HomeMy WebLinkAboutMansfield Y Soccer 11/30/2016Commonwealth 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: 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:.
ANTHONY BRUNO, OWNER
Whose place of business is:
MANSFIELD YOUTH SOCCER FIELDS
32 PLYMOUTH STREET
PERSON(S) IN CHARGE
ANTHONY BRUNO
Permit Expires: November 30, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee: $67.50
License Number: FS -162
Milk & Cream V
BOARD OF HEALTH
michaeCMCCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
pp ica ion mus esu mi e
1) Establishment Name �� r, _0
a eas ays a ore e p anne opening a e
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2) Establishment Address
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3) Establishment Mailing Address (if different)
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4) Establishment Telephone No
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5) Applicant Name & Title: r1���n.�
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6) Applicant Address ��tr,�E,;c(� e oj� r) -
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:
D An Association
W1 A Corporation
D An Individuals
D A Partnership
D 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.)
Name & Title:
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Address:
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Telephone No:
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24 Hour Emergency No:
FAX:
E-mail:
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P c = �,r�,,_5 (� � , 1 �•
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
__T_
E-mail:
Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
16) No. of Food Employees:
DEP Public Water Supply No: (If applicable) (1
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
i] Caterer $12.50
] Moblie Moblie Start Date:
Retail ( Sq. Ft)
[;(Milk & Cream $5.00
Moblie End Date:
Food Service up to 100 or
] Mobile Food & Consession $37.50
Moblie Comments:
up to 10' PHF display $62.50
Food Service up to 101 -200
]Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
21) Length of Permit:
5. Annual
or up to 25' PHF display $75.00
] Food Service up to 201 +
or 25'+ PHF display $137.50
] Food Service - Institution
( Meals/Day)
] Pushcart $12.50 # of Pushcarts:
] Residential Kitchen $50.00
Retail Food $50.00
F-1Retail Snack Food $12.50
] Tobacco Products $12.50
] Seasonal
Seasonal Dates: (),Cf �- ��4 �fdcc
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food (fime/temperature controls required)
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)
Sale of Commercially Pre -Packaged Non-PHFs
]T 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
Cold Holding For Single Meal Service
] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
E]Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
] Customer Self -Service of Non PHF and Non-
Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control)
] Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs
] Offers Raw Or Undercooked Food Of
Animal Origin
Other Food Operations
Juice Manufactured and Packaged for
Retail Sale
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
El 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 Food Code.
24) Signature of Applicant:
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:
26) Signature of Individual or Corporate Name:
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: � � • ��r�-r,6� ��=n c�:5 � -�f� t
LL
Address:
al &u C k6,v" I e S 511, eel i
City/State/Zip: JV
v Phone #
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 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.]
�' �, 6 —q E; X — cl I Y L,J
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 poucy rmunnauUn.
* *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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company N
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. #_
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 the pains and penalties of perjury that the information provided above is true and correct.
Signatureist \
Date:��' q� fj
Phone ih ` C4 C q q
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: Phone #:
www.mass.goviara
ACCW" CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
05/13/2016
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
Bizlnsure LLC
222 Broadway Suite 6
Oakland, CA 94607
CONTACT
NAME:
PHONE (415) 704-1408 aC No):
AIC No Ext :
E-MAADDRESS: su ortbizinsure.com
INSURERS AFFORDING COVERAGE NAIC H
INSURER A : Berkley Regional Specialty Insurance Company 31295
LIMITS
INSURED
INSURER B :
INSURER C :
Anthony Bruno DBA AJ Bruno Concessions
INSURERD:
996 Charles Street
North Providence, RI 02904
INSURER E
INSURER F
oCVICIf1N HIIIMRFR•
COVERAGES t;tKI ItK.A 1 c Numor-M.
LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE
OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADDL SUER POLICY EFF POLICY EXP
TR TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MM/DDIYYYY
LIMITS
A GENERAL LIABILITY 0068826 05/13/2016 05/13/2017
RRENCE ENTED $ 1,000,000
EA HOCCUEF
$ 100>000
X COMMERCIAL GENERAL LIABILITY
PREMISES Ea occurrence
N/A
CLAIMS -MADE FRI OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 2 000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
X1 POLICY M PRO M LOC
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS AUTOS
PROPERTY DAMAGE $
NON -OWNED
Per accident
HIRED AUTOS AUTOS
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
__-DE_DT1
RETENTION $
WORKERS COMPENSATION
WC STATU- OTH-
I E
E.L. EACH ACCIDENT $
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE❑
OFFICER/MEMBER EXCLUDED?
N / A
E.L. DISEASE - EA EMPLOYE $
(Mandatory in NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
I
II
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
This certificate is issued for evidence purposes only.
HU
Anthony Bruno DBA AJ Bruno Concessions SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
996 Charles Street ACCORDANCE WITH THE POLICY PROVISIONS.
North Providence, RI 02904
AUTHORIZED REPRESENTATIVE --
r, eeoo -)nen Acnon nnRPr)RATInN- All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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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.
�^ P
�� .� /J � .�• pi'JnD
Signature of Individual or Corporate Name
"Social Security No. (Voluntanj) or Federal
Identification Number
By: Corporate Officer (Mandatorti, 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.doc