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HomeMy WebLinkAboutFirefly's 7/30/2016Commonwealth 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:. STEVEN A. ULISS Whose place of business is: FIREFLY'S @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: STEVEN ULISS, OWNER Permit Expires: July 30, 2016 License Number: FS -46T Food Fee: $25.00 BOARD OF HEALTH AichaeCAcCCean, Chairman Commonwealth 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:. STEVEN A. ULISS Whose place of business is: FIREFLY'S @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: STEVEN ULISS, OWNER Permit Expires: June 18, 2016 License Number: FS -46T Food Fee: $50.00 BOARD OF HEALTH MichaeCNcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -46T FOOD ESTABLISHMENT PERMIT APPLICATION (Applicaft—n musfbe submitted ems before the planne opening date 1) Establishment Name FIREFLY'S @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 350 EAST MAIN STREET MARLBOROUGH, MA 01752 1 4) Establishment Telephone No (508)357-8883 5) Applicant Name & Title: STEVEN A. ULISS 6) Applicant Address 350 EAST MAIN STREET, MARLBORO, MA 01702 7) Applicant Telephone No.: (508) 357-8803 24 Hour Emergency No,: (608) 277-9672 18) Owners Name & Title STEVEN A. ULISS 19) Owner Address (If different from applicant) 350 EAST MAIN STREET, MARLBORO, MA 01702 Owner's telephone number 508 3578883 11) If a corporation or partnership, give name, title, and home address of officers 10) Establishment Owned By: [I An Association or partner. El A Corporation Name Title Address Individual (A 04ur M A Partnership l[ALAES (�It_ek_4c mfeeovk6ell-VWy- 171 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc Name & Title: STEVEN ULISS, OWNER Address: 350 EAST MAIN STREET, MARLBORO, MA 01702 Telephone No: (508) 367-8883 24 Hour Emergency No: (508) 277-9672 FAX: E-mail: STEVEULISS(a)_VERIZON.NET Alt E -Mail: L 1KERRI(ZD.FIRFLYSBBQ.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 15 - - - -- - - - - -- ----- 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: STEVEN ULISS If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of i certificate - ri 9) Person Trained in Anti Choking Procedures (If 25 Seats or more): /'. j - - - 20) Location: ❑ Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: I ❑ Annual ❑ Seasonal i Seasonal Dates: Q Temporary Temporary Start Date: ( / Temporary End Date. ? E Temporary Time: Rain Date: 23) Food Operations ;(Check all that apply): 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution Meals/Day) [Caterer $12.50 ❑ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (tlmellemperature controls required) Non-PHF's - non -potentially hazardous food(no timeltemperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non -PRFs j ❑ Sale of Commercially Pre -Packaged PRFs ❑ Delivery of Packaged PHFs 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 ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E] offers RTE PHF in Bulk Quantities �Ij Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date - -- --- or Reconditioned Food To be completed by the Board of Health - - — Total Permit Fee: $50.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy f the information provided in this application and affirm that the food establishment operation will comply wit 05 MR 590.000 and all other applicable law, I have been instructed by the board of health on how to obtain copie S'CMR 590.000 and the federal Food Code. 24) Signature of Applicant: 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: 26) Signature of Individual or Corporate Nar 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. * Sign n ividual or Corporate Name (Mandatory) By: fG s : C icer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UIP wivw.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: City/State/Zip:i 1 i `` i if �d Are ygi an employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part-time),* 2,E] I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.0 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]* 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] *Any applicant that checks box H I must also fill out the section below showing their workers' compensation policy intor mason. **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 H 1. I am an employer that is providing workers compensation insurance for, rn employees, Below is the policy it formation. Insurance Company Name; Insurers Address; vC iii [ City/State/Zip; o„ Business Type (required); 5, 0 Retail 