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Home My WebLink AboutBen & Jerry's 10/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment 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:. JASON SWEENEY, PRESIDENT Whose place of business is: BEN & JERRY'S - THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: SEAN SELTZER, MANAGER Permit Expires: October 31, 2016 License Number: T-123 Food Fee: $100.00 BOARD OF HEALTH ,Atichae(McCCean, Chairman Date Received Date Inspected Approved By Permit # Issued Xfinity TemporaryEstablishment r i Application (Application must be submitted at least 7 working days before the planned event.) 1) Establishment Name:'� I 2) Establishment Address: I l U ( 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant Name & Title: GS S h( C 6) Applicant Address: 7) Applicant Telephone No: dl S 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 r ora 1 • An in lvidual • Apartnership ® Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address tiS0 S Pfesi n al �- -EYi •+/� 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: Z ' Address: Telephone No: Fax: Emergency Telephone No: 0 t/ 13 District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: 590 appl t cation6-2.d oc 14) Water Source: Q h 1'ClJ (V� Y3 4jG;� Gi p�� (+ 15) Sewage disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: S (� , (� = i(I 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food erotection Management: Required as of 101112001in accordance with 105 CMR 590.003(A) Pfeas attach copy ofcerLW afe. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): 0 Yes 0 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) ❑ Annual 'A Sea on I/Dates: 1 � ❑ Tem orary/Dates ime: Definitions: PHF— potentially hazardous food(time/temperature controls required) 23) Food Operations: Non-PHFs — non- potentially hazardous food (no timeftemperature controls required) RTE— ready -to -eat foods (Ex. sandwiches, salads, mums 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 Packaged Non-PHFs for 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 Li Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service u Vrrers n i c rnr m cswK �tuanuues Other (Describe)' 7o be completed by the Board of Heallh ❑ Retail Sale of Salvage, Out -of Date Total Permit Fee ($25 per day): or Reconditioned Food Payment is due with application I, 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 CMR 590.000 and th federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, 1 ce ify under the penalties of 4Aury 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: _7 S ✓ J 1 d 3 G q - i 26) Signature of Individual or Corporate Name: S�f\ �CGd� 5ka7SIKe., 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. �sU� 5 _ P�csid Signatur f Individual or Corporat ame By: Corporate Officer (Mandatory, if pplicable) KSWk S60 S o?s lhr-. -�5✓ 3 M 3� **Social Security No. (Voluntary) 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\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc —� Department ofIndustrial Accidents Office of Investigations 600 Washington, , Boston, AM 02111 Workers' Compensation Insurance Affidavit: General Businessi a, 1; licant InformationPlease1 Business/Organization Name: Address: City/State/Zip: I � J� Phone #: G_I ) 5 3 6 b S q 560 Are you an employer? Check the appropriate box: 1. .1 am a employer with Si lo 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, § 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. M Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing IL ❑ Health Care 12. ❑ Other *Any applicant that checks box #1 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, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: HrA r\UVer (_�S Insurer's Address: 11 ' Y n 160 cc S �' City/State/Zip: U Policy # or Self -ins. Lic. # w --L / V 1'1 U 1�' T) --M Expiration Date:_ ?,11111-7 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 certify, under the pains and penalties of perjury that the information provided above is true and correct, Official use only. Do not write in this area, to he completed by city or town 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.gov/dia Phone AC40R" CERTIFICATE OF LIABILITY INSURANCE M/DD/YYYY) TYPE OF INSURANCE 3/229/209/2016 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 CONTACT NAME: PHONE Et):781-848-8600 FA N,):781-843-8807 o: - - McSweeney & Ricci Insurance Agency, Inc. 420 Washington Street 420 Braintree MA 02185 E-MAIL ADDREss: rir c ti me e e ricci.c INSURERS AFFORDING COVERAGE NAIC # DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 INSURERA:The Hanover Insurance Group 229 PERSONAL & ADV INJURY $1,000,000 INSURED BEN&J-1 INSURER B: INSURER C: Ben & Jerry's INSURER D: Boston Scoop Shops Inc 174 Newbury Street Boston MA 02116 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 1100940415 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 ADDL INSR SUER WVD POLICY NUMBER POLICY EFF MWDD POLICY EXP MM/DD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR ai- OBNA88129000 3/27/2016 3/27/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGO $2,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS X X H RT DSAUTOS AUTOS AWNA88059800 3/27/2016 3/27/2017 COMBINED$ Ea accident) G $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE OBNA88129000 3/27/2016 3/27/2017 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED FX7 RETENTION $10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE MN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below / A I W2NA88122700 I 3/27/2016 I 3/27/2017 X I WC STATUT OTH- TO L 1 E E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEd $500,000 E.L. DISEASE - POLICY LIMIT 1 $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) c1=oTtGIceTF lane nFR CANCELLATION U 1985-1U1 U AGUKD GUKPUKA I LUN. All rights reserved. ACORD 25 (2010/05) 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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. Ben and Jerrys Boston MA 02116 AUTHORIZED REPRESENTATIVE ai- U 1985-1U1 U AGUKD GUKPUKA I LUN. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 0 - ZO 060