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HomeMy WebLinkAboutAlberto's Pub & Pizza 10/02/2018Commonwealth 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: TEMPORARY FOOD PERMIT 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:. SHEILA MACPHERSON Whose place of business is: ALBERTO'S PUB & PIZZA 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOHN ARMSTRONG Permit Expires: October 02, 2018 Food Fee: License Number: T-15 WAIVED BOARD OF HEALTH Michaet`-McCCean, Chairman Temporary Food Establishment Permit Application- - (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: 2) Establishment Address; ( V, -'V K�r-,-f i 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant/Owner Name & Title: 6) Applicant/OwnerAddress: J 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: t CN, Address: \J v i Telephone No: L-Fax: Emergency Telephone No: 10) Event Attending Date(s): Event Name: Event Location: Event time: 11) Check one 12) Solid waste disposal plan: Food Truck Caterer Other: i-, 13) Water Source: 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: Food Protection Questionnaire for Catered Events Date of Event: `^ ? _- E l Event Time. Location of Event: fir", :`; _ a List all foods that you will be chilling, holding, cooking, On ice/Refrigerated Cooking re heating at the event location: Reheating Food Manager Certification Person Trained On Site? ❑ Yes ❑ No Allergen Awareness Menu Label Present? V, Yes D No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41°F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. ! ". s...,w ':. ;.C- 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hot/ cold holding temperatures Offsite and held at proper hott, cold holding temperatures Offsite, cooled and reheated on site Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager. t 'i br' V _t+ x Allergen Awareness 18) For caterers: Cityrrown where food establishment permit is held. Please attach a copy of the caterer's permit: For food trucks, please list additional communities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the accuracy of the information provided in this application and I 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. 19) Signature of Applicant: %ti_ ';'E"_t > ,` 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. 20) Social Security Number or Federal ID. - 21) Signature of Individual or Corporate Name: 'i zw Z"-- Please include copiesof a a. , e and Allergen AA..a+a • g certificates 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, iifApplicable) i **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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORIvl.doc Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, NIA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses _Applicant Information Please Print Legibly Business/Organization Name: ('! Address: it-i.1 Are you an employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part-time). * 2. I 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 #: Business Type (required): 5. Retail Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care 12. Other 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 employees, a workers' compensation policy is required and such an organization should check box 91. am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. nsurance Company Name. V,, nsurer's Address: L' E -'ity/State/Zip 'olicy # or Self -ins. Lie. # i ', _ - _ C z' - r = ' ? Expiration Date: attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). "ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a me 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 if 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. do hereby certtfy, under the pains and penalties ofperjury that the information provided above is trite and correct. signature:`'__ . Date: 'hone #. ? t L,- 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.gov/dia ALBEPUB-01 hT1rKe1t1I3i A`O/20 CERTIFICATE OF LIABILITY INSURANCE DATE/06/15//2018V 018 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 have ADDITIONAL INSURED provisions or 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 CONTA NAM E:CT R. S. Gilmore Insurance 27 Elm St North Attleboro, MA 02760 __ PHONE FAX Arc, No, EzO: (508) 699-7511 lac, Ne):(508) 699-7511 EDORIEss INSURER(S) AFFORDING COVERAGE NAIC # _ INSURERA: Republic Franklin Insurance Company 12475 INSURED INSURER B: Utica Mutual