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Home My WebLink AboutCovidien 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:. LPM HOLDING CO., INC. Whose place of business is: COVIDIEN 15 HAMPSHIRE STREET PERSON(S) IN CHARGE. GERALD PACE Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-17 BOARD OF HEALTH MichaeCMcC(ean, Chairman Milk & Cream 0 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: LPM HOLDING CO., INC. having a place of business at: COVIDIEN 15 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-17 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 FSFS17 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address COVIDIEN 15 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 15 HAMPSHIRE STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 452-4114 5) Applicant Name & Title RUSSELL QUEENAN, GENERAL MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (508) 261-8218 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: (978)897-0660 LPM HOLDING CO., INC. 24 MAIN STREET, MAYNARD, MA 01754 (978)897-0660 10) Establishment Owned By. 11) If a corporation or partnership, give name, title, and home address of officers Ll An Association or partner. I A Corporation Name Title Address An Individual L`rtef-b_J' t �4-Stit,— - C r c� Ittlia �Etjyt avel_t.._(`ici-C l_�-7 ❑APartnership �al4ti6? '1±_iX �iSIC��it t t� �� u u 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: GERALD PACE Address: 113 JACKSONIA DRIVE, NO. PROVIDENCE RI 02911 Telephone No: (508) 261-8215 24 Hour Emergency No: (978) 897-0660 - - FAX: I(774) 218-1613 E-mail: RQUEENAN@LPMHCI.COM Alt E-Mail: IECAF - E8610 - EPICUR - EAN - FEAST.COM 13) District Or RegionalSupeisor (if aplicble) Name & Title: IRUSSELL QUEENAN Address: 2 LIBERTY STREET, CLINTON, MA 01510 Telephone No: (978) 375-4899 FAX: (978)897-3719 24 Hour Emergency No: (978) 375-4899 E-mail: RQUEENAN@LPMHCI.COM Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No of Food Employees: 4 17) DAYS/HOURS: M-F 6 AM - 5 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. jRequired as of 101112001 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) ❑� 20) Location: [] Permanent Location ❑ Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ,J', Annual !l Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: R.;n n.ro 22) Establishment Type [_ 1 Retail ( Sq. Ft) [s l Food Service up to 100 or up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 , 1 Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution Meals/Day) GERALD A. PACE ❑ Caterer $25.00 ❑./ Milk & Cream $10.00 [ I Mobile Food & Consession $75.00 [-� 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 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHF'' non -potentially hazardous food(no timeRemperature controls required) Check all that apply)' I RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [_J Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order [_] Hot PHF Cooked and Cooled or Hot Held o - -- -- -- ! --- -- --of PH of And for More Than a Single Meal Service I __I Sale of Commercially Pre -Packaged [ i Preparation of PHFs For Hot And _ --- -- — Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ] Delivery of Packaged PHFs -..-.._--_-- Susceptible Population Facility ----- -- -- - -- ❑ Sale of Raw Animal Foods Intended _J Reheating of Commercially to be Prepared by Consumer I❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ervice of Non PHF and Non - Perishable Foods Only -------------- Preparation of Non-PHFs Other Food Operations -� Customer Self -Service Ice Manufactured and Packaged for Retail Sale j Juice Manufactured and Packaged f Retail Sale Offers RTE PHF in Bulk Quantities Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin [] Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health --_------_-- - -- J 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 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: i\® it..,_.FI �Y1'�✓ 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: 04-2273500 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: COVIDIEN ADDRESS: 15 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 452-4114 FAX NUMBER: OWNER OF BUSINESS: (978)897-3719 LPM HOLDING CO., INC. TELEPHONE OF OWNER: (978) 897-0660 FEDERAL IDISS NUMBER: 04-2273500 FEE: $10.00 PERMIT NUMBER: FS-17 SIGNATURE: -(�_•_� J..4� -- 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. n C Signature of Individuals or Corporate Name By: Coker (Mandatory, if Applicable) bi d �60() **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:\Hn1th\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc KIN The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 UIV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERh4 TTING AUTHORITY. Applicant Information Please Print' m1R LE; `n3 C'}/ i 4 N,, p';c eel ea r Business/Organization Name: a, ( 01 c to u=- Address: W Are you an employer? Check the appropriate box: 1. �.I am a employer with , `fG P 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.] Phone -CG; -6, Business Type (required): 5. ❑Retail 6, ❑Restaurant(Bar/Eating Establishment 7. ❑ Office and/or Sales (inel. real estate, auto, etc,) S. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 I. ❑ Health Care 12.MOther N Fe+-ei:t7 *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 employces, a workers' compensation policy is required and such ao organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's C 0,KC) [ Policy # or Seif--ins, Lic. # 61+ it Q0 b CI'ko I4? I `I Expiration Date: 1 11 ! I� 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 ofperjury that the information provided above is true and correct. 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#: www.mass.govtdia ACOR" CERTIFICATE OF LIABILITY INSURANCE 11._.,/ �ATE(MMloolrvvv) 11/30/2017 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(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 Roger Keith 6 Sons 1575 Main Street Brockton MA 02301 CONTACT Janelle Litto NAME: PHONE J�O.. (508)583-1106 _ /C No: (508)583_8478 A ORESS; 7litto@rogerkeith.com INSURERS AFFORDING COVERAGE NAIC N _ INSURER A:TRAVELERS 25623 INSURED LPM Holding Co. Inc. 24 Main Street Maynard MA 01754 INSURER B:MA Retail Merchants WC Gr'oU INSURER C:FFEDERAL INSURANCE 20281 INSURER D;NH ASSOCIATION MEMBERS WCT INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2017 LPM HOLDING MASTER 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 itim SUER WVD POLICY NUMBER POLICY EFF (MMIDD[YYYYI POLICY EXP flMM1DD1YYYY1LIMITS X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Eaocowmmce $ 1,000,000 MED EKE (Any one person) _ $ 10,000 6306C830447 1/l/2017 i/l/2018 PERSONAL &ADV INJURY $ 1,000,000 included liquor liability AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 GEN'L $1,000, 000 limit X POLICY E jECOT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 Liquor Liability $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO AUTOS SCHEDULED AUTOS AUTOS 8107C399675 1/l/2017 1/l/2018 BODILY INJURY (Par accident) $ PROPERTY a cdeol DAMAGE $ HIRED AUTOS AUTOS ED $1, 000 DEDUCTIBLES RENTAL REIMBURSEMENT $ A X UMBRELLA LIAB 11 X OCCUR 2UP91M4890816 1/1/2017 1/1/2018 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 C X EXCESS LIAR CLAIMS -MADE DIED I X I RETENTION$ 10,000 35.000.000 $ 35, 000, 000 79882528 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N X PER OTH- STATUTE ER _ A ANY PROPRIETORIPARTNERrEXECUTIVE F--7 OFFICERIMEMBER EXCLUDED? Ly J (Mandatory In NH) N/A p,�g6C8]139-8-16 1/1/2017 r1/d/2018 -: E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE EA EMPLOYE $ 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below AZ,CT, ME, NJ, NY, PA, RI, VT E.L. DISEASE- POLICY LIMIT $ 1,000,000 B WORKRES COMP. MA ONLY 014000502016117 1/1/2017 1/l/2018 1,000,00011,000,000/1,000,000 WORKERS COMP. NH ONLY 030009100240117 1/1/2017 1/l/2018 1,000,000/1,000,000/1,000,000 DESCRIPTION OF OPERATIONS l LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) POLICY LIMITS IN EFFECT AT POLICY INCEPTION 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 DONOVAN DUNN/KEIJJI------- ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) OEM LL Q� z � z � � W-4 � � u � W-4 � � � � � /\ij\ 0 f 4 / \ \ \ � C ))® all I1§ g 2 � ) ar) / $2\\ ) F%\ ® / \\\§ ! w ) AMERICAN HEALTHIN INSTITUTE A member of the HSI family of brands RECOGNITION OF COMPLETION Jerry Pace has successfully completed ASHI Online Training for: CPR and AED All Ages (G2015)-DC (Blended) Completion Date: 09/26/2017 Blended learning consists of computer -based, online lessons combined with hands-on skill practice and performance evaluation. This document confirms that the above -named individual has completed the required online lessons and is now eligible for hands- on skill practice and performance evaluation by a current and properly authorized ASH] Instructor. "' Fn�llh °�tintaly