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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 777 WEST STREET PERSON(S) IN CHARGE: SHEILA WOOD Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-23 BOARD OF HEALTH Michael McCCean, Chairman Milk & Cream ❑O Commonwealth of Massachusetts Town of Mansfield 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 @ TYCOXENDALL 777 WEST STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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-23 Board of Health .MichaeC.MCCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred C FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-23 - --- - --- ---- - — FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name EPICUREAN FEAST @ TYCOIKENDALL 2) Establishment Address 777 WEST STREET 3) Establishment Mailing Address (if different) 24 MAIN STREET DEC it 4 20V MAYNARD, MA 01754 4) Establishment Telephone No (508) 261-8000 5) Applicant Name & Title: RUSSELL QUEENAN, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 3764899 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) 375-4899 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers l An Association or partner. A Corporation Name Title Address An Individual 4 E I c 5 4 Gcj! Gil l S f--- P 1 A Partnership` , u 4 p L1 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) -_ —__ --- Name & Title: PAGE =�1IQ i Address: 14-3-dACKSON-DRIVE�ART+WZROVlDfiN E ffl-t129h 1 Telephone No: 808}; --1293 ']°ri.(-,�(�-)`rjLtj 24 Hour Emergency No: eM FAX: (978) 897 3719 E-mail: qOVIDIEN.COM Alt E Mail: la- 13) District Or Regional Supervisor (if applicable) Name & Title: RUSSELL QUEENAN Address 2 LIBERTY STREET, CLINTON, MA 01510 Telephone No: (978) 375-4899 24 Hour Emergency No: (978) 375-4899 FAX' I (978) 897-3719 E-mail: RQUEENAN@COVIDIEN.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 1 17) DAYS/HOURS: MON-FRI 7:00 AM-1:30 PM 18) Name of Person In Charge Certified in Food Protection Management: GERAb Jue tla c� 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 SHEILA J. WOOD certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑� -- - Ali 20) Location: Permanent Location 22) Establishment Type I -] Caterer $25.00 li ] Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) W Milk & Cream $10.00 Moblie End Date: lam) Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: I_] Food service up to 101 -200 $25.00/freezer Annual or up to 25' PHF display $150.00 Pushcart $25.00 # of Pushcarts: 0 Seasonal i.._j Food Service up to 201 + ❑ Residential Kitchen $100.00 Seasonal Dates: or 25'+ PHF display $275.00 ❑Retail Food $100.00 1 1 Temporary ❑ Food Service - Institution [] Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: �- --- _- - - 23) Food Operations Definitions PHF- Potentially hazardous food (timeRemperature controls required) Nan-PHFs non -potentially hazardous food(no timeRemperature controls required) (Check all that apply) RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre Packaged Non-PHFs J PHFCooked To Order ❑� Hot PHF Cooked and Cooled or Hot Held - ---- - - i sale of Commercially Pre Packaged PHFs -- -- ----- - ❑_ Preparation of PHFs For Hot And for More Than a Single Meal Service ___ __ _-__- ❑ PHF and RTE Foods Prepared For Highly r -- - --- — Delivery of Packaged PHFs Cold Holding For Single Meal Service -, ------- ----- -- - -- ----- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility (] Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand --:.- --- - ----- --- _. Customer Self -Service of Non PHF and Non- (],Customer Self -Service Perishable Foods Only contact alternative, time as a public health [ I Ice Manufactured and Packaged for T ✓Preparation of Non-PHFs Retail Sale control) ❑ Offers Raw Or Undercooked Food Of Other Food Operations J Juice Manufactured and Packaged for Retail Sale Animal Origin , ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities -__ Catered Events or Institutional Food Service ❑ Retail Sale of Salvage Out -Of -Date .._..____. .__... To be completed by the Board of Health or Reconditioned Food --" - "" --- Total Permit Fee: $125.00 Payment is due with application wawed 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 c and paid state taxes required under law. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 04-2273500 26) Signature of Individual or Corporate Name: Town of Mansfield - Board of Health Application for Milk and Cream Permit r Town of Mansfield 6 Park Row Mansfield, MA 02048 I 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: 777 WEST STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: OWNER OF BUSINESS (978)897-3719 LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 375-4899 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $10.00 PERMIT NUMBER: FS-23 SIGNATURE: DATE: 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. Signature of Indi�or Corporate Name By: korporaty Officer (Mandatory, if Applicable) 64111)\')�`1<) Jtv **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 F nIthVane's DocumentsTERMIT APPLICATIONS\TAX CERTIFICATION FORMdoc The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Name: Address: b (i s ( Phone #: Are ou an employer? Check the appropriate box: Business Type (required): L I am a employer with ,jCGt employees (full and/ 5. ❑Retail or Part-time).* 6. f-IRestaurantBar/EatingEstablishment 2: 0 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $• ❑ Non-profit 3, ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have I 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11 ❑ Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, �^ 12.�Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have cxemplcd themscives, but the corporation has other employces, a workers' compensation policy is required and such an ' organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Insurer's City/State/Zip: 116 l may. ' (I I If Policy # or Self -ins, Lic. #- � � 1 OUi} .`.) (i`�� ^ III Expiration Date: 1 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 #: 11 �V - ,Ai V1 -'o G, (, o 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 w O W U w w U v z Mai z w z w O W N N W N O O xr � fn N Q" tl z `� oU U w O N O 4 z U Q q fA o 0 ��o � IN 4 .m 9 P4 �Q 0 a M � M •� M 0 w v w �dx o w C a L w ,N A � � d � d %' w V d � � •N N w d m 2 A m V X N V W T LL 2 o �C' o N i- L.C) I- m B O Q u ❑ ❑ J ACORO® CERTIFICATE OF LIABILITY INSURANCE `..�1 DATE (MMIDOIVYYY) F 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; PHONE (508 583-1106 FAX A N ,J:dlj' ) A/C No : (508) 583-8478 Roger Keith S Sons 1575 Main Street E-MAIL litto erkeith. com ADDRESS:3 ro @ 4 AFFORDING COVERAGE NAIC N --INSURER(S) INSURER A:TRAVELERS 25623 Brockton MA 02301 INSURED _ _ INSURERB14A Retail Merchants WC Grou INSURER C:FFE_DERAL INSURANCE 20281 LPM Holding Co. Inc. INSURERD:NH ASSOCIATION MEMBERS WCT 24 Main Street INSURER E: 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. INSR LTR TYPE OF INSURANCE ADOL SUER POLICYNUMBER POLICY EFF fMWODNYYYi POLICY EXP (MIWDO/YYYYtLIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Eaoccurrence $ 1,000,000 MED EXP(Any one person) $ 10,000 6306C830447 1/1/2017 1/1/2018 PERSONAL &ADV INJURY $ 1,000,000 included liquor liability AGGREGATE LIMIT APPLIES PER: POLICY ❑JECT DLOC GENERAL AGGREGATE $ 3,000,000 GEN'L X $1, 000, 000 limit PRODUCTS - COMP/OP AGO $ 2,000,000 Liquor Uabllily, $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidem) $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO ALL OS SCHEDULED AUTOS AUTOS 8107C399675 1/1/2017 1/1/2018 BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS $1,000 DEDUCTIBLES PROPERTY DAMAGE Per accMonl $ RENTAL REIMBURSEMENT $ A X UMBRELLA LIAB X OCCUR ZUP91M4890816 1/1/2017 1/l/2018 EACH OCCURRENCE $ 25 000 000 X AGGREGATE $ 25 000 000 C EXCESS LIAB CLAIMS -MADE LED X RETENTION 10 000 36,000,D00 $ 35, 000, 000 79882528 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? � (Mandatory in NH) Under Dyes, DESCRIPTION DESCRIPTION or OPERATIONS below N / A PJUB6C87139-8-16 AZ, CT, ME, NJ, NY, PA, RI, VT 1/1/2017 1/1/2018 X PEfl OTH- STATUTE ER F.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYER $ 1,000,000 E.L. DIBEASE- POLICY LIMIT 1 $ 1,000,000 B WORKERS COMP. MA ONLY 014000502016117 1/l/2017 1/1/2018 1,000,000/1,000,000/1,000,000 WORKERS COMP. NH ONLY 030009100240117 1/1/2017 1/1/2018 1,000.000/1,000,000/1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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 4; J --e- 1988.2014 ACORD CORPORATION. All rinhts ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)