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HomeMy WebLinkAboutMansfield Music & Arts 09/18/2016t .<, Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 °ermit to Operate a Food Service Establishmen 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:. DAVID COCCIA Whose place of business is: MANSFIELD MUSIC & ARTS SOCIETY NORTH COMMON PERSON(S) IN CHARGE f./A01-.Il 1114:4 Permit Expires: September 18, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-153 BOARD OF HEALTH MichaeCNcCCean, Chairman WAIVED FOR BOARD OF HEALTH USE ONL . 3'` +moi Date received: Date Inspected: Approved Permit # I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at leastdays before the planned opening a e 1) Establishment Name iAV\ 0\ VW_kS ( C -4- 6 VZ, 2) Establishment Address S-77 ® � 'St [Mn,vkS b ,e k eQ QUA 3) Establishment Mailing Address (if different) 4) Establishment Telephone No S c) 5) Applicant Name & Title: 6) Applicant Address G b S x'14 ✓Z v`L. rA v-4- Vvui "S ITIr � l , 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation !' Name Title Address An Individual Lc C� V��2es�e� �i� S ��t 3 I%�-cC� rtu l� �`_e _p_ ���s_ _ Zi NI2c-,r(_-9 02 -- A Partnership Other legal Entity L �,& u4- 2�c, �e �� "`j'I? �e W4s 2 w V-. Q 14 � 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: 1 Address: Telephone No: cM,i �s e �� �-�.��� CQ- A � r _ 24 Hour Emergency No: FAX: -\e_.eVW1 Wt A - -- - - --- - E-mail: - Alt E -Mail: �_ K ----- ---- ----- 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: - - ---- FAX: - — --- E-mail: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 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): _ �^ 20) Location: ^' Permanent Location 22) Establishment Type Mobile Moblie Start Date: i, ; Retail ( Sq. Ft) Mobile End Dale: ;,,1 Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: Annual Seasonal Seasonal Dales: Temporary Temporary Start Date: `I ( i 'I I Temporary End Date: �.. Temporary Time: Rain Dale: ii,' j 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 Dessertsllce Cream $25.00/freezer Pushcart $25 # of Pushcarts: A Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 23 Food O erations I Definitions: PHF- Potentially hazardous food (timeAemperature controls required) p Non-PHFs - non -potentially hazardous food(no timeAemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 1 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 Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non PHFs Other Food Operations 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 Juice Manufactured and Packaged for 1?1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ` _'� )Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals forCatered Events or Institutional Food Service j 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 580.00 and the federal Food Code. ���24) Signature of Applicant' —� d 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 slate tax returns and paid stale taxes required under law. t f` 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, have filed all State tax returns and paid all State taxes required under law. NK M C%� S * Signature of Individual or Corporate Name (Mandatory) By: ` Corporate 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/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: VVI, VAl - cpj( Address:_ Z:2 -?'2 _ K y4�� VP,-� d,, sl City/State/Zip: P ( c Phone #: 3 1�:l - Z !�7- 2- 2 - Are you an employer? Check the appropriate box: 1..01 am a employer with 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 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.] 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 1111 health Care 12.❑ Other *Any applicant that checks box N 1 must also fill out the section below showing their workers' compensation policy information. -irthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box i11. I am an employer that Is providing workers' compensation insurance for my employees. Below is the policy information. (2=6810 Insurance Company Name:L Insurer's Address: " l U -1-e City/State/Zip: ( c) V-4-" (D I �-S / Policy # or Self -ins. Lic. # O k 7--- Seo 0 ? �� `U_�,_ftxpiration Date: i t c2 t ? 