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Home My WebLink AboutEpicurean Feast@Tyco/Kendall 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 HOLDINGS CO., INC. Whose place of business is: EPICUREAN FEAST @ TYCO/KENDALL 100 HAMPSHIRE STREET PERSON(S) IN CHARGE: BRIAN CLOUGHERTY Permit Expires: December 31, 2018 Food Fee: $150.00 License Number: FS-24 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: LPM HOLDINGS CO., INC. having a place of business at: EPICUREAN FEAST @ TYCO/KENDALL 100 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-24 Board of Health NichaeCMcCCean, 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-24 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name EPICUREAN FEAST @ TYCO/KENDALL 2) Establishment Address 100 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 24 MAIN STREET _pr MAYNARD, MA 01754 4 Establishment Telephone No p (508)261-8000 5) Applicant Name & Title: RUSS QUEENAN, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 375-4899 24 Hour Emergency No.: (774) 284-3071 8) Owners Name & Title LPM HOLDINGS CO., INC 9) Owner Address (If different from applicant) 24 MAIN STREET, MAYNARD, MA 01754 Owner's telephone number (978) 897-0660 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. ii A Corporation Name Title Address .I An Individual - i �ot LLIM,ScW .__ etc me?µ C)l py Lar .�_(lld-Qi°1.5y A Partnership 0 u w c V 4 �u-�s�s�tScw-Jtir2�d' I Other legal_Entity — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IBRIAN CLOUGHERTY Address: 36 RODNEY ROAD, N. ATTLEBORO, MA 02760 Telephone No: I(508) 838-1856 FAX: I(774) 284-3071 E-mail: ECAFE837(WEPICU REANFEAST.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title RUSSELL QUEENAN Address: Telephone No: FAX: 24 Hour Emergency No: (774) 284.3071 LIBERTY STREET, CLINTON, MA 01510 78) 375-4899 24 Hour Emergency No: (978) 375.4899 (978) 897-3719 E-mall: 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: 5 17)DAYS/HOURS: MON-FRI 7AM-1:30PM 18) Name of Person In Charge Certified in Food Protection Management: BRIAN J. CLOUGHERTY 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 certificate i 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: [J] Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: i] Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): 22) Establishment Type ❑ Retail ( Sq. Ft) [.] Food Service up to 100 or up to 10' PHF display $125.00 yi Food Service up to 101 -200 or up to 25' PHF display $150.00 IJ Food Service up to 201 + or 25'+ PHF display $275.00 [J� Food Service - Institution ko Meals/Day) ❑ Caterer $25.00 [] Milk & Cream $10.00 F 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 Definitions: PHF - Potentially hazardous rood (time/temperature controls required) Non-PHFs- non -potentially hazardous rood(no timelemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) n Sale of Commercially Pre -Packaged Non-PHFs I (] PHFCooked To Order Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale [] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Susceptible Population Facility Vacuum Packaging / Cook Chili Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for I I Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ---1 or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $150.00 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: 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: to C A Y 1 v Ai� CC) Covidien—Mansfield 12/19/2017 11:56:03 AM PAGE 2/002 Fax Server Town of'rlllansfield - Board of Health Application, for Milk and Cream .Permit Town of Mansfield 6 Park Row Mansfield, MA 02048 1 hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: EPICUREAN FEAST @TYCO/KENDALL ADDRESS: 100 HAMPSHIRE STREET TELEPHONE AT LOCATION: (608) 261-8000 FAX NUMBER: (978) 897-3719 OWNER OF BUSINESS: LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 897-0060 FEDERAL IDISS NUMBER: 04-2273500 FEE: $10.00 PERMIT NUMBER: FS-24 C SIGNATURE: DATE: IRW -17 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. �4P AA a kj Gl ,,JAI ha, _14 I KDCXA'a ; Signature of Individual 4 Corporate Name By: Cor orate OffiLer (Mandatory, if Applicable) "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 Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02774-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTHORITY. Business/Organization Name: a Address: y L City/State/Zip: 1.