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HomeMy WebLinkAboutAlberto's Tri Town Tasting 10/4/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishmen 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:. TIMOTHY MCCARTHY Whose place of business is: ALBERTO'S - 9TH ANNUAL TRI -TOWN FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE TIMOTHY MCCARTHY, OWNER Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-131 BOARD OF HEALTH 'AlichaeC.9�IcCCean, Chairman WAIVED `14 Date Received Date Inspected Approved By Permit # Issued Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: L 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No: - 24 Hour Emergency No: C 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: • An association • A corporation 4 An individual • A partnership • 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 Direct) v Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Mana2er etc.) Name & Title: t �A C- x V Address: P-1 /k Telephone No: C -Fax: Emergency Telephone No: 13) District Or Regional sup rvisor (if applicable) Name & Title: Address: Telephone No: Fax: 590application6-2.doc Food Establishment Information 14) Water Source: _ 15) Sewage disposal: ;° 3 DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: Required as of 10/1/20011n accordance with 105 CMR 690.003(A)pease a tach ca Of Car Cafe. -" 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): (YYes'' ® No 20) Location: 22) Establishment Type(check all that apply) ❑. Caterer (check one) ❑ Retail ( Sq. Ft) I, Food Delivery Com,- Permanent Structure 0 Food Service - ( I °�_> lu Seats) ❑ Residential Kitchen for Retail Sale ❑ Mobile S k Food Service - Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service -- Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) ❑ Annual ❑ Seasonal/Dates: UK Temporary/Dates/Time: Definitions. PHF— potentially hazardous food(timeltemperature controls required) 23) Food Operations: Non-PHFs — non- potentially hazardous food (no time/temperature controls required) (check all that apply): RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre- 1. PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service. ❑ Sale of Commercially Pre- Z- 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 Pian (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service Of Non- ❑ Ice Manufactured and Packaged for i4 Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Only. L Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -of Date or Total Permit Ree: Reconditioned Food Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I 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 59QMQ,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. 26) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: TAX CERTIFICATION FORM 1 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 a r **Social Security No. (Vohlntany) or Federal Identification Nitniber By: Corporate Officer (Mandatory, 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:1Usetsls1eite\Desktop\Scotfs Documents\Food Establishments- Temp1TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industria! 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 l - Business/Organization Name:z; Address: C [ ` City/State/Zip. . � a �� �� � i< - � ,� �,,� �� ��, ���;,�: Phone# s 4 Are you an employer? Check the appropriate box: I. Q 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.] 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. El Manufacturing 11.❑ Health Care 12. ❑ Other '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 the corporation has other employees, a Nvorkers' compensation policy is required and such an organization should check box # 1. I ant an employer that isprovitlirig workers' compensation insitrartce for tuy employees. Below is the policy information. Insurance Company Name: a Q-1, Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # C ! i, ; ! S %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 tap 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 herebv certify, under the pains and penalties of perjury that the information provided above is true and correct. Phone #• Official use only. Do not write in this area, to be completed by ci(v or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk a. Licensing Board 5. Selectmen's Office 6. Other Contact Person: vmw.nlass.gov/dia Phone #: AC®RCERTIFICATELIABILITY INSURANCE DATE (MM/DaYYYYI TYPE OF INSURANCE 5/9/16 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 Twinbrook Insurance Brokerage 400A Franklin Street Braintree, MA 02184 CONTACT Scott Handorff PHONE Edio 781) 843-7000 q/X No): (781) 848-6100 E-MAIL ADDRESS: shandorff INSURE S AFFORDING COVERAGE MAIC# INSURER A: Selective Insurance Co. DAMAGE TO PREMSES(EaENTEoccu encs $ 100,000 INSURED INSURER B:AmTrust North America Inc Alberto's Italian Kitchen INSURER C: Timothy G. McCarthy INSURER D: 241 Mansfield Ave Norton, MA 02766 INSURER E: 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. ILTR TYPE OF INSURANCE ADDL I SR SUBR WVD POLICY NUMBER POLICY EFF MIDDY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR 52187660 8/15/15 8/15/16 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMSES(EaENTEoccu encs $ 100,000 MED EXP (Ary one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 G EN'L AGG REGATE L I MI T APP U E S PE R }{ POLICY PRO- LOC ECT PRODUCTS - COMP/OPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALL O WN -D SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS —AUTOS COTIcNdEeDaSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY $ DAMAGE eracEnt $ A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE 1 52187660 1 8/15/15 8/15/16 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED RETENTION $ Retention $ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBER EXCLUDED? (Myandatory in NH) describe DESCR PTIONunder OF OPERATIONS below N I A KWC1047534 1/1/16 1/1/17 i XWORMT TU- OTH- E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 A Liquor Liability S2187660 8/15/15 8/15/16 1,000,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ER Town of Norton 70 East Main Street Norton, MA 02766 CANCELLATION 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 Joseph Rizzo/sh © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACO RD Phone: Fax: E -Mail: timmcc60@aol.com 6 cs t s s s o 0 �v a'aE m B E d B L6 x v w V C C o.® -0U B U U � t d) v o CD o 0 w B L c 0 B U c c Y C z d) �O C d1 0 Y � � V d! UI i u w In � � .W u L b S to -00, /- � B YB U in a - d1 I Y.. ry C � d) w Q � N LU\ �v b R wa O N N ® S a' � Vl u,� w \ w 3 u� r ® O i _ u ..0 . cs t s s s o �Z U �v a'aE Date *Put the name of your restaurant on first line then sign the form. We, AJ request a waiver of the Food Service Permit Fee for the following reason: Taste of Tri -Town Food Festival on 1014/16 located at the Xfinity Center in Mansfield Thank you, -§ig—nature Title