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Home My WebLink AboutAlden Park @ Xfinity 10/01/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: XFINITY 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:. WALTER WUNDER, OWNER Whose place of business is: PARK RESTAURANT MANAGEMENT GROUP/DBA ALDEN PARK @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: WALTER WUNDER, OWNER Permit Expires: October 01, 2016 License Number: FS -160 Food Fee: $125.00 Milk & Cream F*/1 BOARD OF HEALTH Alichaec.%CClean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit# Issued FS -160 FOOD ESTABLISHMENT PERMIT APPLICATION r -(App1ica&o_n__musJ�ubmit teaVifeast�ays�reth_e_pVa_nn_ec_F`op_e—nJng_da_ Ue--- WALTER WUNDER, OWNER 1) Establishment Name PARK RESTAURANT MANAGEMENT GROUP/DBA ALDEN PARK @ THE XFINITY C 2) Establishment Address 885 SOUTH MAIN STREET Telephone No: 3) Establishment Mailing Address (if different) 160 COLONY PLACE PLYMOUTH, MA 02360 4- L 1 E-mail: 4) Establishment Telephone No (508) 830-6777 -----�WUNDER(cDALDENPA-RKRESTAURANT.COM Alt E -Mail: 5) Applicant Name & Title: WALTER WUNDER, OWNER 13) District Or Regional Supervisor (if applicable) Name & Title: WALTER WUNDER, OWNER 6) Applicant Address 11 BUTLER ROAD, BRAINTREE, MA 02184 11 BUTLER ROAD, BRAINTREE, MA 02184 7) Applicant Telephone No.: (508) 846-3165 24 Hour Emergency No.: (508) 046-3165 (508)846-3165 24 Hour Emergency No: (508) 846-3165 8) Owners Name & Title WALTER WUNDER, OWNER 9) Owner Address (If different from applicant) 11 BUTLER ROAD, BRAINTREE, MA 02184 I FAX: Owner's telephone number 5088463165 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. V A Corporation Name Title Address El An Individual I L1 A Partnership L1 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc,) Name & Title: WALTER WUNDER, OWNER [Address: 11 BUTLER ROAD, BRAINTREE, MA 02184 Telephone No: (508) 846-3165 24 Hour Emergency No: (508) 846-3165 1 E-mail: -----�WUNDER(cDALDENPA-RKRESTAURANT.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: WALTER WUNDER, OWNER Address: 11 BUTLER ROAD, BRAINTREE, MA 02184 Telephone No: (508)846-3165 24 Hour Emergency No: (508) 846-3165 WUNDER@ALDEN PARKRESTAURANT.COM =E-mail: I FAX: Food Establishment Information 14) WATER SOURCE: ON -BOARD 15) SEWAGE DISPOSAL: ON -BOARD DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: EVENTS @ XFINITY CENTER 18) Name of Person In Charge Certified in Food Protection Management: BRENT E. CLARK 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 J -- --- --- - -- 19) Person Trained in Anti Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permane�n, Location I � 22) Establishment Type ❑ Caterer $12.50 �/❑ Moblie Moblie Start Date: �i / ❑ Retail ( Sq. Ft) FV1 Milk & Cream $5.00 Moblie End Date: WOO W Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: XFINITY EVENTS 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: ❑ Annual or up to 25' PHF display $75.00 ❑ Pushcart $12.50 # of Pushcarts: 0 Seasonal ❑ Food Service up to 201 + ❑ Residential Kitchen $50.00 or 25'+ PHF display $137.50 ❑ Retail Food $50.00 Seasonal Dates: 49 ,i - -- _ -- ❑ Food Service - Institution ❑ Retail Snack Food $12.50 — - — ❑ Temporary Temporary Start Date: 1 ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially Non-PHFs hazardous food (time/temperature controls - non -potentially hazardous food(no time/temperature required) controls required) ,(Check all that apply): RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) 0 Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs FV_1 Preparation of PRFs For Hot And F] PHF and RTE Foods Prepared For Highly ----- ----------- --- --- Cold Holding For Single Meal Service ❑ Delivery of Packaged PHFs --- --- Susceptible Population Facility _ -- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer 1 - - - -- ❑ Reheating of Commercially _ -_-_ -_ - -_-___ _. -_ ❑ Vacuum Packaging / Cook Chill ------i Processed Foods for Service Within 4 Hours --- - . -- F] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- Customer Self -Service Customer Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for ale _ Retail Sale----- LPerishable F -1 Preparation of Non-PHFs - i ❑ Offers Raw Or Undercooked Food Of _ Other Food Operations ❑ Juice Manufactured and Packaged for Juice Retail Sale Animal Origin -� ❑ Prepares Food/Single Meals for ❑Offers RTE PHF in Bulk Quantities u Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service -- - - ---- - or Reconditioned Food To be completed by the Board of Health I, the undersigned, attest to the accuracy of Pe inforrat on prop establishment operation will co pi 1, 1 ( R 5r 0. 00 and board of health on how to obtain of ,� C 5 .000 ar 24) Signature of Applicant: iotai Permit ree: 4)-izo.vv Payment is due with application ❑ waived ethis application and affirm that the food r applicable law. I have been instructed by the federal Food Code. 