HomeMy WebLinkAboutEdible Arrangements 10/4/2016Commonwealth of Massachusetts
M
Town of Mansfield
' Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
°ermit 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:.
JOHN BARRY, OWNER
Whose place of business is:
EDIBLE ARRANGEMENTS - 9TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @
THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) W CHARGE
JOHN BARRY, OWNERIOPERATOR
Permit Expires: October 04, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T-128
BOARD OF HEALTH
Michae( McCCean, Chairman
11 i -pi
,-,�,5LI
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By 'IN Permit# Issued
Food Establishment Permit Applicaffb-n---------
(Application must be submitted at least 30 days before the planned opening date)
11) Establishment Name:
2) Establishment Address:
7q C�
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
6) Applicant Name & Title:
6) Applicant Address:
,
I -
7) Applicant Telephone No: 24 Hour Emergency No:
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By:
11�-- An association
corporation
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 Directly Res pons ble For Daily Operations (Owner, Person in Charge, Supervisor, Manager etc.)
Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No: j
A
13) District Or Regional Supervisor (if applicable)
Name &Title,
Address:
Telephone No:
Fax:
5 90appi icatio[16 -2. doe
Food Estabiisoment Information
14) Water Source:
15) Sewage disposal:
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:
)
Re aired ss of 10/112001in accordance with 105 CMR 590.003(A)araso a n cn a� r�_a�a.
i r
19) Person Trained In Anti -Choking Procedures (if 26 seats or more): ® Yes ® No
20) Location:
22) Establishment Type(check all that apply)
❑ Caterer
(check one)
❑
Retail ( Sq, Ft)
❑ Food Delivery
(3 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)
❑ Annual
❑ Seasonal/Dates:
❑ Temporary/Dates/Time:
Definitions: PHF- potentially hazardous food(time/temperature controls required)
23) Food Operations:
Non-PHFs -- non- potentially hazardous food
(no time/temperature controls required)
RTE- ready -to -eat foods (EX, sandwiches, salads, muffins which need no further processing)
(check all that apply):
❑ Sale of Commercially Pre-
❑ 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-
❑ 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 Rl E PHF in Hulk quantities
Other (Describe): To be completed by the Board ofHealth
❑ Retail Sale of Salvage, Out -of Date or Total Permit Fee:
Reconditioned Food 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 593"00 and all other applicable law. I have been instructed by the board of
health on how to obtain copies of 106 CMR.8tib.t)00 an the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certify Linder 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:
U`)
26) Signature of Individual or Corporate Name:
i
TAX CERTIFICATION FORM
I certify tinder 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.
ture of lridividti4 or Corporate Name By; Corporate Officer (Mandy nj, if Applicable)
"'Social Security No. (Voluntani) 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. Tliis
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
CAUscrs\sleile\Dcsktop`Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORAM.doe
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.goildia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: S -A -
City/state/Zip:
a
.fi Phone #: "5 ` "V3 S Z
Are you an employer? Check the appropriate box:
1. U 1 am a employer with _—L2— employees (fall 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 area 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.❑ Manufacturing
11.❑ Health Care
12.a'Other
`Any applicant that cheeks box # I must also fill out the section below showing their workers' compensation policy infonnation.
#*irthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should cheek box ti 1.
I brit tot erttplgi'er that is providing ivorkets' contpelisotiort irrstirance for itty eittployees. Belo iv is the policy /information.
Insurance Company Name:
Insurer's Address: 3(ron €,,)X- 5 i JA -- -.__
City/State/Zip: t 17_.
Policy # or Self -ins. Lic. # > 6, C- (t ° �S3 Expiration Date: /,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late).
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 Corm of a STOP WORK ORDER and a tine
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 certif , y` ' t to gins and penalties of perjury that the information provided above is trite and correct,
4
a
Si.natt,re: Date:_ _
Official use onty. Do not write in this area, to be completed by tilt' or town ofelat.
City or Toren; Permit/License 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/'T'own Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
"-mv.nmss.gov/dia
A� ®® CERTIFICATE OF LIABILITY INSURANCE
DAT0103/2016 Y)
10/03/2016
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 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
CO TACT
NAME:
Automatic Data Processing Insurance Agency, Inc.
a/CONr o Ext): AJC, No):
1 Adp Boulevard
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC If
Roseland, NJ 07068
ED -
PREMISES Ea occurrence $
INSURER A : Hartford Insurance Company of the Midwest 37478
INSURED
INSURER B
MJM ENTEPRISES INC
375 CENTRAL ST
INSURERC:
PRODUCTS - COMP/OP AGG $
Foxboro, MA 02035
INSURER D:
INSURER E:
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
INSURER F:
COVERAGES CERTIFICATE NUMBER: 556946 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
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE D OCCUR
EACH OCCURRENCE $
ED -
PREMISES Ea occurrence $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PRO-
JECT ❑ LOC
OTHER:
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
er
P $
accident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY N
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? ❑Y
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
N
76WEGNG9633
10/02/2016
10/02/2017
X STATUTE ERH
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYE - $ 500,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
CERTIFICATE HOLDER CANCELLATION
iftikl bToTi C1Wol:7oZKa7:7:lol:L,41[ol. w_\I nn- iTi3i�7 41
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
O
C a
O
CL
X LL
LU U
c
O O
U �
C O
N a-
' v
0) o
m LL
c
m O
� 4-
c m
o c
m �
O C
L O
v
a i
o U)
U- z
Q
m a�
N zi
Z
L (n
o a
-C C
U)
+ CO
UC
(n O
m
a z 'm
m
C
C
@ U
a)
C n
0
0
En U
m m
U .U)
U .0
U) U
O
N z I--,
TI— 0 T-
00
Q
CN Z N
� a
C— X
/ w
O 0LLI /OrY\/
F
Q
Q
0
za
0�
Q U
a �
X
w n
w a
m
0 3
w i2
Q U
0
o Q m
m
C-
R-
2
2
Ln
o
ti
rN
V
�
o
0
U h
iai Cy
Mq�
zo
d
N NN�
O
N
N -
p
y
ti
�
� � V
C�
0
v
m
� •N H
�
O
o
U
�
O
�
�
ct
ct
C
R-
2
2
N
ti
rN
V
MM
Q
U h
iai Cy
Mq�
zo
d
N NN�
6i a
R-
2
2
0
ti
ti
zo
y
ti
�
� � V
C�
0
v
m
� •N H
�
o
R-
2
2
Date
t i
*Put the name of your restaurant on first line then sign the form.
We, Gcl�' i � !-,[ 4 -n ( 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,
Signature
LX& 4C:
Title