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HomeMy WebLinkAboutMenchie's Patriot Place 10/4/2016Commonwealth of Massachusetts 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:. GEORGE KARAVASILEIADIS Whose place of business is: MENCHIE'S PATRIOT PLACE - 9TH ANNUAL TRI TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE GEORGE KARAVASILEIADIS Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-154 BOARD OF HEALTH MichaeCMcCCean, Chairman WAIVED Date Received FOR BOARD OF HEALTH USE ONLY Date Inspected Approved By 7 Permit # Issued Food Establishment Permit Applic . ' n (Application must be submitted at least 30 days before the planned ­opeWn-.----__ 1) Establishment Name: "y--tjF-'S p T(ZJ OT pCFtrCt, 2) Establishment Address: M 3 T 10 UC- Fo 1%o(z0 Cr4 MA 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 6) Applicant Name & Title: acoo-cx& P-AAsi w --i AD, 5 6) Applicant Address: rJ (C -OJT !t MSI 7) Applicant Telephone No: - rJ®���-cE3 ^ c�p �'� 24 Hour Emergency No: 1 _ 501?_9H3 P c�o1� 31- 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: m An association A corporation ✓ An individual © Apartnership m Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address 534 —soATl ST Ae I GpKCs� k11RA�1' �IC�kDfS �tCZ1r-C'v�r O.,�A43 I 53�— T �c�kPWA-Sit,c f,1s/ O�fCC-V- O'S4.�-r 12) Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc.) Name &Title: 16D17> N/ Address: w. AV • "4 0, 53� Ssxl'C1( n Telephone No: 1' SOg' a`E 3 - q,0 Fax: N A Emer enc Telephone Na I- $ — g43r��� � 13) DistrictOr Regional Su ervisor (if applicable) Name & Titte: Address: Telephone No: Fax: :. 590app6cahon .doc E=i.l �Ot v1 fro 0 S- ULGO 'J. cot4l Food Establishment Information 14) Water Source: 16) Sewrage disposal: DEP Public Water Supply No: (If applicable) 5 C-P'rI C_ 16) Days and Hours of Operation: kMN` t^Rr - likM-tC)r'a1 'SA'f- SctA) ti - 11 PM 17) No. of Food Employees: 1� 18) Name of Person In Charge Certified in Food Protection Management: Required as of 10/1/20011n accordance with 105 CMR 590.003(A) � tRAV 1 t CIAct 1 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): m Yes m No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery Permanent Structure �W Food Service - ( 94 Seats) ❑ Residential Kitchen for Retail Sale Mobile ❑ Food Service -- Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service - Institution Home ( Meals/Day) o Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) ❑ Annual ❑ Seasonal/Dates: tol'04/16 5:0��. 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- reddy-to-eat foods (EX. sandwiches, salads, muffins which need no further processing) check all that apply): ❑ Sale of Commercially Pre- o 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. a Deliveryof 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 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. ❑ 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): ❑ Retail Sale of Salvage, Out -of Date or Reconditioned Food 1, the undersigned, attest to the accuracy of the information provided in this app establishment operation will comply with 105 CMR 590.000 and al Wapplicahealth on how to obtain copies of 105 CMR 590.09_ , To be completed by the Board of Health Tota l Permit Fee: Payment is cine with application and I affirm that the food I have been instructed by the board of 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 state taxes required under law. 25) Social Security Number or Federal ID: 09-s— q6-46(0 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 "Social Security No. (Votitntaty) 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 tinder the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scotes Doelzments\Food Establishments- Temp\TAX CERTIRCATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AIA 02111 `� s• ° www.mass.gov/dia Workers' Corti pensation Insurance Affidavit Generali Bushiiesses ant Information Please P / Business/Organization Name:-r�c.t�( �S 7A-Tg40'T \_l>&A-CC— Address: aG ATVI- 1 `fit -its 'Foy &OFGaG-0 City/State/Zip: Phone #: SOS '5LF�-'0,00 O Are you an employer? Check the appropriate box: I. ❑ 1 am a employer with [ employees (full and/ or part-time).` 2. ❑ 1 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, yt(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 IU.❑ Manufacturing t I .❑ Health Care 12.