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, tinder the pains �and/penaltles of perjury that the information provided above is true and correct clonAr,rrp / -L ( � Date: 1 I d l 6 -2- official use only. Do not write /it 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: Phone www.mass.guvrum AC"R © CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 07292D16 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 Patricia Smith, CPCU, ARM, AAI NAMEFred C. Church, Inc. 41 Wellman Street PHONE 978 3227217 FAX(978) 454-1865 Awjll X* 10 N0 1: No. _ Loy/ell, MA 01851 E-MAIL ADDRESS:psm11hQ1redcchurch,com (800)226.1865 INSURER(S) AFFORDING COVERAGE NAIC 11 _ INSURER A: Church Mutual insurance Company 18767 INSURED The Now England Annual Conference of The United Methodist Church INSURER B: INSURER C:__— PA. Box 24D 276 Essex Sbeel INSURER D Lawrence, MA 01842.0449 INSURER E; INSURER F: GOVERAGES CERTIFICATE NUMBER' 56776 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 TYPE OF INSURANCE ADDL�SUBR - POLICY NUt4BER M MODnYYY MMID NYXYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA 1 GE TO eE Cu D n e pgymfses $ 300,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one pe(son) $ 15,000 CLAIMS -MADE D OCCUR PERSONAL &ADV INJURY $ 1,000,000 A 026125002915535 81112016 8/112017 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 $ POLICY PRO- LOC COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea aCCIde01 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ A gUTOSULED 026125002915535 8/1/2016 811/2017 AUTOSNED N X X ON -OWNED PROPERTY DAMAGE P r Edon $ _ HIREDAUTOS AUTOS $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 10,000,000 $ AGGREGATE $ 10,000,000 A EXCESS LIAR X CLAIMS -MADE 026125081915537 811!2016 8/1/2017 _ $ _ _ I X RETENTION$ 10,000 DED] ORKERS COMPENSATION WAND X WC STA7U- OTH- ELEACH EACH ACCIDENT $ EMPLOYERS' LIABILITY500,000 A ANY PROPRIETOWPARTNER/EXECUTIVE � OFFICERIMEM13ER EXCLUDED? N / A 026125007856581 1/1/2016 '1/12017"' 500,000 (Mandatory In NH) E,l. DISEASE • EA EMPLOYE $ _ E.L. DISEASE -POLICY LIMIT $ 500,000 Ilyes, describe undef DESCRIPTION OP OPERATIONS below DESCRIPTION OF OPERATIONS! LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is rolulred) Evidence of Coverage for Faith Fellowship United Methodist Church, Mansfield, MA use of premises at MMAS Black Box Theater for worship services Mansfield Music & Arts Society 377Norih Main Street Mansfield, MA 02048 Client 0 ACORD 25 (2010/05) 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 X11 c�<a t_ r \f n 10RR.9n1n ACORn CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Mansfield Board of Health Date We, V \ U request a waiver of the Food Service Permit Fee for the following reason Thank you, Signature Title Jane Doucette From: Sent: To: Cc: Subject: Hi Jane, The # is 042195414 Dave Coccia, Dave <davecoccia@verizon.net> Friday, September 16, 2016 10:37 AM Jane Doucette Ken Butler; DAVE@MMAS.ORG Re: MMAS FOOD PERMIT On Sep 16, 2016, at 10:34 AM, Jane Doucette <Jdoucette@mansfieldina.com> wrote: Hi Ken and Dave, I will need your FID #. The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it, if you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and rnalware, and may have been autonfraticaliy archived by Mimecast ttd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your Truman generated data, Specializing in; Security, archiving and compliance. To find out more Click Here. June 1, 2016 David Coccia 60 Stearns Avenue Mansfield, MA 02048 Dear Mr. Coccia: Town of Mansfield 6 Park Rory, Mansfield, Massachusetts 02048 Board of Selectmen At its meeting on March 2, 2016 the Board of Selectmen approved your application for the MMAS Arts and Music Festival, September 17-- 18, 2016 at the North Common from 8:00am — 5:00pm. Please note the following list of restrictions that the Board advises you pay close attention to: • Per Chief of Police Ron Sellon, contact Lieutenant Tracy Juda at the Mansfield Police Department a MINIMUM of two weeks prior to the event to schedule proper detail coverage. No vehicles will be allowed to park on North Main Street, Crocker Street or Chauncy Street (surrounding the Common). The contact number for the Mansfield Police is 508-261-7301. • Per Fire Chief Neal Boldrighini, if propane is to be used a permit must be obtained through the Department. The contact number for the Mansfield Fire 508-261-7318. • Per the Board of Health Agent, Scott Leite, food permits are required and must be in hand five days prior to the event. The contact number for the Board of Health is 508-261- 7366. • Per the Building Inspector, Bob Blackman, a tent permit is required for tents over 700 square feet. The contact number for the Building Department is 508-261-7360. • Please contact the Park and Recreation Department with regards to scheduling the North Common and submission of your insurance certificate. At this time no publicity has been approved as this office has not received any drawings for approval. If there are any changes to your event please notify the Board of Selectmen's office immediately. As always, if we can be of any assistance, please contact us at 508-261-7372. Sincerely, tC� �alen Tracey Executive Secretary, Board of Selectmen cc: Police Chief Ron Sellon Fire Chief Neal Boldrighini Board of Health Agent Scott Leite Building Inspector, Bob Blackman Park and Recreation Director, Sherri Gurnon