6. r' Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales (incl, real estate, auto, etc,) 8. ❑ Non-profit 9. ❑ Entertainment 10,0 Manufacturing 11,0 Health Care 12,0 Other 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 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, re pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: Phone #: Official use only, Do not write In this area, to be 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: Phone #: _ 1nvw.mass.gowaia ® -%'► -CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDIYYYYY) 4/5/16 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 Twinbrook Insurance Brokerage 400A Franklin Street Braintree, MA 02184 CONTANAME: Scott D Handorff PHONE 781) 843-7000 FAC No: wtlL ADDRESS: shandorff@twinbrook.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA: Firemans Fund INSURED Bodacious BBQ LLC dba Firefly's, etal 350 East Main Street Marlborough, MA 01752 INSURER B: Paramount INSURER C:Arbella Protection INSURER D: INSURER E: INSURER F: 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. ILTR TYPEOF INSURANCE ADDL INSR SUBR WVO POUCY NUMBER POLICY EFF MIDON POLICY EXP MMIDDIYYYY LIMITS A GENERALLIABILITY MXX80967176 12/31/15 12/31/16 EACH OCCURRENCE $ 1,000,000 DAMAGE (RENTED PREMISES (Ea occurrence) $ 100,000 X COMMERCIAL GENERALLIABILITY MED EXP (Arty one person) $ 5 000 CLAIMS -MADE a OCCUR PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OPAGG $ 1,000,000 $ PRO POLICY LOC C AUTOMOBILE LIABILITY 1020024743 12/31/15 12/31/16 COaccideent, INGLELIMIT $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED PROPEE nDAMAGE $ X X HIREDAUTOS _ AUTOS $ A UMBRELLA LIAB X OCCUR XAU48886642 12/31/15 12/31/16 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION WC033656 13 8/1/15 8/1/16 M OTH- X WCSTIAl AND EMPLOYERS' LIABILITY YIN ANY PROPRIErDRIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 OFFICER/MEMBER EXCLUDED? 7 (Mandatory in NH) NIA E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability MXX80967176 12/31/15 12/31/16 Aggregate 1,000,000 Each Common Ca 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 'g Live Nation Workdwide, Inc. and its landlord or licensor, if applicable, and each of their parents, partners, affiliates, subsidiaries, successors and assigns (collectively, the "LM Parties") and their respective officers, directors, shareholders, employees, agents and representatives are Primar and Non-contributory Additional Insureds as respects to the see remarks for more information Event: 6/16/16 and 6/18/16 RFRTIFMATF HOLDFR CANCELLATION © 1988-2010-ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Live Nation Worldwide, Inc ACCORDANCE WITH THE POLICY PROVISIONS. 9348 Civic Center Drive AUTHORIZED REPRESENTATIVE Beverly Hills, CA 90210 Joseph P. Rizzo /dam © 1988-2010-ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: Remarks Continued: operations of the Named Insured, its agents, employees, representatives only with respect to liability that arises out of the acts or omissions and of any other person or organization for whose act or omissions the required to insure per written contract, but only to the extent of the under such contract. Cross Liability is included in General Liability. and contractors but of the named Insured; named insured is liability assuemed C U � A GN m Ou W^' ¢2 V n Q� 0 �1 i C U � A GN m Ou W^' ¢2 V n Q� KA w O C/) 0 _ � N v r -t o � O � N, r EL lv fi o r U J � C} v �QJ F --� U U q Q A K 0 _ � N v o � O � N, r 2 0 .r ^Y v o � O � lv fi w V 2 Choke/Save Participant. Has successfully completed a Choke/Save class for AdulU ci &Unconscious ` - Beth A. Oleson AHA instructor Trainer 508-758-3188 American -Safety Health Institute Inst. bdoleon@gnail.com Issue Da et Expiration ate I MARLBOROUGH HEALTH DEPARTMENT THE MARLBOROUGH HEALTH DEPARTMENT HAS ISSUED FOOD PERMIT TO: NAME: Firefly's ADDRESS: 350 East Main Street DATE ISSUED: 12/8/2015 PERMIT TYPE: Annual HAS BEEN ISSUED PERMIT # FP 15-50 TO CONDUCT BUSINESS WITHIN THE CITY OF MARLBOROUGH, IN ACCORDANCE WITH FEDERAL FOOD CODE 105 CMR 590.000 AND THE 1999 FOOD CODE AND ALL RULES AND REGULATIONS SET FORTH BY THE CITY OF MARLBOROUGH, HEALTH DEPARTMENT. I UNDERSTAND THIS PERMIT MAY BE REVOKED AT ANY TIME, IF COMPLIANCE OF TOWN RULES AND REGULATIONS ARE NOT MET. -t 1 THIS PERMIT WILL EXPIRE ON: 12/31/2016 DIRECTOR OF PUBLIC HEALTH Catbl.een Liberty THIS PERMIT IS NON -TRANSFERABLE iCt BOARD OF HEALTH James Griffin, Chairman John Curran, MD, Vice Chairman Robin Williams, Member y PLEASE POST IN A CONSPICUOUS PLACE