❑ Other applicant that checks box #t 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, it workers' compensation policy is required and such an organization should check box # 1. I an: an entployer that is providing workers' compensation insurance for my employees. Below is the policy itrfornratioir. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic 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 STOP WORK ORDER and a fine of up to $250.00 a day against the v olato e adv�ed that a copy of this statement may be forwarded to the Office of Investigations of the DIA for -it t—nc rae cow rage v ifieation. do hereby cer,'autder the � U S - 2 43 - `Any information provided above is Date: (997, Official use only. Do not write in this area, to be completed Uv city or town official. City or Town: Permit/License # and correct. Issuing Authority (circle one): i. Board of Health 2. Building Department 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office 6. Other Contact Person: mvw.mass.gov/dia Phone #: A�O�Q® C" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) F09/16/2016 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. 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 have ADDITIONAL INSURED provisions or 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 CONTACT NAME; Amir Saleki Timothy Gaspar Insurance Services, Inc.PH 'Al A COIN Exit: (818)302-3060 AID Nol: (818)436-6122 5900 Canoga Ave. Suite 110 E-MAIL _...] ADDRESS: amir.saleki@gasparinsurance.com Woodland Hills, CA 91367 PERSONAL & ADV INJURY $ 2,000,000 INSURER(S) AFFORDING COVERAGE NAIC# License #: OG66626 INSURERA: Massachusetts Ba IllsuranCB Com an INSURED INSURER B: Travelers Insurance Company25682___.._ New England Frozen Ventures, Inc. INSURER C :A DBA MEN523 - Menchies of Foxborough, M --- D: 534 South St. Apt 1 -INSURER Wrentham, MA 02093 INSURER E: POLICY I PEC° U LOC INSURER F : rnvGRAr_Gc rFRTIFICATF NIIMRFR- nnnnnnnn-n REVISION NUMBER: 1 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF - POLICY EXP LTR S D POLICY NUMBER MMIDDIYYYYi MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � 'OCCUR Y OD3A73562200 10/01/2016. 10101/2017 EACH OCCURRENCE $ 210001000 : DAMAGE TO RENTED PREMISES Ea occurrence $ 300 00U__ MED EXP (Any one person) $ 5,000 _...] PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: : X POLICY I PEC° U LOC PRODUCTS - COMP/OP AGG $ 40-00,000 $ OTHER: A AUTOMOBILE LIABILITY ', OD3A73562200 10/01/2016 10/01/2017 Ee a.dan MBINDSINGLE LIMIT $ _ 2,000 000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ -- - PROPERTY DAMAGE $ Per accident OWNED SCHEDULED', AUTOS ONLY AUTOS HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY UMBRELLA LIAROCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR -MADE _CLAIMS DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERlEXECUTNE YIN UB1G896141 10/0112016 10/01/2017 H X STATUTE -R __ E.LEACH ACCIDENT $ 1,000,000 _ E.L. D_I_S_EASE- EA EMPLOYEE $ 1,00_0_,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA _ E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Personal Property OD3A73562200 10/01/2016 10/01/2017 Replacement Cost $334,750 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This policy includes a Blanket Additional Insured Endorsement — the certificate holder is an additional insured if required by written contract. Town Hall of Mansfield, MA as additional insured. Location: 268 Patriot Place #E11 Foxborough, MA 02035. oTIGI_AT uni nco CANr:FI I ATInN ' V 1Ht5U-ZU15 AL;UKU L UKYU" I IIJIV. All rl9nt5 re5erveu. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Printed by ARS on September 16, 2016 at 10:39AM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall of Mansfield, MA ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row, Mansfield AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 (ARS) ' V 1Ht5U-ZU15 AL;UKU L UKYU" I IIJIV. All rl9nt5 re5erveu. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Printed by ARS on September 16, 2016 at 10:39AM r, In- ao r Insurance Graup. OD3 A735622 1001608 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SUMMARY OF COVERAGES Limits Page 1. Additional Insured by Contract, Agreement or Permit 1 2. Additional Insured - Broad Form Vendors 2 3. Alienated Premises 2 4. Bodily Injury Redefined 2 5. Broad Form Property Damage - Borrowed Equipment, Customers 2 Goods and Use of Elevators 6. Incidental Malpractice (Employed Nurses, EMT's and Paramedics) 3 7. Personal and Advertising Injury - Broad Form 3 8. Product Recall Expense $25,000 Occurrence $50,000 Aggregate 3 9, Unintentional Failure to Disclose Hazards 5 10, Unintentional Failure to Notify 5 This endorsement amends coverages provided under the Businessowners Coverage Form through new coverages and broader coverage grants. This coverage is subject to the provisions applicable to the Businessowners Coverage Form, except as provided below. 1. Additional Insured by Contract, Agreement or This insurance applies on a primary basis if Permit that is required by the written contract, Under SECTION 11 - LIABILITY, C. Who Is An agreement or permit. Insured, Paragraph 4. is added as follows: b. This provision does not apply: a. Any person or organization for whom you (1) Unless the written contract or written are performing operations when you and agreement has been executed or permit such person or organization have agreed in has been issued prior to the "bodily writing in a contract, agreement or permit injury", "property damage" or "personal that such person or organization be added and advertising injury"; as an additional insured on your policy. Such (2) To any person or organization included person or organization is an additional as an insured by an endorsement Insured only with respect to liability for issued by us and made part of this "bodily injury", "property damage" or policy; "personal and advertising injury" caused, in whole or in part, by: (3) To any person or organization included as an insured under Item 1.a.2. of this (1) Your acts or omissions; or endorsement; (2) The acts or omissions of those acting (4) To any lessor of equipment: on your behalf, (a) After the equipment lease expires; but only with respect to: or (3) "Your work" for the additional insured(s) (b) If the "bodily Injury", "property at the location designated in the damage" or "personal and contract, agreement or permit; or advertising injury" arises out of the (4) Premises you own, rent, lease, control or sole negligence of the lessor; occupy. 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 5 (5) To any: (a) Owners or other interests from whom land has been leased which takes place after the lease for that land expires; or (b) Managers or lessors of premises if: (i) The occurrence takes place after you cease to be a tenant in that premises; or (ii) The "bodily injury", "property damage" or "personal and advertising Injury" arises out of structural alterations, new construction or demolition operations performed by or on behalf of the manager or lessor; or (6) To "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to render any professional services. c. Additional insured coverage provided by this provision will not be broader than coverage provided to any other insured. d. All other insuring agreements, exclusions, and conditions of the policy apply. 2. Additional Insured - Broad Form Vendors Under SECTION II - LIABILITY, C. Who Is An Insured, paragraph 5, is added as follows: 5. Any person or organization with whom you agreed, because of a written contract or written agreement to provide insurance, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; demonstration, testing, or the substitution of parts under instruction from the manufacturer, and then repackaged in the original container; e, Any failure to make such inspection, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business in connection with the distribution or sale of the product; f, Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises In connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any thing or substance by or for the vendor; or h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in paragraphs 5.d, or 5.f.; or (2) Such Inspections, adjustments, test or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products, 3. Alienated Premises b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; 4. d. Repackaging, unless unpacked solely for the purpose of Inspection, Under SECTION it - LIABILITY, B. Exclusions, paragraph 1.k.(2) is replaced in its entirety with the following: (2) Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises and occurred from hazards that were known by you, or should have reasonably been known by you, at the time the property was transferred or abandoned. Bodily Injury Redefined Under SECTION 11 - LIABILITY, F. Liability and Medical Expenses Definitions, definition 4, is replaced in its entirety by the following: 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 2 of 5 4. "Bodily injury" means bodily injury, disability, sickness or disease sustained by a person, including death resulting from any of these at any time. "Bodily Iniury" includes mental anguish or other mental iniurry resulting from "bodily injury". 