�ittyt.Q',��1�. TUBA; G—p+ckrr'.�N Phone #: C1 q� - Ecl q _ow Are ou an employer? Check the appropriate box: Business Type (required): 1. [ 1 am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2: 0 1 am a sole proprietor or partnership and have no q. Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment' their right of exemption per e. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance required]* l l ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, � q with no employees. [No workers' comp. insurance req.] tAny applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information. **If the corporate of5eers have exempted Ihemsdves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing worke n' compensation insurance for my employees.Below is the policy information Insurance Company insurer's Address; City/State/Zip: Policy # or Self -ins. Lic. #- 0 1 LlL C`) Ap l 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 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 thee�pains and penalties of perjury that the information provided above is true and correct. Signature • iL3.tJ - Ad �'t' ;.F.C" % Date: nj,, C) I 1 l 01 Q (1- G Official use only. Do not write in this area, to be completed by city or town of 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 ACORO® CERTIFICATE OF LIABILITY INSURANCE kk/ DATE(MM/DD/YYYY) 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 CONTACT Janelle Litto NAME: Roger Keith & Sons 1575 Main Street _ PHONE (506) 583-1106 FAX AIVQ,NE I)A/(506)593-8470 ; C No ADDRESS: Ilitto(drogerkeith,COr11 INSURERS AFFORDING COVERAGE NAG# INSURER A:TRAVELERS 25623 Brockton MA 02301 INSURED INSURERB:MA Retail Merchants WC Group INSURER 0:FFEDERAL INSURANCE 20281 LPM Holding Co. Inc. INSURER D:NH ASSOCIATION MEMBERS WCT INSURER E: 24 Main Street INSURER F: Maynard MA 01754 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, ILTP TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD YYY POLICY EXP MMIDD YYYY LIMITS X AL LIABILITY COMMERCIAL GENERTED EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE AlLXOCCUR pREM SESAGE OEa oocur ante 1,000,000 MED EXP(Any one person) _$ $ 10,000 6306C830447 1/l/2017 i/l/2018 PERSONAL &ADV INJURY $ 1,000,000 included liquor liability GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 01, 000, 000 limit X POLICY u JEC-CT 1-1LOG PRODUCTS-COMP/OPAGG $ 2,000,000 Liquor Liability $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidenl $ 1,000,000 X BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS 8107C399675 1/l/2017 1/l/2018 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accidenl $ NON -OWNED HIRED AUTOS AUTOS 01,000 DEDUCTIBLES _ RENTAL REIMBURSEMENT $ A X UMBRELLA LIAR X OCCUR ZUP91144890816 1/1/2017 1/1/2018 EACH OCCURRENCE $ 25,000,000 X AGGREGATE $ 25 000,,000 C EXCESS LIA8 CLAMS -MADE DED X I RETENTION$ 10,000 35,000,000 $ 35, 000, 000 79882528 A WORKERS COMPENSATION AND EMPLOYERS'LIABILITV YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERNEMBER EXCLUDED? yN/A (Mandatory In NH) PZfU86C87139-8-16 1/l/2017 1/112018' X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEO $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below p2, CT, ME, NJ, NY, PA, RI, VT E.L. DISEASE - POLICY LIMIT $ 1 000,000 B WORKRRS COMP, MA ONLY 014000502016117 1/1/2017 1/l/2018 1,000,000/1,000,000/1,000,000 WORKERS COMP, NH ONLY 030009100240117 1/i/2017 1/l/2018 1,000.000/1,000,000/1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached It 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 DUNN/KEIJJI 5- 01988-2014 ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) reserved. \( \\\ \\ U LU /) mc \k 00 r a\ / .: �. � : w O W U w F� W U V uzu 1 * z ran W z w P4 z W (V F+1 W 61 O 4kr) kn in k z � U Q Q s, C O ty 'G 0 n O Ell v y � M yyyy�yjj 7 A 0 � N M M 0 v v Z a � �Q'C tl � l O � AMERICAN HEALTHM INSTITUTE A mernboi of tho fISI family of brands RECOGNITION OF COMPLETION Brian Clougherty has successfully completed ASHI Online Training for: CPR and AED All Ages (G2015)-DC (Blended) Completion Date: 04/17/2017 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 ASHI Instructor. hsi Health &Safety