Loading...
HomeMy WebLinkAboutRed Roof Inn 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: RETAIL SNACK FOOD 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:. Whose place of business is: RED ROOF INNS #0274 60 FORBES BLVD. PERSON(S) IN CHARGE: FRANKIE TODESCO, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: RS-3 BOARD OF HEALTH MichaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued j FOOD ESTABLISHMENT PERMIT APPLICATION j (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name R-eA Rcz,-F Inns- # _0 R `] 2) Establishment Address 6 U rt) r �S V Mu fiS' 6 e.4 MA 6204 3) Establishment Mailing Address (if different) Telephone No 5-v K 33 - UR 54)Establishment ) Applicant Name & Title: 6) Applicant Address 7) Applicant Telephone No.: — 24 Hour Emergency No.: 18) Owners Name & Title ----8 W kRi——J]T, LL G--- I 9) Owner Address (If different from applicant) 15 15 L•V A LTO N PAR -Lc vA✓ N w ALLM Nq 6 - Owner's telephone number (4 _ 2 �.�._ ��� 430. 10) Establishment Owned By: (l An Association 11) If a corporation or partnership, give name, title, and home address of officers or partner. tJ A Corporation Name Title Address EEJ An Individual IN A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:. _ -- i R cinki e TA Psco Qeneml NtancLaev Address: 60 Viorbe-� 9I0,, Matwfi- cP MA 6au`f,5 _ Telephone No: 24 Hour Emergency No: FAX: 3_. —E-mail: 1 0�k`ly rP fe&kbJ- Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: iAddress: Telephone No: 24 Hour Emergency No: FAX: E-mail: FOOD JUL 0 3 2Q18 RMT_ x^4 >4 Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 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. Required as of 10/l/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). 20) Location: ® Permanent Location 22) Establishment Type ® Caterer $25.00 [NIMobile Mobile Start Dale: Retail ( Sq. Ft) Q Milk & Cream $10.00 Mobile End Date: © Food Service up to 100 or i] Mobile Food Consession Mobile Comments: up to 10' PHF display INCLUDING NO PHF PREPARED ON SITE $75.00 21) Length of Permit: FOOD TRUCKS $125.00 (] Manufacture Frozen Dessertsllce Cream Annual Food ❑ Service $25.00ffreezer or up o 25' PHF display $150.00 -l- -- Seasonal Q Food Service up 2+ Pushcart #of Pushcarts: Seasonal Dates: S or 25'+ PHF display 275.00 a $ Residential Kitchen $100.00 a Temporary Q Food Service - Institution ® Retail Food $100.00 Temporary Start Date: ( Retail Snack Food $25.00 Temporary End Date: MealslDay) Tobacco Products $25.00 Temporary Time: Rain Date: 23) Food Operations Difinih'ons:PHF - Potentially hazardous food rnme4emperature controls required) Non-PHFs - non -potentially hazardous faod(no fime/temperature controls required) ,(Check all that apply): RTE- ready -to -eat roads (Ex, sandwiches, salads, mums which need no fudherprocessing) Q Sate of Commercially Pre Packaged Non-PHFs I] PHFCooked To Order ® 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 __ ----- --- 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 (] Reheating of Commercially to be Prepared by Consumer 19 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- ®Customer Self -Service 11 11 Use of Process Requiring A Variance Perishable Foods Only _— l and/or HACCP Plan (Including bare hand .____....._-..__ __ . _-_.....__.. Q ice Manufactured and Packaged for contact alternative, time es a public health Preparation of Nan-PHFs Retail Sale control) Other Food Operations ® Juice Manufactured and Packaged for ® Offers Raw Or Undercooked Food Of Retail Sale Animal Origin IN Offers RTE PHF in Bulk Ouantitles -' ®Prepares Food/Single Meals for .. ___ _ 0 Retail Sale of Salvage, Out -Of -Date _ Catered Events or Institutional Food Service ---- --- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application n waived 1, 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: Pursuant to MGL Ch.62C, sec. 49A, 1 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: i+ ri " �3 Fl Lv t X26) Signature of Individual or Corporate Name: p { TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ZLe By: Corporate Qffic r (tYlimdittary, if'Applicable) Au f�orilc., RipvL-S Vtfi, <,'t"t _ # 7- 336 $ ?—i "Social Security No. (Voluntary) or Federal ldenti(l'cation 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. C!,Usetslslnitu\Desktopt5cult's Docamentffood Est0livhments- PempVt AX CERTIFICATION FORM.doc rite Commonwealth of Massachusetts Department of Industrial Accidents k1F Ofjlce of Investigations 600 Washington Street Boston, MA 02111 tvwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Am lieant Information Please Print I,eoi- - 13usutess/OrgantzattonName:_...