1�,- ' 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. 27-4002963 25) Social Security Number or Federal ID: ( '� 26) Signature of Individual or Corporate Name: I certify under the penalties of perjury that I, to my best knowledge and belief, j have filed all State tax returns and paid all State taxes required under law. * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 27-4002963 ** 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 Print Legibly Business/Organization N Address: 141 School St GiddyUp Producions LLC City/State/Zip: South Portland, ME 04106 Are you an employer? Check the appropriate box: 1.0 1 am a employer with 2 _ employees (full and/ or part-time).* 2. ❑ 1 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 thein 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 #: 207-210-8655 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 10.0 Manufacturing 11. ❑ Health Care 12,® Other running event production *Any applicant that checks box 111 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 ill. I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy information. Insurance Company Name: Philadelphia Insurance Co Insurer's Address: One Bala Plaza, Suite 100, Bala Cynwyd, PA 19004 City/State/Zip: Bala Cynwyd, PA 19004 Policy # or Self -ins. Lic. # PHPK1544831 Expiration Date: 10/15/17 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, r der the pains and penalties of perjury that the information provided above is true and correct. J y 9/21/16 Cinn�fnrw• __ 207-210-8655 Official use only. Do not write Its 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.gov/dia Phone ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 9/21/2016 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). PRODUCER CTOSS Insurance-PortlandPHOc.NENo. 2331 Congress Street Portland ME 04102 CONTACT NAME: y Kimberl@ Perreault (207)780-1677 A/C No: (207)780-6377 ADORIEss:kperreault@crossagency.com INSURERS AFFORDING COVERAGE NAIC q INSURER A :Philadel hia Ins Co INSURED Giddy Up Productions LLC 141 School Street South Portland ME 04106 INSURER B :Maine Employers Mutual Ins Co 11149 INSURER C : INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:16/17 Master REVISION 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 ADDL INSD SUER D POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY _ CLAIMS -MADE OCCUR PHPK1544831 10/15/2016 10/15/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE PREM SESOEa ocou ence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONALBADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X _ POLICY E] PRO LOC OTHER: GENERAL AGGREGATE $ 1,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 Professional Liability $ 1,000,000 AUTOMOBILE LIABILITY _ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS WNED HIRED AUTOS AUTOS COaa accident SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ – PROPERTY DAMAGE $ — - Per accident UMBRELLA LIAB_ EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 1810106677 10/15/2016 10/15/2017 X STATUTE EERH _ E.L. EACH ACCIDENT $ 500 000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) UERI It-IGA I t HULUtK �n1w111n 11— Sample Certificate 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 Perreault/BD7` P V I`JOO-LU 14 HIiVKU VVRrIJRM I IVIY. H11 11!J11LA 1 V0W1 VCU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 00140» AC40 E® CERTIFICATE OF LIABILITY INSURANCE F°9 21/2016' 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). PRODUCER CONTACT Kimberley Perreault NAME: y PHONED (207) 780-1677 AIC No; (207)7t30-6377 Cross Insurance -Portland ADDRESS:kperreault@crossagency.com 2331 Congress Street INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE $ 1,000,000 INSURER A:Philadel hia Ins Co Portland ME 04102 INSURED INSURERB Maine Employers Mutual Ins Co 11149 INSURERC: Giddy Up Productions LLC INSURER D: 141 School Street INSURER E : AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON --OWNED HIRED AUTOS AUTOS INSURER F: South Portland ME 04106 COVERAGES CERTIFICATE NUMBER -.16/17 Master REVISION 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 ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR PHPK1544831 10/15/2016 10/15/2017 EACH OCCURRENCE $ 1,000,000 IMAGE TO PREMISES(E. occur ence)$ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO 7 JECT LOC OTHER: GENERAL AGGREGATE $ 1,000,000 PRODUCTS - COMP/OPAGG $ 1,000,000 Professional Liability, $ 1,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON --OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Paraccidenl UMBRELLA LIAB EXCESS LIAB H OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MB (Mandatory in H) EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 1810106677 10/15/2016 10/15/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) r`FRTIFIRATF Flnl r)FR CANCELLATION ACORD 25 (2014/01) IN SO 2 5 1901 40 11 U 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sample Certificate THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE K Perreault/BD7 PeNil pAM""AA-* ACORD 25 (2014/01) IN SO 2 5 1901 40 11 U 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD