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HomeMy WebLinkAboutThe Energy Lab 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:. LUTHER WHITE, PRESIDENT Whose place of business is: THE ENERGY LAB, INC. 280 SCHOOL STREET PERSON(S) IN CHARGE: LUTHER WHITE, PRESIDENT Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-89 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream O 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: LUTHER WHITE, PRESIDENT having a place of business at: THE ENERGY LAB, INC. 280 SCHOOL 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-89 Board of Health MichaeC-%fcCCean, 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 89 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Wening 0svta)4,>- 1) Establishment Name THE ENERGY LAB, INC. 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 40 ARROWHEAD ROAD WRENTHAM, MA 02093 4) Establishment Telephone No (508) 680-6734 5) Applicant Name & Title: LUTHER WHITE, PRESIDENT 6) Applicant Address 40 ARROWHEAD ROAD, WRENTHAM, MA 02093 7) Applicant Telephone No.: (508) 680-6734 24 Hour Emergency No.: 30 2017 (508)280-4696 (781)820-2618 8) Owners Name & Title LUTHER WHITE, PRESIDENT 9) Owner Address (If different from applicant) Owner's telephone number (508) 680-6734 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 An Individual A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: LUTHER WHITE, PRESIDENT Address: 40 ARROWHEAD ROAD, WRENTHAM, MA 02093 Telephone No: (508) 680-6734 24 Hour Emergency No: (508) 280.4696 (781) 820-2618 rFAX: - E-mail: LDWHITE@NRGLAB.COM - Alt E-Mail: 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: 2 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. LUTHER D. WHITE Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate J 119) Person Trained in Anti -Choking Procedures (If 25 Seats or more) 20) Location: V1 Permanent Location 22) Establishment Type ❑ Caterer $25.00 _ Moblie Moblie Start Date: � I-- J Retail ( Sq Ft) P Milk & Cream $10 00 Moblie End Date: ill Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 -1 21) Length of Permit: [] Food Service up to 101 -200 jl Annual or up to 25' PHF display $150.00 Seasonal Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: `- - -- _-__- _ --- ` _' Food Service - Institution !.. Temporary Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: - i_ Mobile Food & Consession $75,00 Li Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 Retail Snack Food $25.00 1 ] Tobacco Products $25.00 23) Food Operations Definitions. PHF- Potentially hazardous food (timeltemperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) ;Check all that apply): !, RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) 1�!, Sale of Commercially -- Order _ --T Pre -Packaged Non PHFs i PHFCooked To Order [ _i Hot PHF Cooked and Cooled or Hot Held --- ---- -- for More Than a Single Meal Service !, Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And -'; Delivery of Packaged PHFs - 1 Cold Holding For Single Meal Service ❑HFPand RTE Foods Prepared For Highly ---- - - Susceptible Population Facility Reheating of Commercially'Sale of Raw Animmalat Foods Intended _- Processed Foods for Service Within 4 Hours to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill - _ - w— -- j.__i Customer Self-service of Non PHF and Non- { -- - -- Customer Self Service I [ I Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only --- --- _---- J Ice Manufactured and Packaged for contact alternative, time as a public health 1✓ Preparation of Non-PHFs Retail Sale - _ control) Other Food Operations Juice Manufactured and Packaged for [ J Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑_ Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date ---- or Reconditioned Food - - r To be completed by the Board of Health Total Permit Fee: $125.00 Payment is due with application (,- 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 obtain copies of-1.05-CMR-590:000_ and the federal Food Code. 24) Signature of Applicant: ( P/" V- Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury 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: 46 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: THE ENERGY LAB, INC. ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 680-6734 FAX NUMBER: OWNER OF BUSINESS: LUTHER WHITE, PRESIDENT TELEPHONE OF OWNER: (508) 680-6734 FEDERAL ID/SS NUMBER: 46-2870170 FEE. $10,00 PERMIT NUMBER: FS-89 SIGNATURE: . 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. 1 lb w Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) ,-I6-,an Di)1} "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 HmIthVane's Doau ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doe 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 Please Print Lezibly Business/Organization Name: `ire�Sf1a, Address: . 0433 It 's+ City/State/Zip: m6n 5�VJ61 6"A 0 3i))y ' Phone #: Are you an employer? Check the appropriate box: + Business Type (required): I. N I am a employer with employees (full and/ S. ❑ Retail or part-time).* 6. Restaurant/Bm/FatingEstablishment 2: 0 lam a sole proprietor or partnership and have no 1, 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 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10, ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑ Health Care4. ❑ We. are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance.i 12,❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomiafion. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such ao ' organization should check box M. I am an employer that is provUing workers' eompensadon insurance for my employees. Below is the policy informado$. Insurance Company Name: %}:7C.=1 °S 0 �i c., Insurer's Address: C'j - �iy', ( qli o City/StatcMp: (y li p Policy # or Self -ins, Lic. # ci � L, j $" { � Expiration Data: 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 r�the—p--ai--ns anal penaldes of perjury that the information provided^ above is true and correct Date: Ii'"/Cal Official use only. Do not write in this area, to be completed by city or town offieiat 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 #: Client#: 46342 2NRGLA ACORDa, CERTIFICATE OF LIABILITY INSURANCE D111282D/YYYV) 11128/2017 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: Dowling & O'Neil Insurance Agy _ PHONE 508 775-1620 F"ix 5087781218 AIC A/C, No 973 lyannough Road E-MAILEzt: IL -- P.O. Box 1990 ADDRESS: Hyannis, MA 02601 INSU RER(S) AFFO_RDI NO COVERAGE NAICIf _ INSURER A: Theaanrnrd 19682 INSURED The Energy Lab, Inc. DBA The NRG Lab INSURER — --- C/O Luther White INSURERC: INSURER 0 40 Arrowhead Road INSURERE: Wrentham, MA 02093 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 CONTRACTOR 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. LTRR _ TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO ENTED PREMISES no. ance $ MED EXP(Any one person) $ CLAIMS -MADE ❑OCCUR PERSONAL& ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -C_O_M_P/OPAGG _ $ POLICY PRO- JECTLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea aalden BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS Per accident BODILY INJURY ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident �$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE BED RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? L NJ NIA _ 08WECCP0502 11/011201711101/201 X�WC STATU- OTH- 7 LI S ER E.L. EACH ACCIDENT $1000000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Insurance coverage is limited to the terms, conditions, exclusions, other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered, waived, or extended the coverage provided by the policy provisions. Town of Mansfield 6 Park Row Mansfield, MA 02048 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 ACORD 25 (2010/05) 1 of 1 #S202376/M202374 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LS1