Insurance Company 25976 _ INSURER C:AMGuard 42390 Alberto's Pub & Pizza, Inc. INSURER D: 241 Mansflbld Avre Norton, MA 02766 - —— INSURERE: INSURER F : ' COVERAGES CERTIFICATEW UMBER' REVISInNI NIHIVIRFR- 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 I 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 Lm TYPE OF INSURANCE .ABBE SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS A COMMERCIAL GENERAL LIABILITY __ CLAIMS -MADE ❑ occuR 5068302' 08I14/2017 08114/2018 EACH OCCURRENCE $ 1,000,000 __- DAMAGE TO RENTED PREMISES Ea $ 50,000 MED EXP An one arson 16,090 _ GEN'L PERSONAL& ADV INJURY $ 1,000,000 AGGREGATE LIMITAPP,LIE$PER: POLICY ❑ jqT LOC" OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOP AGG $ 1,000,000 —`- AUTOMOBILE LIABILITY ANYAUTO'. OWNED SCHEDULED AUTOS ONLY AUTOS p AUTOS ONLY AUTOS ONMLY " 4, COMBINED SINGLE LIMIT $ BODILY INJURY Per arson $ — - BOODILY INJURY Per acdtlent - Pe0,aacident AMAGE B UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE 5068304 08/14/2017 p 0811412018 EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE V/N ?ManEatry. NM)EXCLUDED? if yes, describe under DESCRIPTION OF OPERATIONS below N/A ALWC949998 04125/20104J0412512019�" " " PER OTH- T TUTS ` E E.L. EACH ACCIDENT ' _ 500,000 E.L.500,000 DISEASE -Eq EMPLOYE $ E.L. DISEASE' -POLICY LIMIT' 59D,DBD DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If s ace is requlred) Includes liquor liability. Re: Norton Founders Day Event at Yelle School in Norton, MA on 611612018. town of Norton is listed as addidional insured with respects to general liability as required per written contract. Town of Norton 70 East Main St Norton, MA 02766 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 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD S,�rTr MASSACHUSETTS DEPARTMENT OF REVENUE Form MT-1 - a u ? fNA Sales Tax on Meals and Beverages Registration Certificate '�1J Ls This registration must be posted and visible at all times. ALBERTO'S PUB & PIZZA, INC, Account ID: MLS-18802399-004 241 MANSFIELD AVE Certificate Number: 433778688 NORTON MA 02766-1355 This certifies that the taxpayer named above is registered under Chapters 62C and 64H of the Massachusetts General Laws to sell meals and beverages at the address shown above. This registration is non -transferable and may be suspended or revolted for.failure to comply with state laws and regulations., Effective Date: March 19, 2018 Z 0 W W ry CU J W U m z O co W N (D Q M ce) X N Lo W It 0 .o :� LS �\ � I � ( 2 ' �� §}}\) §Q/ ( ƒ@aJ « <<\ / Mansfield Board of Health Request for Fee Waiver for Food Permit Date <:-11 r4 (`e .,. r We, z ; (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: This is a request from a town department. Please list the department: We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: for food/drink being served. We are a religious organization. We are not charging a fee Other: The Taste of the Tri-Town Thank you, Signature (cy.-t.-.� Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: I Tri-Town Chamber Food Tasting "Congratulations, because ofyour past support and with the help of our partners, we have been able to donate $52,682 to the food pantries of- Foxborough, Mansfield and Norton " MrYes, Sign Us Up! Im ast� o ■ r1mTown i ne Iri-Town Chamber Food Tasting Event Date: Tuesday, October 2, 2018 Time: 5:00pm — 7:00pm Location: the Vinity Center 885 South Main St., Mansfield Note: There is no fee for a Restaurant to Participate. The Chamber Supplies, 8'Banguet Table, Table Cloth, Table Top Restaurant Sign and will hand out Large Plates, Napkins & Utensils for Attendees at the door IMPORTANT NOTES If you are located outside of Mansfield you must obtain a food permit (the fee has been waived, but you still need the permit) see 2nd attachment. PROPANE: If You will be using Propane you will need a permit in advance from Mansfield Fire Department 508-339-7492 - Do You Need Electric? YES or NO rj f ? of Establishment for Signage Contact Name s ress Menu Items You will be Uttering for The Taste of Tri-Town (this for marketing before and during eve - Would you like to contribute to the Raffle Table? ; YES) or NO If Yes, Please list you. Please Respond to the Chamber to Reserve Your Space - Thank You p: 508-339-5655 f: 508-339-8333 e: office@tri-townchamber.org Tri--Town www.tri-townchambenorg FoxPx�rough•Mnnsficld•Norton Silver Sponsor: Silver Sponsor: Friend of: