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HomeMy WebLinkAboutM.Fanelli Travel 05/08/2016Commonwealth 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: FOOD SERVICE TEMPORARY 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:. MARK FANELLI Whose place of business is: MARK FANELLI TRAVELING - XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: PAULA M. CUSHING-POTE Permit Expires: May 08, 2016 License Number: FS -134T Food Fee: $100.00 BOARD OF HEALTH 7vlichaecNcCtean, Chairman 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: TEMPORARY FOOD PERMTI 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:. MARK FANELLI Whose place of business is: MARK FANELLI TRAVELING - XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: PAULA M. CUSHING-POTE Permit Expires: May 08, 2016 License Number: FS -135T Food Fee: $100.00 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit# Issued FS -135T FOOD ESTABLISHMENT PERMIT APPLICATION F___' (Application must esumiffsat least 30 day_s Veffi-re—the planned opening datq)—__] 1) Establishment Name MARK FANELLI TRAVELING - XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) P.O. BOX 249 RINDGE, NH 03461 4) Establishment Telephone No (978) 634-0701 5) Applicant Name & Title: GIAVANA FANELLI 6) Applicant Address 44 GRAHAM STREET, LUNENBURG, MA 01462 1 -7) -- Applicant --Telephone No.: (978) 230-2321 24 Hour Emergency No.: (978) 230-2329 a i I., 00/y, 8) Owners Name & Title MARK FANELLI 9) Owner Address (If different from applicant) 41 CASPIAN WAY, FITCHBURG, MA 01420 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 11 An Association or partner. W A Corporation Name Title Address 0 An Individual El A Partnership El Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: DAN TIBITS6 oPJ9alJ9 / # u to 17q A 2 CuShj' t_� 1 --poo Wi /M 1170 Telephone No: (603) 770-1784 24 Hour Emergnq No: (97) 230-2329 FAX: E-mail: Man'onS Yi'edolOi a i I., 00/y, Alt E-mail: 13) District Or Regional Supervisor (if applicable) Name &,Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 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 SERVICE TEMPORARY 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:. MARK FANELLI Whose place of business is: MARK FANELLI TRAVELING - XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: PAULA M. CUSHING-POTE Permit Expires: May 08, 2016 License Number: FS -136T Food Fee: $100.00 BOARD OF HEALTH MichaeCMcCCean, Chairman A� " CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD/YYYY) 03/08/2016 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 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 Allied Specialty Insurance, Inc. 10451 Gulf Blvd CONTACT NAME: (2N o E • (FAX No): E-MAIL ADDRESS: Treasure Island, FL 33706-4814 INSURERS AFFORDING COVERAGE NAIC# INSURER A: T.H.E. Insurance Company 12866 PREMISES Ea occuDAMAGE TO rrence) $ INSURED Mark Fanelli's Traveling Amusement Park INSURER B : PERSONAL & ADV INJURY $ P 0 BOX 249 INSURER C: INSURER D: Rindge, NH 03461 INSURER E: AUTOMOBILE INSURER F: COVERAGES CERTIFICATE NUMBER: 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 NUMBER POLICPOLICY MM/DDY EFF POLICY Y PLIMITS AUTHORIZ RREPRESENTATIVE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ PREMISES Ea occuDAMAGE TO rrence) $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F_� JECTPRO F—]LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDNON-OWNED AUTOS ONLY AUTOS ONLY COMEaBINED SINGLE LIMITdent $ acci BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIvE OFFICER/M EMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WCP0004451 013 04/16!2016 04/16/2017 �/ X STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is afforded in the State(s) of: CT, MA, NH & RI CERTIFICATE HOLDER CANCELLATION ©1988-201"CORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ RREPRESENTATIVE (/41a ©1988-201"CORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ai iI A w Z w p co Q N cz Z c E a X .� e-- w p 0 CD LL (V o O.a g Lu o X ` Q r- N w o `o w FM w�c my -i I w '1 H Q [ OR o C4 A 7 ey Q 'b m � , � a �•-� UQ;s .n I m w o bO CL fi O 0 h O v V tai �• � � bo t a v m �6 _0 a) 4- Q) CL E 0 U vi E 0 tO 4-� O W" F- 0 .Q 0 U V a3 j, 0 ai -j3 -u cz UJ CD -E'If u 0) cc = cn cn In 0 cz wul o 0 N Lf) �D N 0 U -j UJ M - 6 Lf) D U 0 4- ra -E o v,)' u 00 alf LN P t^ • ci N Fti O m G �, ❑ cqv 3 q '= O pu e� `-ipu Wk+ o47,� a wj 0 0 Q1 O H //mayy P t^ • ci N Fti O m G �, ❑ cqv 3 '= O pu e� `-ipu Wk+ o47,� 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 Avl2licant Information Please Print Legibly Business/Organization Name; Hfttek an Trawhro Amoeiner Y k Address: T 0, (2 City/State/Zip:AM I Phone #: Q � Are y an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6,estaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, Fj Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• 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.❑ Manufacturing no employees. [No workers' comp, insurance required]* I l ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'_comp. insurance req.] 12.❑ Other *Any applicant that checks box 91 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 #I. I am an employer that is providing v rker ' com ensatioonn^insurance forfmy employees. Below is the policy information, Insurance Company Name: / e �J l� ! � a %a a ' C f Insurer's Address: City/State/Zip: tt a T5 ha L 331106— ql� Policy # or Self -ins. Lic. # C�® lJ�'7"� J Expiration Date:J & jo j 7. Attach a copy of the workers' compensation policy declaration page (showing the policy number nd 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 par and penalties of perjury that the information provided above is true and correct Sitrrrature:�/f'/(�J�+� /' � Data: Phone #: 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: www.mass.gowaia Phone 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. ZL. ___ � /C-4, _�� - * Signature of I dividual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ® �/ 395 ** 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. FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -134T FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MARK FANELLI TRAVELING - XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) P.O. BOX 249 RINDGE, NH 03461 4) Establishment Telephone No (978) 534-0701 6) Applicant Name & Title: GIAVANA FANELLI 6) Applicant Address '44 GRAHAM STREET, LUNENBURG, MA 01462 7) Applicant Telephone No.: (978) 230.2329 24 Hour Emergency No,: (978) 230-2329 8) Owners Name & Title MARK FANELLI 9) Owner Address (if different from applicant) *41 CASPIAN WAY, FITCHBURG, MA 01420 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers i El An Association or partner. O A Corporation Name Title Address 1:1 An Individual r0A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: DAN TIBITS (60'shloo- Rk 41 atcb'�(s Poo wlm)�akn (603) 770-1784 24 Hour Emergeno-fd: (97,8) 230-2329 FAX E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: 14) WATER SOURCE TOWN Food Establishment Information 15) SEWAGE DISPOSAL: SELF CONTAINED DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: Soo / Z — 5 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 Mobile Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Mobile Comments: up to 10' PHF display $62.50 21) Length of Permit: ❑ Annual ❑ Seasonal Seasonal Dates: ❑ 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 Temporary ❑ Food Service - Institution Temporary Start Date: %n�( it y 1 ( Meals/Day) Temporary End Date: / 1 Temporary Time: Rain Date: DAN TIBBETTS 'Paula M Cu hhrt�q��r.��@. ❑ Caterer $12.50 ❑ 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 23) Food Operations Definitions: PHF - Potentially hazardous food (time/lemperature controls required) Non-PHF's - non-potentlally hazardous food(no time/temperature controls required) Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ 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 (�/I Preparation of Non-PHFs Other Food Operations FRIED DOUGH 1, the undersigned �t to the accuracy establishment eration will comps wi board of hea on how tort ' es c ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held I ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility - to be Prepared by Consumer [_1 Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance E]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 ❑ Offers RTE PHF In Bulk Quantities Catered Events or Institutional Food Service i ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $100.0 — Payment is due with application waived itiFvid din thi apSe4 the food 011 — 0d other ppliceen Instructed by the 1J.an the fe eraI F 24) Signatu of Applicant: (� Pursuant to M A, certify under the pena les of and paid state taxes required under lbw. 25) Social Security Number or Federal ID: 02-0449395 26) Signature of individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -136T FOOD ESTABLISHMENT PERMIT APPLICATION -- " ----pp ica ion mus esu mi e a least30—days e ore f e p a� nn ed opening a e - 1) Establishment Name MARK FANELLI TRAVELING - XFINITY CENTER A5uirseo 1 0 --I 2) Establishment Address 885 SOUTH MAIN STREET —j 3) Establishment Mailing Address (if different) P.O. BOX 249 E-mail: RINDGE, NH 03461 Alt E -Mail: 4) Establishment Telephone No (978) 534-0701 5) Applicant Name & Title: GIAVANA FANELLI 6) Applicant Address 44 GRAHAM STREET, LUNENBURG, MA 01462 7) Applicant Telephone No.: (978) 230-2329 24 Hour Emergency No.: (978) 230-2329 8) Owners Name & Title MARK FANELLI 9) Owner Address (If different from applicant) 41 CASPIAN WAY, FITCHBURG, MA 01420 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. W A Corporation Name Title Address ❑ An Individual _ ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisojApanager etc.) Name & Title: DAN TIBITS P/V f' ✓ M / f� Address; A5uirseo 1 0 --I _� Telephone No: (603) 770-1784 978 45-06 8,124 Hour Emergency No: (97 0.2329 FAX: E-mail: / Il')l�►',�n S ~ �'_Q�®ul hd,7� Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: i Telephone No: 24 Hour Emergency No: FAX: E-mail: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: 16) No. of Food Employees: 17) DAYS/HOURS: lhaf-S /o 0 18) Name of Person In Charge Certified in Food Protection Management: DAN TIBBETTS If more than 3 individuals are certified, complete list is on file. SELF CONTAINED an /Z-� e uired as of 101112001 in accordance with 105 CMR 590.003 A Please attach co of 611 v �� g P, Required () PY certificate 19) Person Trained In Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑ Annual ❑ Seasonal Seasonal Dates: Temporary nn��] Temporary Start Date: /�IGi,�/ J� �j47 Temporary End Date: %' eu7 9 b') Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ 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) ❑ Caterer $12.50 ❑ 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 23) Food Operations Definitions: PHF - Potentially hazardous food (Ume/temperature controls required) I Non-PHFs - non -potentially hazardous food(no time/temperature controls required) II (Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I ❑ 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 F-/1 Preparation of Non-PHFs Other Food Operations POPCORN, CANDY/CARAMEL APPLES, SNO CONES COTTON CANDY 1, the undersigned, attest to the a of the establishment operation omply wit 105 C board of health on b to obtain of 1 i ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly F-1Saleof Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill E]Use of Process Requiring A Variance ElCustomer 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 ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health --" Total Permit Fee: $1?Iwaived Payment is due with application tion ro din this a I catio an affir at the food 000 p d I other applpble . w. I av ben instructed by the 24) Signature A�pjjcarrfv u V 1 Pursuant to M L Ch.62C I rtify under the penalf sof and paid state taxes`requir nder law. 25) Social Security Number or Federal ID: 02-0449395 26) Signature of Individual or Corporate Name: I, to my best knowledge and belief, have filed all state tax returns