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Home My WebLink AboutCBS Scene Tri Town Tasting 10/4/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health ermit to Operate a Food Service Establishme 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:. THE KRAFT GROUP Whose place of business is: CBS SCENE RESTAURANT AND BAR- 9TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE CHRIS KLEIN, GENERAL MANAGER Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-133 BOARD OF HEALTH MichaeCMcCCean, Chairman WAIVED FOR BOARD OF HEALTH USE ONLY 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: Sce4-e_S m a 2) Establishment Address: � 0 (z f oyAof A mo 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: U o 5) Applicant Name & Title: SO4 5 X0 Gr C1 'Q 6) Applicant Address: d 0 ^�� L 1^o 6, O A Ua d 3j 7) Applicant Telephone No: S"��, 9 ,� _ ��7 v 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: m An association m A corporation m An individual • A partnership m Other legal entity 49) if a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address 12) Person Directly Responsible For Dally Operations (Owner, Person in Charge, Supervisor, Manager etc.) Name &Title: Address: Telephone No: jaw% 7 S_ Q Fax: Emergency Tele hone No: b ` -. o® 13) District Or Regional Su ervisor (if applicable) Name & Title: Address: Telephone No: Fax: 590apphcahon - ,doc Food Establishment Information 14) Water Source: 15) Sewage disposa : Supply No: A11A DEP Public Water (if applicable) 16) Days and Hours of Operation: S � , - la`, oho 17) No. of Food E ployees: /-/ 18) Name of Person In Charge Certified In F od Protection Management: Required as of 10/112001in accordance with 105 CMR 590.003(A)Ph3ase Mach a ofce fica(e. w 19) Person Trained In Anti -Choking Procedures (if 25 seats or more) m es m No 20) Location: 22) Establishment Type(checkall that apply) a' -/Caterer (checkone) ❑ Retail ( Sq. Ft) a' Food Delivery ❑ Permanent Structure Ca- Food Service - ( '70 V Seats) ❑ Residential Kitchen for Retail Sale ❑ Mobile CSI- Food Service -- Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service -- Institution Home ( MealslDay) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) ❑ Annual ❑ Seasonal/Dates: Temp a I Dates/Time: /d6 Definitions. PHF- potentially hazardous food(timeltemperature controls required) 23) Food Operations: Non-PHFs- non- potentially hazardous food (no timeltemperature controls required) RTE- reddyto-eaf foods (EX. sandwiches, salads, muffins which need no furth or processing) Check all that apply): ❑ Sale of Commercially Pre- PHF Cooked To Order d Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs e, 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 Q- Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4Hours. 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. ff Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged Prepares Food/Single Meals for Catered I for Retail Sale Events or institutional Food Service Other (Describe): ❑ Offers RTE PHI- in BUR Uuamnies ❑ Retail Sale of Salvage, Out -of Date or Reconditioned Food To he completed by the Board of Health Total Permit Fee: Payment is due with application 1, 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 10b CMFj,590.000_and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch, 62C, sec. 49A, I ertify under the penalties of perjury that], 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: 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. q Signature of Ividual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number 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. CAUsers\sleite\Desktop\Scote's DocumentsTood Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street K Boston, MA 02111 ,• " wrvw.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: M G 33 C— Phone #: O r'.)03 ` 4 ay Are you an employer? Check the appropriate box: Business Type (required): 1. [�K am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. restaurant/Bar/Eating Establishment 2. ❑ I 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] g• F-1 Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4. F-1Weare a non-profit organization, staffed by volunteers, l 1.