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HomeMy WebLinkAboutTasty Bite @ Xfinity 08/05/2016Commonwealth 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: 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:. ANITA SCHULTZ Whose place of business is: TASTY BITE C/O BIG FISH PROMOTIONS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: ALICIA MARTINO/PROJECT MANAGER Permit Expires: August 05, 2016 License Number: T-150 Food Fee: $50.00 BOARD OF HEALTH NichaeCvLcCtean, Chairman FOR BOARDOF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued "s 2�-a Xfinity Temporary Food Establishment Permit Application (Application must be submitted at least 7 working days before the planned event.) 1) Establishment Name: C'10 2) Establishment Address:tt��'y ��yW �� � � CA C� 3) Establishment Mailing Address(ifdifferent): 4) Establishment Telephone No: r WA,a, 5) Applicant Name & Title: A ; G\C".- mw' ---Y` 6) Applicant Address: >C) ^ S SS_ r- cN C) 7) Applicant Telephone No: 6;`t�r 24 Hour Emergency No:" � ��F �C"� 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): CJ 10) Establishment Owned By: (D An association m A corporation JK An individual 0 A partnership GD Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address -- 12) Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: ;( ,� Address: Com VC� �t , r -�� (l C.-- 60 , Telephone No: �!) - CAA 0o Emergency Telephone No: I -\ 1 13 District Or Regional Supervisor(if a /icabl'e) Name & Title: Address: Telephone No: 5 app kation -2, oc Fax: Food EstahliShmrant Infnrmatir,n 14) Water Source: ���� \��'��,� �(,t ® 15) Sewage disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: F y��7 a �C>VtA I� a30 30 ?VA 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management:�� Required as of 10/1/2001in accordance with 105 CA4R 590.003(A) Please attach copy ofcedificate. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes ® No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Permanent Structure ❑ Food Service - ( Seats) ❑ Residential Kitchen for Retail Sale Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service - Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) LlT Annual �,, ti ej" ❑ Seasonal/Dates: 4�1� v J6 IS -J, Temporary/Dates/Time: 23) Food Operations: Definitions: PHF- potentially hazardous food(timeltemperature controls required) Non-PFIFs - non- potentially hazardous food (no timeltemperature controls required) (check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre- ❑ PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service. ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And. PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Delivery of Packaged PHFs ❑ Sale Of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer. ❑ Reheating of Commercially ❑ Customer Self -Service ❑ Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service Of Non- ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Only. ❑ Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Offers IRTE PHF in Bulk Quantities _ Other (Describe): To be completed by the Board of Health Total Permit Fee ($25 per day):%�_ ❑ Retail Sale of Salvage, Out -of Date or Reconditioned Food Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and 1 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 690.000 .and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid stag; taxes required under law. 25) Social Security Number or Federal ID: 06,6 \ 26) Signature of Individual or Corporate Name:\ 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Volttntanj) or Federal Identification Number '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\ScotVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations U10 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:�� Address: �So � ffl (1(7es e7�, -5�-. City/State/Zip: �e��n �) , C:r� (� 6c 3 Phone 4 C) Are you an employer? Check the appropriate box: Business Type (required): 1. Yl am a employer with I'D employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7. ❑ 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( .), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. 0 Health Care with no employees. [No workers' come. insurance req.] 12. Other V<0 (lr10k- r ©rV6 *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but die corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: moyuC�_\ 0 I�Y5 UQ3_. cle Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. # i5) G 5 1 �' �j Expiration Date: d atJ� 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. Sij?nature:�A.f`� �� _Date: Phone #: C6 ® " 52) -- '� �S) r) 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.gowma WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AR INFORMATIONI PAGE Issued by LM INSURANCE CORPORATION 27243 Policy Number KC5-31S-611837-015 NEW BUSINESS NEW Account Number 1-611837 1. Insured and Mailing Address BIG FISH PROMOTION'S LLC s0 COMMERCE ST GLASTONBURY, CT 06033 UbeMMutual INSURANCE 175 ger Ift Street Boston, MA 02116 Issuing Office 0354 Issue Date 10-27-15 Sub Account 0000 RISK ID 911833204 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 11-09-2015 to 11-09-2016 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Peart One of the policy applies to the Workers Compensation Law of the states listed here: CT NE B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the stag, if any, listed here: REFER TO RESIDUAL MARKET LUMTED OTHER STATES INSURANCE ENDORSEMENT WC 00 03 26A D. This policy includes these endorsemew-its and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimatel Annual Remuneration of Remuneration Premium See Extension cif Information Page Minimum Premium $ 1,250 (CT) Total Estimated Annual Premium $ 34,025 Premium will be billed ANNUAL Producer 0004-178888 J P SVENDSEN AGENCY PO BOX 3975 WOODBRIDGE CT 06525-0975 WC 00 00 01 A ®1987 National Council on Compensation Insurance,lnc. Ed. 07/01/2011 All Rights Reserved Insured Copy WC 00 00 01 B (CA) Page 1 of 1 June 30, 2017 Expiration Date TOWN OF GLASTONBURY FOOD SERVICE LICENSE BIG FISH PROMOTIONS Is duly authorized to conduct_a Food Service Operation in compliance with the requireinent. of the Public Health Code of the State of Connecticut. Anita Schultz Owner/Operator License # F-17-71 tel. Dire oro ealth .M C: C: ca m '0 ;axonq g c co M c 0 N N h c� rn H c Y uoi}els dead algel .fi .M C: C: ca m Big Fish Promotions, LLC 80 Commerce Street Glastonbury, CT 06033 PH 860-633-4400 FX 860-633-4482 Providence, RI °`t -J' ,J N August 1, 2016 To whom it may concern, Enclosed you will find an Application for a Temporary Food License for Tasty Bite. Tasty Bite will have a sampling tent set up at the 8/3 G-Eazy and 8/5 Florida Georgia Line Concert at the Xfinity Center. Tasty Bite will be handing out free 2 oz samples of Madras Lentils and Long Grain White Rice. The product is shelf stable, pre-packaged pouches. However, we will be opening the pouches to warm them up to hand out. All the necessary paperwork and payment is enclosed. I will be the main contact if there are any issues and I can be reached by Phone at 860-633-4400 or cell after business hours at 203-379-8511, or by email at amartino@bigfishpromotion.com . If you have any questions please feel free to contact me. Thanks so much for your help and have a wonderful day! Sincerely, Alicia Martino Project Manager Big Fish Promotions 80 Commerce Street Glastonbury, CT 06033 (P) 860-633-4400 (F) 860-633-4482 amartino@bigfishpromotion.com ®R - www.bigfishpromotion.com we get your brand into their hands a o C m 00 O UJ d c r z � tU 0 Z ILa 1L n IDC W W-0 0 W-4 � � u OM -4 W10 *--0 AR [�J Q� z *--0 z V) � � z w P4 � � z � � � W-4 � � owi � —W G V7 91 ( @G4 / V7 91