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HomeMy WebLinkAboutThe Downtown 10/4/2016Commonwealth of Massachusetts 4 Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 'ermit to Operate o 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:. RALPH LAVOIE, OWNER Whose place of business is: THE DOWNTOWN - 9TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE RALPH LAVOIE, OWNER Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T•157 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:, 2) Establishment Address: cij-ed.� 1111-1 l� ? U 'Mre--� 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5-c,)&- (4S(- 6 5) Applicant Name & Title:R'C-A-�AV 1 (2-k e 6) Applicant Address: 7,3 11-2LY-141- J'/ -c ---c-1- ' c ---c-17) 7)Applicant Telephone No:� ® r, 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): zOC C' 10) Establishment Owned By: Q An association A 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 Responsible For Daily Operations_ (Owner, Person in Charge Supervisor, Manager etc. Name & Title; Ii, to�) 5L- Address: m C 0- es Telephone No: 52 a 7�7L/� — 36 C/ Fax: Emergency Telephone No: CJ / `/s r 13 District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: 59UapphcaUonb=L. cloc Food Establishment Information 14) Water Source: 15) Sewage disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation:rl ° _ ��`� 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Manageme t: / � � 01` Required as of 101112001in accordance with 105 CMR 590.003(A)geaseatfachw afce rficara. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): 4Gb to 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) ❑ Annuai ❑ Seasonal/Dates: CxA Ll zci i 7p Temporary/Dates/Time: Definitions; PHF— potentially hazardous food(timeltemperature controls required) 23) Food Operations: Non -PRFs -- non- potentially hazardous food (no timeltemperature controls required) RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) (check all that a ly): ❑ 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. v 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. Ll 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 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 R-) E HH1• In Bulk Quantities Other (Describe): To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -of Date or otal 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 9PR 590.000 and the p joral Food Code. 24) Signature of Applicant: Pursuant to MGL Ch, 62C, sec, 49A, I certify under the" enalties 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: 33 26 Signature of Individual or Corporate Name: L%+ 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. Zl�e ignatur o dividtial or Corporate Name By: Cor c(e officef'(Mandatonj, if Applicable) 7-3V/3SyF "Social Security No. (Voluntanj) 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\DesktoplScott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 qV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Da uo Address: q re it i 4 S-4- City/State/Zip: %'1�/ J141 Iq C) Phone #: 5-0 YJ -3-- 2, 3S C Are you an employer? Check the appropriate box: 1. ( 1 am a employer with employees (frill 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.❑ Manufacturing 1 l.❑ Health Care 12.❑ Other 'Any applicant that checks box # 1 most also fill out the section below showing their workets' compensation policy intonnation. **lf the eoiporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 41. I ant an eniplger that is providing workers' compensation insurance for my employees. Below is the policy infornnation. insurance Company Name: CIS Insurer's Address: 2, 1 2 City/State/Zip: l Policy # or Self -ins. Lic. # lam'_ LIL? 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 tip 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, tinder the pains and perry lues of perjury that the information provider/ above is true and correct. 0 Wilms Official use only. Do not write in this area, to be completed by city or tonwr 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: www. mass.Rov/dia Phone #: DOWNT-2 OP ID: AM gco►,e® CERTIFICATE OF LIABILITY INSURANCE `....---� DATE (MMfDD1YYYY) 09/30/2016 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 Estabrook S Chamberlain Ins P. O. BOX 277 Bridgewater, MA 02324-9986 Thomas T. Chamberlain NAME: Thomas T. Chamberlain PHONE 508-697-6963 FAX AIC No, Ext{; No: FAX ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC p INSURERA:T_ravelers Indemnity Co. of CT 25682 INSURED The Downtown INSURER B: 292LME Inc dba 292 W Main St INSURER C: Norton, MA 02766 INSURER D: INSURER E: INSURER F: DAtvIAG TO RENTED PREMISES Ea occurrence Y' 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. INSR LTR TYPE OF INSURANCEADM INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIODIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE OCCUR DAtvIAG TO RENTED PREMISES Ea occurrence Y' MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ PRODUCTS- COMP/OP AGG $ POLICYPRS El LOC JEC f $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _._ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTO AUT01, - PROPERTY DAMAGE $ (Per_a cident� UMBRELLA UAB OCCUR EACH OCCURRENCE AGGREGATE '£ EXCESS LIAB CLAIMS -MADE DED F RETENTION $ '{ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORlPARTNERrERE-UTNE Y�UB1G347281 OFFICERIMEMBEF' EXCLUDED? (Mandatory In NH) N 1 A 07/10/2016 07/1012017 OTH PTATUTE ER , E L EACH ACCIDENT $ 100,000 E L DISEASE EA EMPLOYEE $__ 100,DDD E L DISEASE- POLICY LIMIT $ 500,000 It yes, describe under DESCRIPTION Or OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD m IleLL WLL U cc g o ® N 0 U�0 c0 ,_ 0 Ln tt OO a m tai O � o Z LU 0 LL m - f Q { o oC U i I F 4 LL LL Z u- Z c- m m Q E — Z 1- W m m m � w y m Xm c LLL U) c o Lu U m e ay m D a v CD U (A L C c m 0 U) w Q V o N C � cn Uo c 72 m m L Z z y LAO G m EDQ SE 9 m c v o Q �: �- CSS o N m �— o N m o o - U aU+ W 00 � m z m (U N o X o x o m Z L U �\ W Wti ti `o U) m �— LL LLCL N Q Y Z U O O m m m _ � W W w H i Q Q U m yv aW N 3 m j Q p � N v ; c m _ o= � ED z v _ C, 1# _ c v o a_ m 2 W z W-4 P43 z W W a a Q c X10 N O 7- Q 0 O D iiEe(�(f�(J 00 LL N H H � N Z � a � O F o LI 00 " 1 C S M ti z WIn N C14 cm r N� r .1 W N r Q� 2 �a • .O .&it)" o w o �Cd j; Mansfield Board of Health Waiver 2016 for Food Permit Date a1 C *Put the name of your restaurant on first line then sign the form. We, _/Z)bLO request a waiver of the Food Service Permit Fee for the following reason: Taste of Tri -Town Food Festival on 1014116 located at the Xfinity Center in Mansfield Thank you, I/ E Title