5. Broad Form Property Damage - Borrowed Equipment, Customers Goods, Use of Elevators a. Under SECTION II - LIABILITY, B. Exclusions, paragraph 1.k., the following is added: Paragraph (4) does not apply to "property damage" to borrowed equipment while at a jobsite and not being used to perform operations. Paragraph (3), (4) and (6) do not apply to "property damage" to 'customers goods" while on your premises nor to the use of elevators. b. Under SECTION II - LIABILITY, F. Liability and Medical Expenses Definitions, the following additional definition is added: "Customers goods" means property of your customer on your premises for the purpose of being: a. Worked on; or b. Used in your manufacturing process. c. The insurance afforded under this provision is excess over any other valid and collectible property insurance (including deductible) available to the insured whether primary, excess, contingent or on any other basis. 6. Incidental Malpractice - Employed Nurses, EMT's and Paramedics Under SECTION 11 - LIABILITY, C. Who Is An Insured, paragraph 2.a.(1)(d) does not apply to a nurse, emergency medical technician or paramedic employed by you if you are not engaged in the business or occupation of providing medical, paramedical, surgical, dental, x-ray or nursing services. 7. Personal and Advertising Injury - Broad Form Under SECTION II - LIABILITY, F. Liability and Medical Expenses Definitions, definition 15, "Personal and Advertising Injury", paragraph h. Is added as follows; h. Discrimination or humiliation (unless insurance thereof is prohibited by law) that results in injury to the feelings or reputation of a natural person, but only if such discrimination or humiliation Is: (1) Not done intentionally by or at the direction of: Ttic ppy M �V Jnsurance Croup OD3A735M 1001608 (a) The insured; or (b) Any officer of the corporation, director, stockholder, partner or member of the insured; and (2) Not directly or indirectly related to an "employee", nor to the employment, prospective employment or termination of any person or persons by an insured. 8. Product Recall Expense a. Under SECTION II - LIABILITY, B. Exclusions, Paragraph 1. o. is replaced in its entirely by the following: o. Recall of Products, Work or Impaired Property Damages claimed for any loss, cost or expense incurred by you or others for the loss of use, withdrawal, recall, inspection, repair, replacement, adjustment, removal or disposal of: (1) "Your product'; (2) "Your work"; or (3) "Impaired property"; If such product, work or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous condition in it, but this exclusion does not apply to "product recall expenses" that you incur for the "covered recall" of "your product'. The exception to the exclusion does not apply to "product recall expenses" resulting from: (1) Failure of any products to accomplish their intended purpose; (2) Breach of warranties of fitness, quality, durability or performance; (3) Loss of customer approval, or any cost incurred to regain customer approval; (4) Redistribution or replacement of "your product" which has been recalled by like products or substitutes; (5) Caprice or whim of the insured; (6) A condition likely to cause loss of which any insured knew or had reason to know at the inception of this insurance; (7) Asbestos, including loss, damage or clean up resulting from asbestos or asbestos containing materials; or 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 3 of 5 (8) Recall of "your products" that have no known or suspected defect solely because a known or suspected defect in another of "your products" has been found. b. Under SECTION II - LIABILITY, C. Who Is An Insured, paragraph 4.c. is added as follows: c. "Bodily Injury" or "property damage" do not apply to "product recall expense" arising out of any withdrawal or recall that occurred before you acquired or formed the organization. c. Under SECTION 11 - LIABILITY, E. Liability and Medical Expense General Conditions, 2. Duties in the Event of Occurrence, Offense, Claim or Suit, paragraph e. is added as follows: e. You must see to it that the following are done In the event of an actual or anticipated 'covered recall' that may result in "product recall expense": (1) Give