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Home My WebLink AboutLive Nation 5/31/2015Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Xfinity Temporary Food Permit Type: RETAIL FOOD 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:. LIVE NATION WORLDWIDE INC. DBA XFINITY CENTER Whose place of business is: LIVE NATION WORLDWIDE, INC. DBA XFINITY CENTER 885 SOUTH MAIN STREET Permit good for: 1. Only non-PHFs, pre-packaged will be distributed. 2. The permit fee will be based on the previous year's vendor days. 3. The Xfinity Center shall report weekly on the vendor attendance. License Number: T-23 Food Fee: $250.00 BOARD OF HEALTH Catherine Ann Memory, Chairperson FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit# Issued T-23 XFINITY CENTER TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 7 days prior to planned event),, 1) Establishment Name: LIVE NATION WORLDWIDE, INC. DBAXFINITY,dENTER' Address: h A V I r 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-2331 5) Applicant Name & Title: GRE4&:F' mem*s-,SPONSORSHIP COORDINATOR Kacl,� I Akerl,( 6) Applicant Address 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 452-8028 24 Hour Emergency No.: (508) 452-8028 8) Owners Name & Title LIVE NATION WORLDWIDE INC. DBA XFINITY CENTER 9) Owner Address (If different from applicant): 5870 W. JEFFERSON BLVD., STUDIO H, LOS ANGELES, CA anni a 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. [I An Association W A Corporation LIVE NATION, WORLD WIDE INC. U An Individual El A Partnership 5870 W. JEFFERSON BLVD., STUDIO H, LOS ANGELES, CA [_1 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Lee -Z az o FS K Address: thiq Telephone No: FAX: Emergency Phone (508) 930-6038 P-0- C k -e I A 6 e- in j e 4;,-e rie-, h&j . cern E-mail: ceb L ivy NwhoA, 60"n Alt E-mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: N i f A Telephone No: NiA FAX: N% A Emergency Phone [A Email: Brucemontgomery@livenation.co Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) ❑ Mobile Food Temporary(Snack Size 16) DAYS/HOURS: DURING CONCERT EVENTS 17) No. of Food Employees: 10 PER EVEN 18) Name of Person In Charge Certified in Food Protection Management: Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 20) Location: 22) Establishment Type ❑ Mobile Food Temporary(Snack Size Permanent Location Sampling of Products,Comcast) $25 Temporary per day (for the event) with a cap of $100.00 Temporary Dates: 21) LENGTH OF PERMIT: rneA_f Jo, moo) s. may 30, Ib 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) (Check all that apply): 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) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours [] Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations SAMPLING RTE ❑ Juice Manufactured and Packaged for Ev] Customer Self -Service Retail Sale ❑ Ice Manufactured and Packaged for Retail Sale To be completed by the Board of Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and 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 59/0./000 and the federal Food Code. 241 Sionature of Aoolicant: 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. 25) Social Security Number or Federal ID: 20-3247759 13-40 26) Signature of Individual or Corporate Name: L t Y -t N fib c -n Lki E,,r LncC 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 Corporat ame I-�- q0 s- -)i 5 - "Social Security No. (Volimtanj) or Federal Identification Number Sy: Corporate Officer (Mandator,/, 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:WsetsUeite\Desktop\Scott's DounentsTood Btabtishmenis- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Departinettt of Industrial Accidents Office of Investigations 600 Washington Street Bostan, MA 0211.1 wipm. ttass.gov/dia Workers' Compensation Insurance Affidavit. General Businesses ADPlicant Information Please Print Legibly Business/Organization Name: Address: 6i'9LJ2 CIVIC- City/State/Zip: 2� k -f H i tS , (�l q02-10 Phone #: 32-1- 7 61 `( 3 k -f � Are an employer? Check the appropriate box: 1. [; I am a employer with _ employees (full and/ or part-time).-- 2,E] art-time).-2.❑ lain a sole proprietor or partnership and have no employees working forme 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' camp. 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.) S. ❑ Non-profit 9. Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other "Any applicant that checks box #1 must also Gn out the section below showing, (licit tvorkers' compensation policy inrartnation. "If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compcnsntion policy b required and such an organiuflan shnuld check box 11111. lain an employer that is providing workers' compensation Innsurance for my enmployeer. Below is the policy information. Insurance Company Name: G'C'A 9 L � �� t�f � Insurer's Address: 3c1 Ci pq*_ A{{ djt 7 Policy # or Self -ins. Lie. # PD— QOD to 64 Expiration Date;__ tt I tg 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. t 52 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 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 cert, under the pains and penalties of perjury that the information provided above Is true and correc4 Sigpature: 1 f n 1 r'E;-(l Date: lt 3( i 5~ Phone V: 323 ?64-434-2 Vice President Offcial use only. Do not write in this area, to be completed by city or town offielat City or Town: PermitlLicense 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.gov/din Phone NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of .Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http,//www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: 100 0001064 STARR INDEMNITY & LIABILITY CO NAME OF INSURANCE COMPANY 399 PARK AVENUE NEW YORK, NEW YORK 10022 ADDRESS OF INSURANCE COMPANY 11/01/2014 to 11/01/2015 POLICY NUMBER EFFECTIVE DATES AON RISK INS SVCS WEST, INC. Los Angeles CA 90017 707 WILSHIRE BLVD STE 2600 213-630-3393 NAME OF INSURANCE AGENT ADDRESS PHONE # LIVE NATION ENTERTAINMENT INC MANSFIELD MA 02048 885 S MAIN ST EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work, related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER SECTION 1 --POLICY NUMBERS Line Of Business _ States Policy Number Issuing Com an Workers Compensation CA, AL, AZ, CO, CT, 100-0001066 Starr Indemnity & Liability Co. DE, DC, GA, HI, IL, IN, IA, ICY, LA, ME, MD, Ml, MN, MO, NE, NV, NH, NJ, NM, NY, NC, OIC, OR, PA, RI, SC, TN, TX, UT, VT, VA, WA, WV Workers Compensation MA, FL 100-0001064 Starr Indemnity & Liability Co. Workers Compensation Wl 100-0001067 Starr Indemnity & Liability Co. Auto Liability._All States SISIPCA08311414 Starr Indemnity & Liability Co. General Liability (SIR) All States SISIGCS06003714 Starr Indemnity & Liability Co. General Liability CA SISIGCS06001414 Starr Indemnity & Liability Co. (Specified Certificate Holders) Page 2 of 38 Primary General Casualty Insurance Binder For Live Nation Entertainment, Inc. In consultation with your representative AO N Risk services West, Inc. INDEMNITY & LIAB LITY NOTICE THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK STATE INSURANCE DEPARTMENT. HOWEVER, SUCH FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. PREPARED BY: Thiaice Clay DATED: 10/23/2014 EFFECTIVE DATE: 11/01/2014 EXPIRATION DATE: 11/01/2015 Page 1 of 38