❑ Health Cate with no employees. [No workers' comp. insurance req.] 12.❑ Other `Any applicant that checks box #r must also fill out the section below showing their workers' compensation policy information. **If the corporate officeis have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I that an eniployer that is providing workers' compensation insurance for my employees. Below is the policy infortaration. Insurance Company Name: C r os" To 5V i`WL C e - Insurer's Address: / 111 1) 4reA 1.C). 1 0j City/State/Zip: `J Policy # or Self -ins. Lie. # �j l 0 YLI 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 ce l f12, under the pains and penalties of perjury that the information provided aboveiis true and correct. Si o3 - eft a Official use only. Do not write in this area, to be completed by till' or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Pet -son: wNyw.111ass.gov/dia Phone Function Fax 815082032289 P.1 ACORL7®DATE CERTIFICATE OF LIABILITY INSURANCE IrdMIDDNYYY) 6/29/2016 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(les) 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 Cross Insurance 491 Main Street P.O. BOTS 1388 Bangor ML 04401 CONNAMETACT Judith Cardimino : FHDNE (207)947-7545 AC No: EMAIL g y' co ADDRESS:3 cardiminaCcrossa enc m INSURERS AFFORDING COVERAGE NAIC4 INSURERA.Travel.ers Ins. Co. - INSURED CBS Scene Patriot Place, 7.,hC Attn:Matt Franzosa,Asst Controller One Patriot Place Foxboro MA 02035 INSURERBMEMIC Indemnity Company 11030 INSURER C; INSURERD: INSURER E: INSURER F: CnVFRAnI=_q CFRTIFICATF NIIMRFR:CL1662777022 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 WTH 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 .AD TYPE OF INSURANCE bU5111 POLICY EFF POLICY NUMBER MNNDD.`YYYY POLICEXP IAtA/ODYlWYY LIMITS One Patriot Place X COMMERCIALGENERALLIABILITY I EACHOCCURRENCE $ 1,000,000 A CLAWWAADE ❑X OCCURo DAfM,GE TO REIJTED 100,000 unonual MED EX -(Any me person) $ 5,000 630-3H322228 7/1/2016 7/1/2C17 PERSONAL 9 ADV IVJUFY S 1,000,000 AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000 PROCUCTS - COMPtOP AGG S 2-,000,000 MGEN'L X POLICY ❑ j cT J LOC Employee Bererits S 1,000,000 OTHER: AUTOMOBILE LIABILITY I COMBIN=O SING -E LIMIT S 1 , 000 r 000 Ea <ccrdint BODILY INJURY(Per person) 5 A ANY AUTO ALLOOA=D SCHEDULED AUTOS X AUTOS NON -OWNED HIRED AJTOS X AUTOS 38324062 7/1/2015 7/1/2017 BODILY INJURY (Per occiden.) 5 PRO�ER-Y DAMAG= 5 Per axidenll Nan Owwd Comtlne^Sin e f 1,000,000 X UMBRELLA LIAR OCCJR EACH OCCURRENCE f 5 , OCO 1 000 AGGREGATE t 5 , 000 ,000 A EXCESS LEAS CLAJUS-61ADE i DED P.ETEVTIOP:$ g CUP3n322228 7/1/2016F7/l/2017 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ArrY PROPP.IETORIPARTNcR/EXECUTIVE Y❑ OFFICERAAEN9BER FYCLUDEW n (Mandatory In NH) N f A 3LO1000044 7/1/2016E.LDISEASE x STA UT'ER E.L EACH ACCtCENT ¢ 1,000,000 - EAEMPLOYE I 1 OOO,OCO E.L. DISEASE - POLICY LIMIT S 1,000 .00O If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS! LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Refer to policy for exclusionary endorsements and special provisions. Evidence of renewal coverage rG�TIGIf ATI= unl nrQ r'ANCFI I ATION GD 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmemi SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CBS Scene Patriot Place, LIC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TKG LL,C, New England Patriots ACCORDANCE WITH THE POLICY PROVISIONS. Gillette Stadium AUTHORIZEDREPRESENTATNE One Patriot Place Foxboro, DIA Melanie Carnnbell!t{JC C� GD 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmemi m v1 v� W LV i. N ani � tb+A � C y U y O o ' �Q sN�N V N W 3 ��1 iEl � G LO LOq Vl � o U W (3) z 0 0 N A Q LV i. N ani � tb+A � C y U y O o ' �Q sN�N V N 3 ��1 iEl � G 04 LV O V ��1 iEl 0 y o V V V • � N� V .H LV Mansfield Board of Health Waiver 2016 for Food Permit Date I l a a *Put the name of your restaurant on first line then sign the form. We, C, d S SCAIOR tr request a waiver of the Food Service Permit Fee for the following reason: Taste of Tri -Town Food Festival on 10/4/16 located at the Xfinity Center in Mansfield Thank you, r SigndturY", rr , axe L--' t, Gf't e, Title