us prompt notice of any discovery or notification that "your product" must be withdrawn or recalled. Include a description of "your product' and the reason for the withdrawal or recall; (2) Cease any further release, shipment, consignment or any other method of distribution of like or similar products until it has been determined that all such products are free from defects that could be a cause of loss under this insurance. d. Under SECTION 11 - LIABILITY, F, Liability and Medical Expenses Definitions, the following additional definitions are added: "Covered recall" means a recall made necessary because you or a government body has determined that a known or suspected defect, deficiency, inadequacy, or dangerous condition in "your product" has resulted or will result in "bodily injury" or "property damage". "Product recall expense(s)" means: a. Necessary and reasonable expenses for: (1) Communications, including radio or television announcements or printed advertisements Including stationary, envelopes and postage; (2) Shipping the recalled products from any purchaser, distributor or user to the place or places designated by you; (3) Remuneration paid to your regular "employees" for necessary overtime; (4) Hiring additional persons, other than your regular "employees"; (5) Expenses incurred by "employees" including transportation and accommodations; (6) Expenses to rent additional warehouse or storage space; (7) Disposal of "your product", but only to the extent that specific methods of destruction other than those employed for trash discarding or disposal are required to avoid "bodily injury" or "property damage" as a result of such disposal, you incur exclusively for the purpose of recalling "your product"; and b. Your lost profit resulting from such 'covered recall'. e. Under SECTION 11 - LIABILITY, D. Liability and Medical Expenses Limits of Insurance, the following is added: 5. The Limits of Insurance and rules stated below fix the most that we will pay under this Product Recall Expense Coverage. (1) The Aggregate Limit Is the most that we will reimburse you for the sum of all "product recall expenses" incurred for all "product recall expenses" initiated during the policy period. (2) The Occurrence Limit shown on the Summary of Coverages is the most we will pay in connection with any one defect or deficiency. (a) All "product recall expenses" in connection with substantially the same general harmful condition will be deemed to arise out of the same defect or deficiency and considered one 'occurrence". 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 4 of 5 nce Groupe lnnss> OD3 A735622 1001608 (b) Any amount reimbursed for "product recall expenses" in connection with any one 'occurrence" will reduce the amount of the Aggregate Limit available for reimbursement of "product recall expenses" in connection with any other defect or deficiency, (c) If the Aggregate Limit has been reduced by reimbursement of "product recall expenses" to an amount that Is less than the Occurrence Limit, the remaining Aggregate Limit is the most that will be available for reimbursement of "product recall expenses" in connection with any other defect or deficiency. 6. A deductible of $500 applies per each "Occurrence". 9. Unintentional Failure to Disclose Hazards Under SECTION II - LIABILITY, E. Liability and Medical Expenses General Conditions, paragraph 6. is added as follows: 6. Representations We will not disclaim coverage under this Coverage Form If you fail to disclose all hazards existing as of the inception date of the policy provided such failure is not intentional. 10. Unintentional Failure to Notify Under SECTION 11 - LIABILITY, E. Liability and Medical Expenses General Conditions, 2. Duties In the Event of Occurrence, Offense, Claim or Suit, paragraph f. is added as follows: f. Your rights afforded under this Coverage Form shall not be prejudiced if you fail to give us notice of an "occurrence", offense, claim or "suit", solely due to your reasonable and documented belief that the "bodily injury" or "property damage" is not covered under this policy. 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 5 of 5 Mansfield Board of health Waiver 2016 for Food Permit Date C�I C, ) , *Put the name of your restaurant on first line then sign the form. We, "C-tQCA I C -'S -TP-f R 1OT '-P c 4c_G- 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, Signature 'F- Rte N Cc I S EL- own) Title