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Home My WebLink AboutHoliday Inn 12/31/2018Commonwealth. of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. GAUTAM SHARMA, PRESIDENT Whose place of business is: HOLIDAY INN MANSFIELD 31 HAMPSHIRE STREET PERSON(S) IN CHARGE: DAVID PTAK, GENERAL MANAGER Permit Expires: December31,2018 Food Fee: $275.00 License Number: FS-34 BOARD OF HEALTH MicGiaeC-%UCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: GAUTAM SHARMA, PRESIDENT having a place of business at: HOLIDAY INN MANSFIELD 31 HAMPSHIRE STREET 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-34 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-34 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name HOLIDAY INN MANSFIELD 2) Establishment Address 31 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 31 HAMPSHIRE STREET' 0 4 2017 MANSFIELD, MA 02048 t_ 4) Establishment Telephone No (508) 339-2200-- 5) Applicant Name & Title: VISION HAMPSHIRE LLC 6) Applicant Address 31 HAMPSHIRE STREET, MANSFIELD, MA 02048 7 Applicant Telephone No.: (508) 339-2200 24 Hour Emergency No.: (508) 339-2200 PP P 9 Y 8) Owners Name & Title GAUTAM SHARMA, PRESIDENT 9) Owner Address (If different from applicant) Owner's telephone number (508) 339-2200 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address ylAn Individual A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) j Name & Title: Address: 131 HAMPSHIRE STREET, MANSFIELD, MA 02048 Telephone No: 'I(508) 339-2200 24 Hour Emergency No: (508) 339.2200 FAX: - E-mail: (� P 4k@ i {'OXbo f6 • (o µ ---------- Alt-- E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: i E-mail: Food Establishment Information : 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 30 -.- 1 17) DAYS/HOURS: i 1 S) Name of Person In Charge Certified in Food Protection Management: DANIEL WHITTENBERGER If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 in accordance with 105 CMR 590.003(A) Please attach copy of '.. certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): l] 20) Location: Jl Permanent Location 22) Establishment Type Caterer $25.00 .ICI Mobile Mobile Start Date: [I Retail ( Sq. Ft) IV] Milk & Cream $10.00 Mobile End Date: F] Food Service up to 100 or [ -1 Mobile Food & Consession $75.00 Mobile Comments: ! up to 10' PHF display $125.00 -1 Manufacture Frozen Desserts/Ice Cream -__--- -- 21) Length of Permit: . _,-- ;Food Service up to 101 -200 $25.00/freezer iyi, Annual or up to 25' PHF display $160.00 i..-.i Pushcart $25.00 # of Pushcarts: p -- Seasonal ICI Food Service up to 201 + ,_11 Residential Kitchen $100.00, or 25'+ PHF display $275.00 : Retail Food $100.00 Seasonal Dates: �, ' Temporary - ., — Food Service - Institution _'', Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) _-1 Tobacco Products $25.00 Temporary End Date: Temporary Time: ' Ram Date: - 23)Food Operations Definitions PHF- Potentially hazardous food (timertemperature controls required) Non-PHFs non -potentially hazardous food(no timeBemperature controls required) !(Check all that apply): pp y): RTE - re ady to eaf foods (Ex sandwiches, salads, muffins which need no further processing) -- _. Commercially g -- Sale of Commerciall Pre -Packaged Non-PHFs I �] Hot PHF Cooked and Cooled or Hot Held ' (] PHFCooked To Order - - __ --- —�d _ --- --- ----i Sale of Commercially Pre -Packaged PHFs _ ---- -- -- for More Than a Single Meal ServiceI, ICI Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly WI Delivery of Packaged PHFs 1 ------ Susceptible Population Facility - Sale of Raw Animal Foods Intended _... ]I, Reheating of Commercially 9 y to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service 4 Hours of Non PHF and Non- J PHIF I Use of Process tomer (includingp bare Perriishable Foods Only °, Ice Manufactured andePackaged for alterCCP native, time public Preparation of Non PHFs ----� Retail Sale —__ ) ..__. _-_______ __nd - - contmcltHa 1i Other Food Operations I Juice Manufactured and Packaged for -. Offers Raw Or Undercooked Food Of II ' Retail Sale Animal Origin 1 I� Prepares Food/Single Meals for ] Offers RTE PHF in Bulk Quantities _ Catered Events or Institutional Food Service l Retail Sale of Salvage, Out -Of -Date --- -- or Reconditioned Food To be completed by the Board of Health --- - - Total Permit Fee: $275.00 Payment is due with application � If waived 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 obt�iagopies of MR 590.000 and the federal Food Code. 24) Signature of Applicant: �, �?" G M 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: 47-3112140 � , j " AX 26) Signature of Individual or Corporate Name: VI S1 02" /7UN^-pS�l�G 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: HOLIDAY INN MANSFIELD ADDRESS: 31 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 339-2200 FAX NUMBER: OWNER OF BUSINESS: GAUTAM SHARMA, PRESIDENT TELEPHONE OF OWNER: (508) 339-2200 FEDERAL ID/SS NUMBER: 47-3112140 FEE: $10.00 PERMIT NUMBER: FS-34 i SIGNATURE:✓tC DATE: 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. IL (� Af Signature of Individual or Corporate Name U`7-3ii2146 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. RM-ImIthUme's Doo=ants\PERMrr APPLICATIONS\TAX CERTIFICATION FORM.doc 440YO lbb*t W* itk a.. Vision, Hampshire LLC tSS 31 Hampshire Street IrtAdstt s's; 800 Superior Avenue East, 21st Floor a/ais Cleveland OH 44114 31 orPaw»offl raL iffy..or 7`uwrNs t�er�4't�aacsse #t, ijptrtgAufLority(ilrat@`age), 1,. Bey rtl of H.enl h, 2. Buit Gtg t)ep rtineatS. C zty! tdo ct'ertt' 4,1Li to 'sp . toari4 5 $rtectme»'q �1ifCe. $. O.t6eY GLOBVIS-01 1110GAN a►coRo" CERTIFICATE OF LIABILITY INSURANCE o 11/30/2017 I �►-� 11/30I2017 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 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 PRODUCER Roblin Insurance Agana yy 144 Gould Street Suite 100 Needham, MA 02494 INSURED _.. _.. _... _. Vision Hampshire LLC the Holiday Inn 31 Hampshire Street Mansfield, MA 02048 (AIC, No Eat): 7 455- 7 (Wc, No): 781 449.8976 cross:certificates@roblininsurance.com INSURERIS) AFFORDING COVERAGE NAIC p..... B Travelers Indemnity & Affiliates 25658_ c:ACE American Insurance Co. '122667 D AmTrust Insurance Company of Kansas 15954 I_ Crl\rGBAr pQ QFRTII]ICATR MI IMRRR• 0C1/ICInM lot IMRCR• 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. INSRr TYPEOFINSURANCE ADOL SUBft� then VWDPOLICY NUMBER r POLICY EFF 4 POLICY EXP LIMITS X COMCLAIMSMERCIALGENER LIABILITY EACH OCCURRENCE $ 1, 000,000 I CLAIMS MADE X X OCCUR P- 630-9H994609-TIL-17 06124/2017 DAMAGE TO RENTED 300,000 i106/2412018 I X Liquor Liability $1M PREMISES PREMISES (Ea occurromej $ _ EXP(Any_one person) ,�$. 6,000 I , PERSONAL BAOV INJURY , $. 1,000,000 ". GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 20,000,000 X POLICY JECT LOC'' PRODUCTS COMPIOP AGO $ 2,000,000 �'i OTHER.. ',LIQUOR LIABILIT ' 1,000,000 B 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO BA-9H986394-17-CAG 06124/2017 06/2412018 BODILY INJURY (Per person)_ $ OWNED _ AUTOS ONLY ' AUUTOpSyyN BpOOILV INJUDR �Pel accidenq $ ISCHEDULED 1 AUTOS ONLY _AUTOS ONLY ! f (Pa�euidant AMAGE 1 $ C X UMBRELLALIAB X OCCUR I EACH OCCURRENCE 4_$ 126'000'000 EXCESS LIAR CLAIMS MADE PUMBI6-A-G26786789 06124/2017 06/24/2018 AGGREGATE $ 125,000,000 RETENTION$ $ D WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY YIN TWC3638151 06101/2017 O6/01/2018 PER X�STATUTE_ 'ORH ,.._ 500,000 ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ,_$ OFFICEw MeMBE EXCLUDED? f NN/A 'LOFF(MedEJOUMIn Nlil 500,000 IEL DISEASE -EA EMPLOYEE,$ If yes, describe under�I DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT '�$ SOO,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mom space is required) Issued as evidence of Insurance. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Issued as Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD L � o . m i4 M..4 z 9 00 N N C,,t; N N (3N N N N A O O U O c'hl tttyyy N � M N N 13 Bank N Pktl1 _TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: _ _ BOARD OF HEALTH Date: 12/7l2017 Schedule; JED121717 From Whom Account Number Amount _ HOLIDAY INN MANSFIELD 01512A45006 $10,00 MILK & CREAM PERMIT FEE Cash $ 10.00 _ Checks $ Total $ 10.00 Online or Wire Receipt $ TOTAL: $ 10.00 Mansfield, MA 121712017 To The Officer Makin the Payments. The above is a detailed list of moneys collected. by me amounting in the. aggregate to: $10.00 - I for theperiod ending 12/7/2017 which 1-have paid to the Town Treasurer whose receipt I hold therefor. Employee or De t Head TOWN satin o 4,.:. V Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application fir 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: HOLIDAY INN MANSFIELD ADDRESS: 31 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 339-2200 FAX NUMBER: OWNER OF BUSINESS: GAUTAM SHARMA, PRESIDENT TELEPHONE OF OWNER: (508) 339-2200 FEDERAL ID/SS NUMBER: 47-3112140 FEE: $10.00 PERMIT NUMBER: FS-34 SIGNATURE: L 1 <r� DATE: I00/1 6d�u