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Home My WebLink AboutCourtside Pub 12/31/2018Commonwealth 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: FOOD SERVICE ESTABLISHMENT 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:. ANTHONY BRUNO, OWNER Whose place of business is: COURTSIDE PUB 31 OXFORD ROAD PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-15 BOARD OF HEALTH ,AlichaeC34cCCean, Chairman Milk & Cream fY Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Crean This is to certify that: ANTHONY BRUNO, OWNER having a place of business at: COURTSIDE PUB 31 OXFORD ROAD Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-15 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred yy( tl} FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-15Ji -- FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name COURTSIDE PUB 2) Establishment Address 31 OXFORD ROAD 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-3100 5) Applicant Name & Title: A. J. BRUNO CONCESSIONS LLC 6) Applicant Address 31 OXFORD ROAD, MANSFIELD, MA 02048 ................-_.-_-. -.. -. 7) Applicant Telephone No,: (508) 337-3100 24 Hour Emergency No.: (608) 962-9984 8) Owners Name & Title ANTHONY BRUNO, OWNER 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 J An Association or partner. A Corporation Name Title Address An Individual A Partnership Other legal Entity _ - - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'ANTHONY BRUNO Address: 31 OXFORD ROAD, MANSFIELD, MA 02048 j Telephone 4- hone No: 508 337-3100 24 Hour EmergencyNo: (s08) 962-9984 FAX1(508)06-2245 E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: INiA Address: Telephone No: FAX: r E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: TOWN 4 17) DAYS/HOURS: 7 DAYS PER WEEK 9 AM - 9 PM 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) Wi 20) Location: [/'I Permanent Location 1 22) Establishment Type Mobile Mobile Start Date: Mobile End Date: Moblie Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: I Temporary i Temporary Start Date: Temporary End Date: Temporary Time: Retail ( Sq. Ft) ICI Food Service up to 100 or up to 10' PHF display $125.00 [- 1, Food Service up to 101 -200 or up to 25' PHF display $150.00 -.] Food Service up to 201 + or 25'+ PHF display $275.00 Li Food Service - Institution ( Meals/Day) Caterer $25.00 J'.. Milk & Cream $10.00 ] Mobile Food & Consession $75.00 -, Manufacture Frozen Desserts/Ice Cream ' $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 L ] Retail Food $100.00 Retail Snack Food $26.00 Tobacco Products $25.00 Rain Date: ......_ _....._.... 23) Food Operations Definitions:PHF- Potentially hazardous food(timeltemperature controls required) Non-PHFs - non -potentially hazardous foodino tlmeltemperature controls required) ..(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) jV, Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order L I Hot PHF Cooked and Cooled or Hot Held -- _Pre -Packaged IV i Sale of Commercially Pre Packaged PHFs ] Preparation of PHFs For Hot And for More Than a Single Meal Service _ _- _ __ -- Vi Delivery of Packaged PHFs — Cold Holding For Single Meal Service I I PHF and RTE Foods Prepared For Highly Facility _ -- - - Sale of Raw Animal Foods Intended Susceptible Population ./i Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours-- - Use of Process Requiring AVariance Customer Self -Service of Non PHF and Non- VI Customer Self -Service i and/or HACCP Plan (including bare hand Perishable Foods Oniy -- j Ice Manufactured and Packagedfor contact alternative, time as a public health Vi Preparation of Non-PHFs Retail Sale control) Other Food Operations i__�; Juice Manufactured and Packaged for i',,; Offers Raw Or Undercooked Food Of '... Retail Sale I Animal Origin... Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for . __. Catered Events or Institutional Food Service J Retail Sale of Salvage, Out -Of -Date j or Reconditioned Food To be completed by the Board of Health PermitTotal 126. I'! Payment sdue 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 590.000 and the federal Food Code. 24) Signature of Applicant: tv^n9 1-i" in 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: 81-2524629 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: COURTSIDE PUB ADDRESS: 31 OXFORD ROAD TELEPHONE AT LOCATION: (508) 337-3100 FAX NUMBER: OWNER OF BUSINESS: TELEPHONE OF OWNER: ANTHONY BRUNO, OWNER FEDERAL ID/SS NUMBER: 81-2524629 FEE, $10.00 PERMIT NUMBER: FS-15 SIGNATURE: 64w DATE: 11 _arf ^,2a (7 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 By: Corporate Officer (Mandatory, if Applicable) S (— 25 �-Li64c1 *"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. R: Hm1th\Jme's Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORMdoc \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information qq PIease Print Lelribl Business/Organization Name: 7, Orv� o f' . L LC Address: 3t c>C3o t 4,,j /14c,,5-F,Cal q� , City/State/Zip: M hn'Jt 4 (d 0•16 2A Phone #: 0 `6 - cic� —C ci `S {{ Are you an employer? Check the appropriate box: Business Type (required): 1, R I am a employer with / L employees (full and/ 5. Q Retail "' part-time).* 6. Restaurant(Bar/Eating Establishment 2:1 1 am a sole proprietor or partnership and have no 7, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity, 8• Non-profit [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised 4. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I0, ❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 1. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑Other with no employees. [No workers' comp, insurance req.] 'Any applicant that checks box #1 must also fill out the section below showing theirworkrs' compensation policy information. **If the eorpomte officers have cxempled theoxclvcs, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box#]. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's 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 e, 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 Fire 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 dohereby cerffify, under the pains andpenaides ofperjury thatthe information provided above is true and correct. Signature: Date: /7 PhoneM q0 -CMY'` Official use only, Do not write in this area, to be completed by city or town officiaL City or Tomm: 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 Phone www.ma.�a.guv,wa ° PJB CERTIFICATE OF LIABILITY INSURANCE R001 DATE (M.\1IpDlY YYY) 1/2�2o1s THIS CERTIFICATEIS 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 endorsements . PRODUCER- BIZINSURE LLC/PHS 556706 P: F: PO BOX 33015 SAN ANTONIO TX 78265 CONTACT PHONE FAX IN-, No PAR lac, rvo/ ADD EBS: INCURERhu AFFORDING COVERAGE NAICM INSURER A'. Hartford Accident G Indemnity Co 22357 INSURED ANTHONY BRUNO DBA AJ BRUNO CONCESSIONS 31 OXFORD RD MANSFIELD MA 02048 INSURER B: INSURER C 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, INS'R 11PEOPIN.SURANCE AD, -SPIT Tol'IcTNINIIER POLICYEFF bvmnnrn POLFCI'T"C' J.L1FFn' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE ❑OCCUR DAMAGE TO RENTED PREMISES To occurrence) S MED EXP(Anyone peeth) ; PERSONAL B ADV INJURY ; AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ; GEN'L POLICY PRO ❑ LOG JECT PRODUCTS COMP/OP AGO ; $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E. scodent) $ BODILY INJURY IPre,reeon) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident)5 PROPERTY DAMAGE (Per eccb.nt) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB EACH OCCURRENCE ; AGGREGATE ; EXCESS LIAB HOCCUR CLAIMS -MADE CIS mnllIorvs 5 IDIRNEF.y COMPEA'.CiT/ON '. f.,.01'£HS'/./All/G]l' ANY PROPRIETORIPARTNERIEXEGUTIVE YIN X PER OTIi STATUTE I ER ELL. EACH ACCIDENT 51, 000,000 A OFFICERIMEMBER EXCLUDED? (ManRIInNH) AUA 57 WEC ZU0631 01/01/2018 01/01/2019 E.LDISEASE- EAEMPLOYEE s1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE � POLICY UMIT 51, 000,0()0 DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be ettached If more space Is .,.I.d) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION 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 THE COURTSIDE PUB 31 OXFORD RD MANSFIELD, MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Z w O m _ D Q Z u av O u<. Q LL C o n /^ C AN 1 tL N Lf) w rt p `o w O W U w !--i W U V z H z h� H W z W P 0 z Ym � Z N m d 0 .V y N cd z L) Q Q 0 v g •�N .`C lQ 1A •N N Q b v m N 5 O v ^ H o [{ m A .t2