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: 27-2086831 26) Signature of Individual or Corporate Name: U I )V"- Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: PARK RESTAURANT MANAGEMENT GROUP/DBA ALDEN PARK @ T ADDRESS: 885 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 830-6777 FAX NUMBER: OWNER OF BUSINESS: WALTER WUNDER, OWNER TELEPHONE OF OWNER: 5088463165 FEDERAL ID/SS NUMBER: 27-2086831 FEE: $5.00 PERMIT NUMBER: FS -160 SIGNATURE: DATE: 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. * Signature of Individual or / ✓ Corporate Name (Mandatory) Etc, (Mandatory, if applicable) d7_J' OVIIU 1 ** 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 01 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 k1ri www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le 'bl Business/Organization Name: Gh �c4a&\_01A o �} r e Address: 16 0 (O(O V\ % a& �.�. City/State/Zip: 20Phone #: 43�6`Z%7 Are you an employer? Check the appropriate box: Business Type (required): 1 l 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, F1 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' camp. insurance required]* 11.0 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 tl l 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 d 1. I am an employer that is providing wor� ers' compensation infurance for my employees. Below is the policy information. Insurance Company Name:M&}--LCihwG Insurer's Address: ip� 0)( <% 2-2?— City/State/Zip: 1414(x'21 r -S Policy #'or Self -ins. Lic. #, 01 I Dp i , ��f 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 DTA for insftrance verage verificoo& I do hereby Phone #: !if/y, r er a ains d enalties of rjury that the information provided above is true and correct / Date: 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 #: Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) INFORMA'ION PAGE JRENEWAL AGREE WT PRODUCER: A ent# 812 Renaissance Alliance Insurance Ser 981 Worcester St Wellesley, 31A 02482 Carrier Policy #: 014005032595116 Carrier Prior Policy #: 014005032595115 1. The Insured: Park Restaurant Management Group, LLC Alden Park Mailing Address: 160 Colony Place Plymouth, MA 02360 Fein• Other workplaces not shown above: Type of Business: NO OTHER WORKPLACES FOR THIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on __1./01/2016 to 12:01 a.m. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies state listed in Item 3.A. The limits of our liability under P Bodily Injury by Accident $ 1..000,000 each ac Bodily Injury by Disease $__ ..._ .._ 11000,000 policy Bodily Injury by Disease $ _ ____ 1_, 000,.000.. __- ... each em C. Other States Insurance: 272086831 Corporation 1/01/2017 - the Workers work in each Two are: t D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000308 WC000414(07/90) WC000422B(01/1 ) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required elow is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 f Annual Annual Remuneration Remunera ion Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 3,989.00 Minimum Premium $ 294.00 Expense Constant .00 Dep sit Premium cv ayY �i Q ctf C 6 Z Z AmmumF- � Q CC U O �. L- Q � X Lu LU U W 1 z 1�.. jr is m c O F- c v Vol T— O r N C� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH BOARD OF HEALTH 2016 BUSINESS LICENSE PARK RESTAURANT MANAGEMENT GROUP, LLC D/B/A ALDEN PARK 160 COLONY PL PLYMOUTH, MA 02360 DBA: ALDEN PARK Your 2016 Business License for A LICENSE TO OPERATE A CATERING ESTABLISHMENT is printed below. Please retain a copy for your records. If changes please come down to the Board of Health in person. If you have any q call the Health Department at 508-747-1620 ext. 118. _ CID #: 217339 3L ID #: 101306 are any ►ns, please Iwo THE COMMONWEALTH OF MASSACHUSETTS FEE TOWN OF PLYMOUTH $150 a BOARD OF HEALTH 2016 This is to certify that: PARK RESTAURANT MANAGEMENT GROUP, L C ALDEN PARK Located at: PLYMOUTH, MA 02360 Has been granted: A LICENSE TO OPERATE A CATERING ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A andC�apter 111, Section 5 of the General Laws and 105 CMR 590.000 Expiration date: December 31, 2016 �A Signature ' r " LICENSES ARE NOT TRANSFERABLE THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH m BOARD OF HEALTH 2016 BUSINESS LICENSE PARK RESTAURANT MANAGEMENT GROUP, LLC D/B/A ALDEN PARK 160 COLONY PL PLYMOUTH, MA 02360 DBA: ALDEN PARK Your 2016 Business License for A PERMIT TO OPERATE A FOOD ESTABLISF printed below. Please retain a copy for your records. If there are any changes please to the Board of Health in person. If you have any questions, please call the Health T at 508-747-1620 ext. 118. Operating: Located at: Has been granted: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH BOARD OF HEALTH 2016 PARK RESTAURANT MANAGEMENT GROUP, ALDEN PARK PLYMOUTH, MA A PERMIT TO OPERATE A FOOD EST. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and 5 of the General Laws and 105 CMR 590.000 Expiration date: December 31, 2016 Signature LICENSES ARE NOT TRANSFERABLE CID #: 217339 L ID #: 101306 T is down FEE $ 300 111, Section ,,of2 k-_