��e[i.._�G�{` Address: 60 faCs 1Q_.._—__.------._.--- City/State/lip: Phone Are you on employer? Cheek the appropriate box: ® 1 am a employer with �employees (fill 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 o 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.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. [] Non-profit 9. ❑ Entertainment 10.❑ Manufiurturing 1 I.[] Health Care 12,[Z Other 4 0 , Any npolcmn that chucks box U I nnist also illl out tine section below showing their workers' compensation policy inlortrapon. ° `I I'tile corpnrnto officers have exempted lhernseives, but the corpnrniion ims other employees, a workers*' compensation policy is relloired and such an organization should check box Nl. I am an employer that is providing workers, compensation insurance for my employees, BeIow is the polley inforrmation. Insurance Company Nor insurer's Address: City/State/Zip: Pnlicy is or Self -ins. Lie. 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 NIOL 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 it copy of this statement may he forwaded to the Office of Investigations of the DIA for insurance coverage verification. I elo hereby certif�mdier the pains and ei "V of perjury that the btformation provided above is true and correct, p one ll: <o7, — ?,3`l— a'a a� Expiration Date:— O,11ciai use only. Do not write in this area, to be completer/ by city or town official. City or Town: Permit/License issuing Authority (circle one): 1, Board of /ieaith 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other _ Contact Phone it: www.enoa.gvv,.,m AC<>Rff CERTIFICATE OF LIABILITY INSURANCE 9/6/2018 FDAM(MMIDO/YYM 1 6/1/2018 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 have ADDITIONAL INSURED provisions or he endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 Lockton Companies, LLC 601 108th Avenue NE, Suite 1969 Bellevue WA 98004 NAME: C" AME' ""-"--"— —�" �FaY-- -----" — PHONE -EQGAtlu E"II' -. ----- lac Nm• .,, ADDRESS I11SURER(8)AFFORDING COVERAGE NAICN „INSURER A. The First Liberty —Insurance-Corporation _ --_—_ ..._._. 33588 INSURED 1447203 Red RoofInns,Building The Red Roof Building 605 South Front St. Columbus OH 43215 INSURERe INSURER D : -' — ---- INSURERS. — INSURER F : COVERAGES REDROOI CERTIFICATE NUMBER- 15421 T9A RFVIQln i MIIMGCD: vvvv vvv 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. INSft •.AD �`""------- L. BRi -----------"'_--"' POLICY ErP POLICY EXP Lm TYPE OF INSURANCE p POLICY NUMBER HyMIDDIYYNN1 LIMITS COMMERCIAL GENERAL LIABILITY NOTAPPLICABLE EACH OCCURRENCE $ XXXXXXX _ CLAIMS -MADE u OCCUR E70TtEFlT-ED PREMISESIEaoccunencp)-,,,_, $ XXXXXXX� MEOEXP(Anyanepareon) $XXXXXXX` PERSONAL B AOV INJURY s XXXXXXX GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXXXX POLICY 1:1LOC _J JECT PRODUCTS -COMPIOPAGG $ XXXXXXX OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT A—.— mo $ XXXXXXX BODILY INJURY (Pal person) $ XXXXXXX ANY AUTO BODILY INJURY (PeramidentJ § XXXXXXX AUTOS OWNED SCHEDULED AUTOS OWNED ONLYah HIRED NON WNED AUTOSONLY AUTOS ONLY.. PROPERTY DAMAGE PoracLitlenO v� --- $ XXXXXXX $XXXXXXX _.__. UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE_ $ XXXXXXX EXCESS LIAB CLAIMS -MADE, AGGREGATE _ _—_ ".__ $ XXXXXXX DED RETENTIONS $ XXXXXXX TM A WORKERS COMPENSATION N ORH. X_ AND EMPLOYERS' LIABILITY YIN WC6-64L437760-017 9/6/2017 9/6/2018 SrATurE ANY PROPRIETORIPARTNEIUEXECUTIVE 0 Ft En EXCLUDEW ❑N NIA E.L.EACH ACCIDENT $ 1000000 (MandatoryNH)MBER CEMM In NH) E.L. DISEASE -EA EMPLOYEE $ 1.Q00000 Il yyea, tlescnhe under ___ DESCRIPTIONOFOPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional RommHe Schedule, maybe broached it mom space Is maulred) RE: Red Roof Inns 1110274 @ 60 Forbes Road; Mansfield, MA. 15421326 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All HwnU AD 1ZU1p/U3) The ACORD name and logo are registered marks of ACORD Bank 4 Pktll TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department:, _ BOARD OF HEALTH -FOOD PERMIT _ Date: 7-3-2018 Schedule IJED0732018 - -. 01512-445006 Or 25.00 To The Officer Makihe. Payments_ The above is a detailed Ilsl of moneys collected by me, amounting in the aggregate to: _ $ 25 00 Ifor the_period ending 7-3-2018 which I have paid to the Town Treasurer whose receipt I hold therefor. V. IR